ATS Literature Review, Consultations & Trial - Odyssey House

AMPHETAMINE‐TYPE 

STIMULANT USE 

Literature Review and 

Report of Consultations 

and Trial in the 

Development of a 

Treatment Protocol for 

clients of Therapeutic 

Communities 

Lynne Magor‐Blatch 

Project Officer 

James A. Pitts 

Chief Executive Officer 

Odyssey House McGrath Foundation 

2008 ‐ 2009

Amphetamine‐Type Stimulants: Development of a Treatment Protocol 

© Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2008‐2009 

This work is copyright. You may download, display, print and reproduce this material in unaltered form only 

(retaining this notice) for your personal, non‐commercial use or use within your organisation. All other rights 

are reserved. Requests and enquiries concerning reproduction and rights should be addressed to the 

CEO, Odyssey House McGrath Foundation, PO Box 459, Campbelltown, NSW 2560. 

Page 2 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2008‐2009

Contents 

Figures and Tables 

Acknowledgements 

Project Background 

Section 1: Literature Review 


1. Amphetamine‐Type Stimulants : Background and issues 

15 

1.1. Prevalence: Australia 16 

1.2. Prevalence: New Zealand 20 

1.3. Harms resulting from drug use: New Zealand 21 

1.4. Use of ATS 23 

1.5. Problems associated with ATS use 26 

1.6. Substance use and mental health problems 27 

1.7. Maternal and foetal health 28 

2. Therapeutic Communities 

31 

2.1. Program context 31 

2.2. Treatment outcomes 33 

2.3. Young people 33 

2.4. Correctional populations 34 

3. Treatment approaches 

3.1. 

3.2. 

Characteristics of methamphetamine users entering 

treatment 

Effects of ATS use on psychopathology, aggression and 

cognitive function among clients within TCs: Research 

findings 

3.3. Pathways to treatment 39 

3.4. Pharmacological interventions 40 

3.5. The NSW Stimulant Treatment Program 41 

3.6. The Methamphetamine Treatment Project 42 

3.7. Cognitive and behavioural therapies 43 

3.8. Third Wave Therapies 44 

3.9. Brief interventions 45 

3.10. Stepped‐care 47 

3.11. Online interventions 48 

3.12. Abstinence incentives: contingency management 48 

3.13. Conclusion 49 

4. References 

© Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2008‐2009 Page 3 

6 

9 

11 

13 

35 

36 

38 

53


Section 2: Report of Consultations 

1. Summary of Therapeutic Community and other 

Consultations 

1.1. Principal Drug of Concern 65 

1.2. Assessment Process 66 

1.3. Violence, physical effects and effect on TC, staff and families 67 

1.4. Mental Health issues 68 

1.5. Relationship with Mental Health services 70 

1.6. First stage of treatment 71 

1.7. Treatment interventions 71 

1.8. Treatment protocol 72 

1.9. Postscripts from Prague: Perry Fletcher 

Feedback from the 1st Global Methamphetamine Conference 

15 & 16 September 2008 

The Canberra Institute of Technology 

The Centre for Health, Community and Wellbeing 

73 

1.9.1 Introduction 73 

1.9.2 Methamphetamine and HIV Prevention: Current 

74 

Challenges 

1.9.3 Prevalence and Patterns of Use 74 

1.9.4 The Duality of Methamphetamine Use and Disinhibition 75 

1.9.5 Pharmacology of Methamphetamine 75 

1.9.6 Treatment, withdrawal, medications and interventions 76 

1.9.7 The relationships between methamphetamine use, 

anger and aggression 

78 

1.9.8 References 

79 

2. Information from Therapeutic Community Consultations 

2.1. Report of Gold Coast Consultation 81 

2.2. Report of Sydney Consultation 87 

2.3. Report of Melbourne Consultation 93 

2.4. Report of Perth Consultation 97 

2.5. Report of Canberra Consultation 101 

2.6. Report of Auckland Consultation 

107 

2.7. Report of Adelaide Consultation 

113 

2.8. Consultations: List of Contributors 119 

Page 4 © Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2008‐2009 

63 

65 

81


Section 3: Results of Trial of Treatment Protocol 121 

1. Information on participating Therapeutic Communities 123 

1.1. Mirikai Therapeutic Community 123 

1.1.1. Program Stages 124 

1.2. Cyrenian House 124 

1.2.1. Saranna Women’s and Children’s Program 125 

1.2.2. Program Stages 125 

2. Characteristics of participants 125 

2.1. Substance use 126 

3. Measures 127 

3.1. Participant questionnaire 127 

3.2. Facilitator questionnaire 128 

4. Results 129 

4.1. Participants’ response 129 

4.2. Facilitators’ response 132 

5. Conclusion 135 

© Lynne Magor‐Blatch & James A. Pitts: Odyssey House McGrath Foundation 2008‐2009 Page 5


Figures and Tables 

Figure 1: Thorley’s model of drug harm 16 

Table 1: Summary of drugs ever used/tried: proportion of the 

population aged 14 years or older, Australia, 1993 to 2007 

17 

Figure 2: Proportion of IDU reporting recent use of crystalline 

methamphetamine, by jurisdiction, 2000‐2005 

18 

Table 2: Summary of recent drug use: proportion of the population 

aged 14 years or older, Australia, 1993 to 2007 

19 

Figure 3: Frequent drug users by gender, 2007: New Zealand 21 

Table 3: Drug types used by frequent methamphetamine users in 

past six months by age (2006 and 2007 samples combined) 

22 

Table 4: Frequent drug users by location in New Zealand 23 

Table 5: Major risk and protective factors for harmful substance use 

across the lifespan 

24 

Table 6: Key determinants of risk for young people 25 

Table 7: Range of responses for diverse target groups 35 

Figure 4: Mirikai & Oasis ‐ Primary Drug of Choice 81 

Figure 5: Mirikai ‐ Mental Health Primary Diagnosis 81 

Table 8: Goldbridge ‐ Main Drug of Concern: 2007‐2008 82 

Table 9: Goldbridge ‐ Mental Health Status of Clients: At Assessment 

2007‐2008 

82 

Figure 6: Primary Substance Use of Clients Admitted into the Odyssey 

House NSW TC 

87 

Figure 7: Secondary Drug of Choice Identified by Clients entering the 

Odyssey House NSW TC 

87 

Figure 8: Odyssey House NSW ‐ Comparison 2006/2007 with 

2007/2008 Primary Substance Use identified upon admission 

to the TC: Percentage of the Total Admissions 

88 

Figure 9: Clients Admitted to the Odyssey House NSW TC: July 07 to 

June 08 with a Dual Diagnosis 

88 

Figure 10: Grouped by Diagnosis/Drug use – Odyssey House NSW 88 

Figure 11: Grouped by Drug Use / Diagnosis: Odyssey House NSW 89 

Figure 12: Windana: Total percentages – presenting drug of concern on 

admission 2006‐2007 

93 

Figure 13: Windana: Total percentages – presenting drug of concern on 

admission 2007‐2008 

93 

Figure 14: Cyrenian House ‐ Principal Presenting Drug by Gender 2007‐ 

2008 

97 

Figure 15: Cyrenian House ‐ Principal Drug of Concern 2007‐2008 97 

Table 10: Karralika ‐ Principal Drug of Concern on Admission 101 

Table 11: Karralika ‐ Mental Health Status of Clients: At Admission 101 

Table 12: The Peppers ‐ Principal Drug of Concern on Admission 101 

Table 13: The Peppers ‐ Mental Health Status of Clients at Assessment 102 

Table 14: The Peppers ‐ Mental Health Status of Clients on Admission 102 

Figure 16: Age of clients with Methamphetamine use admitted to 

Higher Ground 

107 



Figure 17: Education level of clients with Methamphetamine use 

admitted to Higher Ground 

108 

Figure 18: S Status of Admitted Methamphetamine Clients: 

Higher Ground 

108 

Figure 19: Criminal Activity Identified of Admitted Methamphetamine 

Clients: Higher Ground 

109 

Figure 20: Odyssey Auckland ‐ Principal Drugs of Concern 2008 109 

Figure 21: Exit Stage of Methamphetamine Clients: Higher Ground 112 

Figure 22: Kuitpo Community: ‘Snapshot’ of Principal Drug of Concern, 

first two weeks in November 2008 

113 

Figure 23: Kuitpo Community: ‘Snapshot’ of most prevalent mental 

health concerns, first two weeks in November 2008 

116 




Acknowledgements 


In the development of the Treatment Protocol, we have consulted with staff and clients of 

therapeutic communities in Australia and New Zealand, with researchers, clinicians, teachers and 

policy officers and drawn on a wide research and clinical literature from across the world. 

The Treatment Protocol has been enhanced through attendance by the principal author at three 

valuable experiential workshops, from which information has been sourced and utilised with 

permission of the authors: 

• Liana Taylor, Mindfulness‐Based Cognitive Therapy, experiential intensive course and 

professional development, Canberra, 12 – 15 February, 2009. 

• Dr Chris Wagner, Adapting Motivational Interviewing to a Group Counselling Setting, Sydney, 

9‐10 March, 2009. 

• Dr Russ Harris, ACT MINDFULLY: Acceptance & Commitment Therapy Training, Canberra, 

23‐24 March, 2009. 

The authors also wish to acknowledge the valuable help and support of the following people who 

provided input through teaching, expert comment and critical appraisal in the development of this 

Treatment Protocol: 

Assoc. Professor Robert Ali Drug and Alcohol Services, South Australia 

Professor Amanda Baker NHMRC Research Fellow Centre for Brain and Mental Health 

Research, University of Newcastle 

Professor Jan Copeland Director, National Cannabis Prevention & Information Centre & 

Assistant Director, National Drug and Alcohol Research Centre 

Dr Russ Harris ACT MINDFULLY, Psychological Flexibility Pty Ltd 

Dr Nicole Lee Turning Point, Melbourne 

Dr Rebecca McKetin National Drug and Alcohol Research Centre, Sydney 

Dr Joel Porter Director, The Pacific Centre for Motivation & Change, New Zealand 

Professor Debra Rickwood Head, Centre for Applied Psychology, University of Canberra 

Liana Taylor Co‐Founder, Director of Training, Mindfulness Centre, Adelaide 

Assoc. Professor Chris Wagner Virginia Commonwealth University, USA 

The authors would also like thank representatives of the following Therapeutic Communities in 

Australia and New Zealand who contributed to the development of the Treatment Protocol through 

consultations in regional centres: 

Queensland: Fairhaven, Goldbridge, Logan House, Mirikai, WHOS Najara 

New South Wales: Blue Mountains Recovery Services, Buttery, Odyssey House, 

Selah Farm, The Peppers, WHOS, Wollongong Crisis Centre 

Victoria: Odyssey Vic, YSAS, YSAS Birribi, Windana 

Western Australia: Cyrenian House, Palmerston Farm, Serenity Lodge 

Australian Capital Territory: ADFACT/Karralika, Canberra Recovery Services, Ted Noffs 

Foundation 

Northern Territory: Drug and Alcohol Services Association, Alice Springs 

South Australia: The Woolshed, Kuitpo Community: Uniting Care Wesley Adelaide Inc. 

New Zealand: Higher Ground Trust, Odyssey House Auckland 

The names of those attending the consultations, and the TCs represented at these gatherings, are 

included at page 119 of this report, following the detailed reports from each of these consultations. 




Project Background 


The Amphetamine‐type Stimulants (ATS) Grants Program was established by the Australian 

Government in 2008 to enhance the capacity of non‐government organisations (NGOs) to respond to 

the rising demand of users of ATS. 

The aim of the program is to reduce the harms caused by ATS to individuals, their families and the 

Australian community. This is intended to be one‐off funding to allow NGO’s to cater for and treat 

ATS users, to attract ATS users into treatment and/or to increase referrals of ATS users into 

treatment services. 

It is expected that treatment interventions funded through the ATS Grants program should: 

1. Reduce and treat the use of illicit drugs. 

2. Be informed by evidence and use models of good practice. 

3. Reduce the risk of infectious disease. 

4. Improve physiological and psychological health. 

5. Reduce criminal behaviour and 

6. Improve social functioning. 

Odyssey House McGrath Foundation was successful in gaining funding support to develop a 

treatment protocol for people who are adversely affected due to their use of ATS. While the 

treatment protocol will be specific for use in the Therapeutic Community (TC) environment, it is 

anticipated that the protocol will also be useful in other treatment settings, and particularly within 

residential treatment environments. 

The project has been conceptualised in three stages: 

Stage 1: A literature review outlining background issues, problems associated with ATS use and 

current available treatment interventions. 

Stage 2: Consultation with members of the National Drug and Alcohol Research Centre and other 

research institutes with expertise in research on ATS. 

: Consultation with members of the Australasian Therapeutic Communities Association 

(ATCA) through forums organised at jurisdictional level, including New Zealand. 

Stage 3: Development of the treatment protocol for people dependent on ATS in a TC environment. 

This has been undertaken in two phases – the development of a draft protocol, trialled and 

evaluated within selected TCs; and the development of the final protocol following 

refinement through consultation and evaluation. 

The information on Stages 1 and 2, together with the results of the pilot evaluation and trial of the 

Treatment Protocol is contained in this document, Literature Review and Report of Consultations 

and Trial in the Development of a Treatment Protocol for clients of Therapeutic Communities. The 

Treatment Protocol for use by staff & clinicians working with ATS clients of Therapeutic Communities 

(Magor‐Blatch & Pitts, 2009) has resulted from the extensive consultations with those working with 

ATS clients in therapeutic communities in Australia and New Zealand, research institutes and others 

with expertise in research, clinical practice and the development of clinical interventions, and is 

contained in the second document provided within the materials in this treatment package. 

In the development of the protocol, we drew heavily on the collected information from 

consultations and other treatment manuals, interventions and guidelines and which have been 



developed within Australia and overseas in working with this client group. We are grateful to the 

researchers and authors who have provided permission for the use of this material. 

Lynne Magor‐Blatch MAPS, MCFP 

B.A. (Hum. & Soc.Sci.); M.Psych (Forensic); Grad.Dip.App.Psych. 

Dip.Teach. (Sec); Cert IV TAA 

Project Officer 



Section 1: 

Literature Review 





1. Amphetamine‐Type Stimulants : Background and issues 

Amphetamine‐Type Stimulants (ATS) are part of the psychostimulant group of drugs and include 

meth/amphetamine, ecstasy, cocaine and some pharmaceuticals (such as dexamphetamine and 

Ritalin). Methamphetamine comes in three common forms: powder (or ‘speed’), methamphetamine 

base (or ‘base’) and crystal methamphetamine (or ‘Ice’). Ecstasy is usually in tablet form and 

contains 3,4‐methylenedioxymethylamphetamine (MDMA) in varying amounts combined with other 

drugs such as meth/amphetamine 1 and ketamine (a general dissociative anaesthetic). In Australia, 

the main ATS used are methamphetamine and ecstasy (National Amphetamine‐Type Stimulant 

Strategy, 2008‐2011). 

ATS stimulate central nervous system activity by increasing synaptic concentrations of three major 

neurotransmitters in the brain: dopamine, serotonin (5‐HT) and noradrenaline (Rothman & 

Baumann, 2003). This has the effect of producing a euphoric sense of wellbeing, wakefulness and 

alertness. Use of ATS is also associated with a range of potentially negative health consequences, 

including increased heart rate, blood pressure, sleeplessness and reduced appetite. There is also 

greater risk of mental health issues, aggression, violence and accident resulting from unsafe 

behaviours, such as unsafe driving. 

Therefore methamphetamine use can be associated with a range of both positive and negative 

effects. Positive effects include: 

• euphoria; 

• increased libido; 

• alertness; 

• diminished appetite; 

• enhanced reflexes; and 

• feelings of confidence and physical strength (ACON, 2006). 

Negative effects include: 

• increased heart rate and irregular heart beat; 

• abdominal pain; 

• sweating; 

• dilated pupils; 

• fatigue; 

• parasitosis (picking and scratching skin); 

• agitation, anxiety and paranoia; 

• confusion, disorientation and hallucinations; 

• psychosis; and 

• violent and aggressive behaviour (ACON, 2006). 

Not all methamphetamine users can be considered dependent. Much of the literature around 

methamphetamine differentiates between regular and dependent users: 

• Regular users are people who use methamphetamines 1‐4 times per month, without their 

use interfering with their ability to function in their everyday life; and 

• Dependent users are usually individuals who use methamphetamine more than once a week, 

and exhibit symptoms of dependence. 

According to the Diagnostic and Statistical Manual of Mental Disorders IV‐TR (DSM‐IV‐TR) 

dependence is characterised by a person experiencing at least three of the following symptoms: 

1 Meth/amphetamine is used to refer to amphetamine and methamphetamine in instances where both forms 

are relevant. 



• tolerance, defined as either a need to use larger amounts to achieve desired effect, or 

decreased effect with continued use of the same amount of substance; 

• withdrawal; 

• increased dosage and duration of the substance use; 

• unsuccessful attempts to cut down or control substance use; 

• increased time spent to obtain the substance, use the drug or come down from the drug; 

• giving up social, occupational and recreational activities because of substance use; and 

• continued substance use despite knowledge of having an awareness of negative 

consequences (e.g., physical or psychological problems) (American Psychiatric Association, 

2000) 

As with any drug, users of methamphetamine may do so on an occasional, regular or dependent 

basis. What constitutes harmful substance use has been the subject of much debate. A traditional 

view has been that drug‐related harm is mostly related to drug dependence. While those who are 

dependent on substances generally do experience harm, it is now recognised that a wider 

perspective needs to be addressed. A useful model highlighting this broader perspective is provided 

by Thorley (1982). 

1.1 Prevalence: Australia 

Intoxication 

Regular use Dependence 

Figure 1. Thorley’s model of drug harm 

The Victorian Amphetamine‐type Stimulants (ATS) and Related Drugs Strategy 2007‐2010 Discussion 

Paper (2007), notes that while the use of ATS in the general community remains low, these drugs are 

now the second most commonly used illicit drugs after cannabis. 

The 2007 National Drug Strategy Household Survey (2008) reports 7.7% of males (0.7 million) and 

4.9% of females (0.4 million) over 14 years of age having tried meth/amphetamine over the course 

of their lifetime. Three percent of males and 1.6% of females aged 14 years and over had used 

meth/amphetamine for non‐medical purposes in the 12 months prior to the survey. A total of 6.3% 

of the general population has used meth/amphetamine. These figures translate to approximately 

1.1 million Australians having used meth/amphetamine in their lifetime. Just 2.3% of the population 

have used meth/amphetamine in the past 12 months. It is important to note that both recent and 

lifetime use of meth/amphetamine has dropped since the 2004 survey. These results are statistically 

significant (AIHW, 2008). 

Lifetime use of ecstasy is higher than meth/amphetamine use, at 8.9% of the population, and recent 

use is 3.5%. Therefore, approximately 1.5 million Australians have used ecstasy at some time in their 

life, and approximately 0.6 million have used ecstasy in the past 12 months. 



Table 1. Summary of drugs ever used/tried: proportion of the population aged 14 years or older, 

Australia, 1993 to 2007 

Ever tried (a) Ever used (b) 

Drug/behaviour 1993 1995 1998 2001 2004 2007 

(per cent) 

Tobacco 50.9 47.4 50.8 49.4 47.1 44.6# 

Alcohol 88.0 87.8 89.6 90.4 90.7 89.9# 

Illicits 

Marijuana/cannabis 34.7 31.1 39.1 33.1 33.6 33.5 

Pain‐killers/analgesics (c) n.a. 12.3 11.5 6.0 5.5 4.4# 

Tranquillisers/sleeping pills (c) n.a. 3.2 6.2 3.2 2.8 3.3# 

Steroids (c) 0.3 0.6 0.8 0.3 0.3 0.3 

Barbiturates 1.4 1.2 1.6 0.9 1.1 0.9 

Inhalants 3.7 2.4 3.9 2.6 2.5 3.1# 

Heroin 1.7 1.4 2.2 1.6 1.4 1.6 

Methadone (d) or Buprenorphine (f) n.a. n.a. 0.5 0.3 0.3 0.3 

Other opiates/opioids (c) n.a. n.a. n.a. 1.2 1.4 0.9# 

Meth/amphetamine (speed) (c) 5.4 5.7 8.8 8.9 9.1 6.3# 

Cocaine 2.5 3.4 4.3 4.4 4.7 5.9# 

Hallucinogens 7.3 7.0 9.9 7.6 7.5 6.7# 

Ecstasy (e) 3.1 2.4 4.8 6.1 7.5 8.9# 

Ketamine n.a. n.a. n.a. n.a. 1.0 1.1 

GHB n.a. n.a. n.a. n.a. 0.5 0.5 

Injected drugs 1.9 1.3 2.1 1.8 1.9 1.9 

Any illicit 38.9 39.3 46.0 37.7 38.1 38.1 

None of the above 8.0 8.1 6.7 7.5 7.9 8.2 

(a) Tried at least once in lifetime. 

(b) Used at least once in lifetime. 

(c) For non‐medical purposes. 

(d) Non‐maintenance. 

(e) This category included substances known as ‘Designer drugs’ before 2004. 

(f) This category did not include buprenorphine before 2007. 

Notes 

1. For tobacco, 1998, 2001, 2004 and 2007 figures represent proportions, of the population, who have smoked 

more than 100 cigarettes in their lifetime. 

2. For alcohol, figures represent proportions of the population who have consumed a full serve of alcohol. 

# Difference between 2004 result and 2007 result is statistically significantly (2‐tailed α = 0.05). 

Source: 2007 National Drug Strategy Household Survey (AIHW, 2008). 



A summary of drugs ever used in Australia from 1993 to 2007 is presented in Table 1 and reports on 

information from the 2007 National Household Survey of Drug Use (2008). Table 2 provides a 

summary of recent drug use. Note that the reported prevalence of substance use depends on the 

question that is asked. Asking whether a person has ever used a drug includes people who may have 

used in the past but no longer use, as well as people who used the drug on only one or a few 

occasions but did not progress to more regular use. This greatly inflates the perceived levels of drug 

use. Asking whether people have used a substance in the past 12 months gives a more current 

estimate of the level of use, although it still gives no indication of the amount of use. 

• In 2007, 44.6% Australians aged 14 years or older had smoked at least 100 cigarettes or the 

equivalent amount of tobacco in their lifetime, declining from the proportion in 2004 (47.1%). 

• In 2007, nine out of every ten (89.9%) people had consumed a full serve of alcohol in their 

lifetime. 

• Marijuana/cannabis had been used at least once by one‐third of Australians aged 14years or 

older in 2007 (33.5%). 

• Over one‐third of the population of Australians aged 14 years or older had ever used any illicit 

drug (38.1%) in 2007. 

It can be seen that in 2007 the overall drug use figures have changed, in some cases quite 

dramatically. Alcohol and tobacco remain the drugs most commonly ever used by the Australian 

community. There has been a significant decrease in both tobacco use (44.6%) and, very 

interestingly, alcohol (89.9%), although these drugs remain the most highly consumed by the 

Australian population. With the exception of marijuana/cannabis (33.5%), the proportion of the 

population who had used illicit drugs at some time in their life was relatively low. As noted 

previously, the use of meth/amphetamine has dropped significantly over the period between the 

two national household surveys, from 2004 to 2007. The illicit drugs which have seen increased use 

are inhalants, cocaine and ecstasy, together with the use non‐prescribed tranquillisers and sleeping 

pills. All these are at a statistically significant level. 

Figure 2 provides information on use by State and Territory from 2000‐2005. Highest use at this 

reporting period was reported in Western Australia, followed by ACT and Tasmania. 

Figure 2. Proportion of IDU reporting recent use of crystalline methamphetamine, by 

jurisdiction, 2000‐2005 (Stafford, Degenhardt, Black, Bruno et. al., 2006) 



Table 2 provides information in relation to recent use of drugs (in the last 12 months). As noted, 

there has been a statistically significant drop in the use of meth/amphetamine (2.3%) but a non‐ 

significant increase in the use of ecstasy (3.5%) and a significant increase in cocaine use (1.6%) and 

the non‐medical use of tranquillisers and sleeping pills (1.4%) (AIHW, 2008). 

Table 2. Summary of recent (a) drug use: proportion of the population aged 14 years or older, 

Australia, 1993 to 2007 

Drug/behaviour 1993 1995 1998 2001 2004 2007 

(per cent) 

Tobacco 29.1 27.2 24.9 23.2 20.7 19.4# 

Alcohol 77.9 78.3 80.7 82.4 83.6 82.9 

Illicits 

Marijuana/cannabis 12.7 13.1 17.9 12.9 11.3 9.1# 

Pain‐killers/analgesics (b) 1.7. 3.5 5.2 3.1 3.1 2.5# 

Tranquillisers/sleeping pills (b) 0.9 0.6 3.0 1.1 1.0 1.4# 

Steroids (b) 0.3 0.2 0.2 0.2 ‐‐ ‐‐ 

Barbiturates (b) 0.4 0.2 0.3 0.2 0.2 0.1 

Inhalants 0.6 0.6 0.9 0.4 0.4 0.4 

Heroin 0.2 0.4 0.8 0.2 0.2 0.2 

Methadone (c) or Buprenorphine (e) n.a. n.a. 0.2 0.1 0.1 0.1 

Other opiates/opioids (b) n.a. n.a. n.a. 0.3 0.2 0.2 

Meth/amphetamine (speed) (b) 2.0 2.1 3.7 3.4 3.2 2.3# 

Cocaine 0.5 1.0 1.4 1.3 1.0 1.6# 

Hallucinogens 1.3 1.8 3.0 1.1 0.7 0.6 

Ecstasy (d) 1.2 0.9 2.4 2.9 3.4 3.5 

Ketamine n.a. n.a. n.a. n.a. 0.3 0.2 

GHB n.a. n.a. n.a. n.a. 0.1 0.1 

Injected drugs 0.5 0.6 0.8 0.6 0.4 0.5 

Any illicit 14.0 17.0 22.0 16.9 15.3 13.4# 

None of the above 21.0 17.8 14.2 14.7 13.7 14.1 

(a) Used in the last 12 months. For tobacco and alcohol, ‘recent use’ means daily, weekly and less‐than‐weekly smokers 

and drinkers respectively. 

(b) For non‐medical purposes. 

(c) Non‐maintenance. 

(d) This category included substances known as ‘Designer drugs’ before 2004. 

(e) This category did not include buprenorphine before 2007. 

# Difference between 2004 result and 2007 result is statistically significantly (2‐tailed α = 0.05). 

Source: 2007 National Drug Strategy Household Survey (AIHW, 2008). 



A worrying trend related to substance use is that age of initiation into many types of substance use 

has decreased (AIHW, 2008). The most recent NHDS data from 2007 reveal that the average age of 

initiation of lifetime use tobacco and alcohol use is 15.8 years and 17.0 years, respectively. These 

both represent a decrease in age from previous years. For the most commonly used illicit drugs, the 

mean age of initiation to cannabis is 18.8 years (a slight increase on 2004 figures) and 20.9 years for 

amphetamine‐type substances. This is again a slight increase on 2004 figures. However, in line with 

the statistics on recent and lifetime use of drugs, the age of initiation for the non‐medical use of 

tranquillisers and sleeping pills and for cocaine has decreased. However, none of these changes is 

statistically significant (AIHW, 2008). 

Degenhardt, Coffey, Moran and colleagues (2007), in their findings from a large cohort study (1943 

adolescents aged 14‐15 years at recruitment) conducted over a ten year period, found 

approximately 7% of the sample had used amphetamines by age 17 years. By young adulthood, 

these amphetamine users were more likely to meet criteria for a range of drugs, have greater 

psychological morbidity and limitations in educational attainment. However, these problems were 

largely accounted for by even earlier‐onset cannabis use. This group was also more likely to have 

engaged in regular alcohol and tobacco use. 

1.2. Prevalence: New Zealand 

The Illicit Drug Monitoring System (IDMS) was first established in 2005 and is conducted annually to 

provide ongoing and timely information on changes in drug use and drug related harm in New 

Zealand (Wilkins, Girling & Sweetsur, 2008). The 2007 IDMS interviewed 324 frequent drug users, 

including 110 frequent methamphetamine users, 105 frequent ecstasy (MDMA) users and 109 

frequent injecting drug users in Auckland, Wellington and Christchurch using purposive sampling and 

snowballing (Biernacki & Waldorf, 1981; Watters & Biernacki, 1989). 

Information provided in the report shows that in 2007 the median age of users in the sample was 28 

years (mean 30 years old, range 16‐58 years old). Frequent ecstasy (MDMA) users were younger 

than either the frequent methamphetamine users (23 years old vs. 31 years old, p

120% 

100% 

80% 

60% 

40% 

20% 

0% 


26% 31% 36% 31% 

74% 69% 64% 69% 

Meth Ecstasy IDU All 

Figure 3. Frequent drug users by gender, 2007: New Zealand 

Source: Wilkins, Girling & Sweetsur (2008). 

In 2007, the drug types most commonly injected by the frequent methamphetamine users in the 

past six months were heroin (100%), other opiates (77%), Ritalin (62%), methadone (59%), 

methamphetamine (35%) and crystal methamphetamine (34%). There was no statistically significant 

change among the frequent methamphetamine users with respect to the level of injection of drug 

types in 2007 compared to 2006 (Wilkins, Girling & Sweetsur, 2008). 

The recently released (February 2009) Research Bulletin from Massey University, Centre for Social 

and Health Outcomes Research and Evaluation (SHORE) provides further analysis of the 2006 and 

2007 IDMS data. A total of 642 frequent drug users were interviewed for the 2006 and 2007 IDMS, 

including 224 frequent methamphetamine users, 216 frequent ecstasy (MDMA) users and 202 

frequent injecting drug users. Of the frequent users, 29% were aged 16 to 24 years (N=66) and 71% 

were aged 25 years or older (N=158). Most of the frequent methamphetamine users were polydrug 

users and older methamphetamine users (over 25 years) were more likely to use on a greater 

number of days in comparison to younger users (52 days vs. 26 days, p=0.0039) (Wilkins, Sweetsur & 

Griffiths, 2009). 

Drug types used by frequent methamphetamine users in the past six months for the combined 

sample are provided in Table 4. 

1.3. Harms resulting from drug use: New Zealand 

Female 

Male 

The 2007 IDMS survey sought information in relation to the harmful impact to areas of the person’s 

life as a result of their drug use. Areas nominated were: Health, Energy and Vitality; Relationships 

and social life; Financial position; Home life; Work and study life; Life opportunities; and legal/police 

problems. Most of the frequent methamphetamine users reported experiencing harm in at least 

one area of their life, with ‘Energy and vitality’ (80%) and ‘Financial position’ (80%) most highly 

endorsed. 

Not surprisingly, according to the report, older users were more likely than younger users to report 

harms resulting from drug use, with Health the only area in which younger users were more likely to 

report harm, although the difference was only slight (77% compared to 76%). However, ‘Life 



opportunities’ was the area in which older methamphetamine users were more likely than younger 

users to report harm associated with their drug use (70% vs. 47%, p=0.0440). This is the only area 

which was statistically significant (Wilkins, Sweetsur & Griffiths, 2009). 

Table 3. Drug types used by frequent methamphetamine users in past six months by age (2006 

and 2007 samples combined) 

Frequent methamphetamine Frequent methamphetamine 

DRUG TYPE users under 25 years (n = 66) users 25 years or older (n = 158) 

Methamphetamine 97% 99% 

Alcohol 94% 78%* 

Cannabis 92% 84% 

Tobacco 86% 80% 

Ecstasy (MDMA) 62% 46% 

Ice (Crystal Meth) 56% 70%* 

BZP Party Pills 52% 30%* 

LSD 50% 27%* 

Nitrous Oxide 32% 14%* 

Mushrooms 24% 16% 

Ritalin 21% 23% 

GHB 18% 13% 

Amphetamine 15% 26% 

Benzodiazepines 15% 34%* 

Antidepressants 14% 8% 

Opioids 14% 29%* 

Cocaine 12% 8% 

Ketamine 12% 9% 

MDA 11% 4% 

Amyl nitrate 11% 11% 

Methadone 5% 27%* 

Solvents 2% 2% 

Heroin 2% 9%* 

* Statistically significant at the 0.05% level 

Source: Wilkins, Sweetsur & Griffiths (2009). 

Life problems were also highlighted in the IDMS study, with frequent users (both older and younger) 

most likely to endorse ‘Argued with others’; ‘Lost your temper’; ‘Had reduced work/study 

performance’ (with younger users noting this as more of a problem than older users: 77% vs. 64%); 

‘Did something under the influence of drugs and later regretted it’. Areas of statistical significance 

were ‘Damaged a friendship’ with older users more likely than younger users to nominate this (74% 

compared to 47%, p=0.0120) and ‘Going into debt’, which was once again more likely to be reported 

as an issue by older users (69% vs. 47%, p=0.0460). Younger users were more likely to report ‘Had a 

car crash’ and this was statistically significant (31% vs. 12%, p=0.0364) (Wilkins, Sweetsur & Griffiths, 

2009). 

In order to further investigate the possibility of the existence of regional variation in drug use, the 

combined findings from the 2006 and 2007 IDMS were examined for variations in drug use between 

the sites examined. Table 5 presents the information about frequent drug users by location: 

Auckland, Wellington and Christchurch (Wilkins, Sweetsur & Girling, 2008). 


Table 4. Frequent drug users by location in New Zealand 

Frequent drug 

user type 

Methamphetamine 

users 

Ecstasy (MDMA) 

users 

Injecting drug 

users (IDU) 

Auckland 

(n=290) 

Source: Wilkins, Sweetsur & Girling (2008). 

1.4. Use of ATS 


Wellington 

(n=161) 

Christchurch 

(n=191) 

Combined 

(n=642) 

54% 21% 18% 35% 

35% 49% 19% 34% 

11% 30% 63% 31% 

The ways in which people take ATS, i.e., the route of administration, will be influenced by the type of 

ATS used. All forms of methamphetamine can be smoked. Amphetamine powder is usually snorted, 

while base methamphetamine is commonly swallowed. Both base and crystal methamphetamine 

can be injected, and injecting is most commonly associated with dependence (McKetin, Kelly & 

McLaren, 2006). 

As alcohol and other drug use may impair judgement and increase the likelihood of impulsivity, 

people with co‐occurring disorders are also likely to be more at risk to themselves and others. While 

this may result from accidental harm, there is also a strong link between AOD use and suicidality, 

especially if the AOD use is overlayed with a mental health condition (McCloud, Barnaby, Omu, 

Drummond & Aboud, 2004; Lee, Jenner, Kay‐Lambkin, Hall, et. al., 2007). 

The National Amphetamine‐Type Stimulant Strategy, 2008‐2011 (NATSS) (2008), details the groups 

and contexts of use that may be associated with particular risks. These include: 

• Young people up to age 18 years where early engagement in drug use is associated with a 

range of problems due to increased vulnerabilities from using at a developmentally young 

age. This may lead to increased risk of dependence, other drug use, mental health problems 

and involvement in criminal activity. These issues may be exacerbated if the young person 

has less access to support services. 

• People with mental health problems. ATS has been found to exacerbate existing 

vulnerabilities and problems and compromise effective mental health interventions, for 

example, some medications may be contra‐indicated for people who have a history of ATS 

dependence (NATSS, 2008). Mental health problems may also result from regular ATS use, 

even where there is no previous vulnerability. 

• Gay, lesbian, bisexual and transgender people have higher rates of drug use, including ATS, 

when compared to the wider community, although they are under‐represented within 

treatment services. This raises the issue of barriers to treatment for people from these 

communities. 



• Some industries have higher rates of usage than others – particularly hospitality, 

construction and transport industries. 

• Diversion to others of the prescribed medications, dexamphetamine and Ritalin, or misuse 

by those for whom the medication has been prescribed. There is also some suggestion that 

ATS use may occur as a result of self‐medication for undiagnosed ADHD. 

• Use by Indigenous Australians appears to be more prevalent in metropolitan regions, and in 

rural centres which are close to mining communities. 

The diversity in risk groups suggests that treatment interventions are needed to target both the 

range and contexts of ATS risk. At the same time, there are a number of common risk and protective 

factors that may be seen as predictive of a range of issues, including conduct disorders, mental 

health problems, poor educational performance and substance use. 

These are set out in Table 5: 

Table 5. Major risk and protective factors for harmful substance use across the lifespan 

Prior to 

birth 

Social 

disadvantage 

Family 

breakdown 

Genetic 

influences 

Maternal 

smoking & 

alcohol use 

Birth outside 

Australia 

Infancy/ 

Preschool 

Parental 

neglect & 

abuse 

Easy 

temperament 

Primary 

school (5‐ 

11 years) 

Early school 

failure 

Conduct 

disorder 

Aggression 

Social and 

emotional 

competence 

Shy & 

cautious 

temperament 

Secondary school 

(12‐17 years) 

Risk factors 

Low involvement in activities 

with adults 

Perceived high level of 

community drug use 

Community disadvantage & 

disorganisation 

Availability of drugs 

Positive media portrayal of 

drug use 

Parent‐adolescent conflict 

Favourable parental attitudes 

to drug use 

Parental AOD problems 

Parental rules permitting drug 

use 

Not completing secondary 

school 

Peers who use drugs 

Delinquency 

Sensation seeking & 

adventurous personality 

Favourable attitude toward 

drug use 

Protective factors 

Attachment to family 

Low parental conflict 

Parental communication and 

monitoring 

Religious involvement 

Source: Loxley, Toumbourou, Stockwell, Haines, et. al., (2004) 

Adulthood 

(18‐64 

years) 

Frequent 

drug use in 

late 

adolescence 

Unemployment 

in early 

adulthood 

Mental 

health 

problems 

Well managed 

environment 

for alcohol 

use 

Marriage in 

early 

adulthood 

Retirement/ 

old age 

(65+ years) 

Losing a 

spouse 

Loneliness & 

reduced social 

support 



Adolescence is a time of experimentation, exploration, curiosity and identity search, part of which 

may involve some risk‐taking behaviour. Substance use is often part of this developmental process, 

particularly within a milieu of social and peer influence and expectancies (Howard, Stubbs & Arcuri, 

2007). When surveyed, young people cite boredom, curiosity, the desire to have fun, and wanting to 

feel good, as the main reasons for commencing substance use (Howard, 1994; Howard & Zibert, 

1990; Spooner, Mattick, & Howard, 1996). 

As Moore and Saunders (1991) have noted, "the use of drugs in some social settings is part of the 

social construction of meaning for individuals and groups" and that substance use is "almost always 

functional" (Moore & Saunders (1991:30). 

Table 6. Key determinants of risk for young people 

Individual 

Factors 

Age and developmental 

stage 

Mental health 

Alcohol and other 

drug use 

Gender & sexuality 

Sexual health 

Determinants 

‐ 12 – 15 y/o 

‐ 16 – 18 y/o 

‐ 19 – 25 y/o 

‐ Anxiety 

‐ Depression 

‐ Eating disorders 

‐ ADHD & hyperactivity disorders 

‐ PTSD (childhood sexual abuse, refugee torture and trauma) 

‐ Gambling 

‐ Obsessive compulsive disorder 

‐ Phobias 

‐ Schizophrenia 

‐ Self‐harm and suicidal behaviour 

‐ Alcohol 

‐ Tobacco 

‐ Cannabis 

‐ Caffeine and over the counter preparations (OTC) 

‐ Benzodiazepines 

‐ Meth/Amphetamines 

‐ Ecstasy 

‐ Cocaine 

‐ Ketamine 

‐ GHB 

‐ Hallucinogens/LSD 

‐ Inhalants/volatile substances 

‐ Opioids (e.g. heroin) 

‐ Polydrug use 

‐ Issues for female/male 

‐ Heterosexual 

‐ Bisexual 

‐ Gay/Lesbian/Transgender 

‐ Risky sexual behaviour 

‐ Contraception 

‐ Sexually transmitted diseases 

‐ Sexuality and sexual identity 

‐ Sexual assault 

‐ Unwanted pregnancy 

‐ Termination of pregnancy 

‐ Perinatal mental health 

‐ Parenting information for young parents 



Most young people who initiate substance use will not develop significant problems. 

Experimentation and a variable pattern of onset and termination are therefore common (Newcomb 

& Bentler, 1989). However, the aetiologies of substance use initiation, occasional use, regular use 

and dependency may be different (Hawkins, Lishner, Catalano, & Howard, 1985). Hence it is 

possible that some young people may be more likely to experiment, to experiment earlier, and to 

find such experimentation rewarding. Young people who maintain and escalate their use are 

believed to be more vulnerable to the presence of more problematic backgrounds and lack adequate 

and accessible internal and external resources (Howard, et.al., 2007). 

1.5. Problems associated with ATS use 

The number of recorded hospital separations 2 for people with drug‐induced psychosis as the primary 

problem among those aged 10–49 years increased from 55.5 per million population in 1993–1994, to 

253.1 per million population in 2003–2004. In 1999‐2000, the total number of hospital bed‐days for 

amphetamine‐induced psychosis was 5,679, increasing to 8,068 in 2003‐04. In 2004/05 there were 

15,000 recorded drug treatment episodes for amphetamine or methamphetamine (AIHW, 2006). 

Amphetamines accounted for the largest proportion of all drug‐induced psychosis separations from 

1999–2000 to 2003–2004, ranging from 41% in 1999–2000 to 55% in 2003–2004, while cannabis 

accounted for 39%–45% of separations over this period (Degenhardt, Roxburgh, & McKetin, 2007). 

The number of both cannabis‐ and amphetamine‐induced psychosis separations per million 

population was highest among the 20–29‐year age group, while age‐specific rates among the 10–19‐ 

year age group were lower for amphetamine‐induced psychosis than for cannabis‐induced psychosis 

(41.6–61.9 and 80.5–111.1 separations per million population, respectively). Data collected over this 

period also showed that age‐specific rates for cannabis‐induced psychosis remained relatively stable 

across all age groups, compared with steady increases for amphetamine‐induced psychosis 

(Degenhardt, et.al., 2007). While some of these presentations will remit, others will clarify into a 

diagnosis of schizophrenia (Howard, et.al., 2007). 

Increasing doses of ATS may exacerbate the risk and severity of problems, both in terms of physical 

and mental health. There is growing evidence about a range of problems, including: 

• Cardio‐vascular problems, including hyper‐ and hypotension, increased heart rate and 

irregular heart‐beat; 

• Risk of cardio‐vascular and cerebro‐vascular crises, such as stroke, in vulnerable individuals; 

• Mental health problems, including confusion, paranoia, anxiety, depression and psychosis; 

• The likelihood of developing a dependency, especially associated with injecting ATS and 

smoking crystalline forms of methamphetamine; 

• Risk of blood‐borne viruses (e.g., Hepatitis C and HIV); 

• Low levels of concentration; 

• Cognitive impairment; 

• Poor eating habits, often resulting in poor general health; 

• Sleep disorders, tiredness and fatigue; 

• Agitation, aggression and violence; 

• Increased impulsivity and risk taking; 

• Social and family disruption; and 

• Accident and injury resulting from the above conditions (NATSS, 2008). 

2 Hospital separations refer to the reason for a patient’s stay in hospital based on their medical records after 

treatment has been completed, rather than the reason for admission. 



A large proportion of ATS dependent users will experience psychological problems. These will 

include depression, anxiety and psychosis. Meth/amphetamine intoxication, particularly where 

there is simultaneous use with alcohol and other drugs, often results in agitation and aggression and 

will impact on frontline workers and families. This leads to significant resource implications for 

workers and organisations, including law enforcement, mental health and alcohol and other drug 

(AOD) services. The impact on families may also be dramatic, raising the need to support all family 

members as well as the person using ATS. 

Kaye, Darke, Duflou and McKetin (2008) found a total of 371 cases from the National Coronial 

Information System (NCIS) from between 1 July 2000 and 30 June 2005, in which methamphetamine 

was listed as the cause of death. The mean age of decedents was 32.7 years: 77% were male and 

35% were employed. Route of administration was predominantly by injection (89%). In 89% of 

cases other drugs were also detected, and most commonly benzodiazepines (41%) and morphine 

(36%). Deaths were overwhelmingly accidental, with 14% determined to be suicides. 

1.6. Substance use and mental health problems 

In addition to its being a time of experimentation and exploration, late adolescence to early 

adulthood is also a time during which some serious but treatable mental disorders may initially 

present (for example, schizophrenia and bipolar mood disorder, especially for males, and 

depression, especially for females; Burke, Burke, Regier, & Rae, 1990). Substance use may develop 

prior to, concurrently with, or following the onset of a comorbid psychiatric disturbance, creating an 

additive or cumulative two‐way interaction between psychiatric symptoms and substance use 

(Friedman, Utada, Glickman, & Morrissey, 1987; Greenbaum, Prange, Friedman, & Silver, 1991; 

Tarter, 1990). 

For people who are developing, or who have developed a mental disorder, relief may be sought in 

substance use (Howard, et. al., 2007). Some people appear to self‐medicate to relieve symptoms of 

mental disorders, and while this may assist to some extent in relieving negative thoughts and 

feelings, it is likely to be less effective for the positive symptoms of psychosis. People will also use 

substances to experience euphoria, to relax, to alleviate boredom, to fit in and socialize, and to feel 

‘normal’ (Howard, et. al., 2007; Mueser, Bellack, & Blanchard, 1992). This is the case both for people 

with a mental health problem, and for those who are not experiencing a co‐occurring problem. 

Mental disorders can be associated with an earlier onset and more problematic course of substance 

dependency, and are significant predictors of a negative substance use outcome (Carey, 1996; 

Morris & Wise, 1992; Wade, Harrigan, McGorry, Burgess, & Whelan, 2007). Substance use by those 

with a mental health disorder can also precipitate and/or exacerbate symptoms and increase the risk 

for suicide (Mueser, et.al., 1992; NSW Health, 2000). 

Studies consistently indicate more negative outcomes for adolescents with comorbid issues (Baker, 

Bucci, Lewin, Richmond, & Carr, 2005), with those with comorbid disorders having earlier onset of 

substance use, greater frequency of substance use, and more chronic use than those without 

comorbid disorders (Rowe, Liddle, Greenbaum & Henderson, 2004). Also noted in most studies 

focusing on the impact of first onset psychosis and depression, are increases in family difficulties, 

stigma, discrimination, homelessness, involvement in the juvenile/criminal justice system, and 

decreased competence, support, social responsiveness, education and employment participation, 

and compliance with treatment (Howard, et. al., 2007; Davis 2003; NSW Health, 2000). Delays in 

getting suitable treatment can exacerbate problems for the person, their family, carers, and service 

providers (Lines, 2000; Sung, Erkanli, Angold, & Costello, 2004). 



People with mental illness are much more vulnerable to the adverse effects of a whole range of 

drugs. Hence people with schizophrenia who use cannabis (for example) have: 

• higher rates of admission to hospital; 

• higher doses of medication; 

• higher rates of unemployment, suicide, and imprisonment; and 

• more severe mental health problems. 

Illicit drugs and alcohol can also interfere with the way in which prescribed medications work, and 

increase the risk of side effects. In particular, alcohol can affect the rate of metabolism and cannabis 

use may result in the person’s prescribed medication needing to be increased to provide a 

therapeutic benefit. 

It is generally accepted that rates of substance use are higher among those with mental illness 

compared to those without, and that people who use illicit drugs are more likely to experience 

mental illness than non‐users. Results from the National Drug Strategy Household Survey 2004 

(AIHW, 2007) show that almost two in five persons who used an illicit drug in the past month 

reported high or very high levels of psychological distress. The most common mental health 

problems experienced by people who use illicit drugs are anxiety and mood disorders. Of particular 

concern is the association between ATS, cannabis and mental health problems, particularly in young 

people. 

While it cannot be implied that cannabis use causes schizophrenia in people who would otherwise 

not have developed it, there is good epidemiological evidence of a significant association between 

cannabis use and the risk of meeting criteria for schizophrenia (Degenhardt & Hall, 2002). There is 

also good evidence to suggest that cannabis use is a more important risk factor for psychotic 

symptoms among those with a family history of, or pre‐existing, schizophrenia (Degenhardt, et.al., 

2007). Additionally, there is concern regarding the association between cannabis and ATS, especially 

methamphetamine, with increased admissions of young people to acute psychiatric facilities with 

apparent psychosis (Degenhardt, et.al., 2007). 

Survey data from the 2005 report, Australian Secondary School Students’ Use of Over‐the‐Counter 

and Illicit Substances, showed that 95% of secondary school students had never used 

amphetamines, including methamphetamines and ice (White & Hayman, 2006). Amongst all 

students surveyed around 1% indicated that they had used amphetamines regularly in the year prior 

to the survey. Although the data shows a low usage rate in school students, with increasing age, the 

proportion of students to have ever used amphetamines increases (3% of 12‐year‐olds; 8% of 16‐ 

year‐olds and 7% of 15‐ and 17‐year‐olds). Therefore, the pattern of amphetamine type substance 

use in young people suggests a low level of experimentation with the drug and with very few 

reporting recent use (White & Hayman, 2006). However, illicit and licit drug use in young people is 

associated with serious road crashes, problems with drug misuses and dependence and future 

polydrug use (Nicholas & Shoobridge, 2005). 

1.7. Maternal and foetal health 

Methamphetamine use in pregnancy has been associated with increased risk of miscarriage, 

premature birth and problems in the newborn period. Babies born to mothers who are 

methamphetamine users may also exhibit signs of withdrawal (OTIS, 2005). This includes jitteriness 

and trouble sleeping and eating (OTIS, 2005). There have also been cases of birth defects, including 

heart defects and cleft lip/palate, in exposed babies, but researchers do not yet know whether the 

drug contributed to these defects (Smith, LaGasse, Derauf, Grant, et.al., 2006). 



As most methamphetamine users are also polydrug users, including alcohol and cigarettes, the 

effect on the foetus can be multi‐fold (OTIS, 2005). A 2006 study found that babies of women who 

used methamphetamine were more than three times as likely as unexposed babies to grow poorly 

before birth (Smith, et.al., 2006). Even when born at term, affected babies tend to weigh less than 

about 5 pounds (2.27 kgs) and have a smaller‐than‐normal head circumference. 

However, as there are limited studies in this area, there is no known safe level of methamphetamine 

use during pregnancy and the magnitude of defects associated with methamphetamine use during 

pregnancy is unknown (OTIS, 2005; March of Dimes, 2004). 




2. Therapeutic Communities 


The Australasian Therapeutic Communities Association (ATCA, 2007), with member agencies in 

Australia and New Zealand, provides the following definition of a Therapeutic Community: 

A Therapeutic Community is a treatment facility in which the community itself, 

through self‐help and mutual support, is the principal means for promoting personal 

change. 

In a therapeutic community, residents and staff participate in the management and 

operation of the community, contributing to a psychologically and physically safe 

learning environment where change can occur. 

In a therapeutic community, there is a focus on the biopsychosocial, emotional and 

spiritual dimensions of substance use, with the use of the community to heal 

individuals and support the development of behaviours, attitudes and values of 

healthy living. 

Therapeutic communities (TC) were first established in the United Kingdom and United States more 

than 50 years ago, coming from two different models, but converging in practice during the 1970s. 

In general, TCs are illicit drug and alcohol‐free residential settings that use a hierarchical model with 

treatment stages that reflect increased levels of personal and social responsibility (NIDA, 2002). In 

the UK, and especially within prison and youth TCs, a democratic model is also used. These have 

some important differences to the more usual hierarchical model most commonly employed within 

US and Australasian TCs (Rawlings, 1999). 

2.1. Program context 

The Australian and New Zealand experience have some important differences to the overseas model, 

and particularly the USA experience, since each are developed within a harm minimisation 

framework. Therefore, an important component of Australian and New Zealand TCs is the 

development of harm minimisation strategies, including education, designed to reduce the risk to the 

person, their family and the broader community. 

ATCA member agencies are cognisant of the public health risks of transmission of HIV and in 

particular of Hepatitis C (HCV) and the need to include safe sex, safe needle use and health education 

messages to clients. While TCs generally have a goal of abstinence from alcohol and illicit drugs, this 

is promoted within the context of reducing harm, including harmful use of alcohol. In Australasia, 

TCs generally consider that an abstinence‐based program does not preclude prescribed medication. 

Many residents and clients of TCs will be on anti‐depressant, anxiolytic or anti‐psychotic medications, 

and some may also be on stable or reducing doses of pharmacotherapies (methadone and 

Buprenorphine). 

TCs differ from other treatment approaches principally in their use of the community, comprising 

treatment staff and those in recovery, as key agents of change. This approach is referred to as 

‘community as method’. TC members interact in structured and unstructured ways to influence 

attitudes, perceptions, and behaviours which are considered to be associated with substance use. In 

addition to the importance of the community as a primary agent of change, a second fundamental 

TC principle is ‘self‐help’. Self‐help implies that the individuals in treatment are the main 

contributors to the change process. 



Wexler (1995) suggests that the major goal of a TC for a substance using population is to alter 

fundamental negative beliefs about oneself and one’s unhealthy lifestyle and to develop a greater 

sense of self‐efficacy and control through increased responsibility. In defining TCs for substance 

users, De Leon (1995) suggests that TCs “…provide a total environment in which transformations in 

the drug users’ conduct, attitudes and emotions are fostered, monitored and mutually reinforced by 

the daily regimen” (cited in Gowing, Cooke, Biven & Watts, 2002: 41). 

Over the past 50 years the therapeutic community has gained recognition as an effective 

intervention approach for a range of client groups. These include substance users in a variety of 

settings, including community and prison‐based programs; families with children and adolescents. 

This has resulted in the traditional TC approach being tailored to meet the specific needs of each of 

these population groups. In the United States, the TC modality has been divided into three sub‐ 

categories: 

• Traditional TCs (1‐3 years duration), which are defined by a goal of total re‐socialisation, 

and which place high demands on residents, utilising confrontational methods and 

imposing sanctions for behaviour modification; 

• Modified TCs (6‐8 months duration), which are characterised by a goal of developing 

practical skills, and which place moderate treatment demands and sanctions on residents. 

These TCs include programs targeted at specific groups or treatment needs (e.g., drug 

using mothers, adolescent drug users, clients with comorbidity or co‐occurring disorders). 

Modified TCs have been shown to be particularly effective in correctional institutions 

(McCollister & French, 2000); and 

• Short‐term TCs (3‐6 months duration), which are distinguished by a goal of providing skills 

to allow the client to survive in society and re‐establish family relationships, and which 

place moderate to high treatment demands upon residents. 

Hence, while TCs were originally based around lengthy periods of stay, in the past two decades 

short‐term residential and outpatient programs have been developed. There is also a continuing 

trend for both TCs and 12‐step approaches to be used in conjunction with other treatment 

approaches (both pharmacological and psychosocial). 

In 2002 the ATCA published Towards Better Practice in Therapeutic Communities (Gowing, et.al., 

2002) and included in that document an extensive outline of the essential elements of therapeutic 

community programs in Australia and New Zealand. In 2003, a set of Service Standards for TCs were 

developed, and at that time formed the basis of the ATCA accreditation process. This process is 

currently being redefined through the National Standards for Therapeutic Communities (AOD), a 

project which is developing standards for TCs through funding from the Australian Government’s 

Department of Health and Ageing. These standards will fit within a national framework. 

Shine and Morris (2000) in their review of the Grendon Programme (a prison‐based TC in the United 

Kingdom) highlight three issues that they consider are ‘crucially important’ to the continued use of 

TCs as an intervention model for substance users: 

1. That therapeutic communities need to be responsive to the evolving organisational 

environments in which they are established. 

2. Therapeutic communities need to be pro‐active in their approach to exploring and 

implementing evidence‐based practice. 

3. There is a need for therapeutic communities to develop and ascribe to theoretical models of 



change, which are distinctively based on the therapeutic community intervention modality. 

2.2. Treatment outcomes 

Good outcomes from TC treatment are strongly related to treatment duration, which are most likely 

a result of benefits derived from the underlying treatment process. Clients who complete at least 90 

days of treatment in a TC have significantly better outcomes on average than those who stay for 

shorter periods (NIDA, 2002). For individuals with many serious problems (e.g., polydrug use, co‐ 

occurring disorders, criminal involvement, mental health disorders, and low employment), research 

again suggests that outcomes were better for those who received TC treatment for 90 days or more 

(Simpson, Joe & Brown, 1997) 

Gowing, et.al. (2002) in Towards Better Practice in Therapeutic Communities, reviewed the research 

literature on TCs and found that between 30% ‐ 50% of those entering a program remain in 

treatment at the three month mark, although about one‐third of people who drop out of treatment 

prematurely, seek readmission (NIDA, 2002). Reported median or mean lengths of stay ranged from 

54 to 100 days. This supports the need for TCs to be linked with other treatment approaches, 

including short‐term programs, outreach and aftercare, to ensure there are alternatives available for 

those who are unable to complete a lengthy residential program. 

In the TC, the level of treatment engagement and participation is related to retention and outcomes. 

Treatment factors associated with increased retention include having a good relationship with one’s 

primary counsellor, being satisfied with the treatment, and attending education classes. Important 

attributes linked to treatment retention include self‐esteem, attitudes and beliefs about oneself and 

one’s future, and readiness and motivation for treatment. Retention can be improved through 

interventions to address these areas. External factors related to retention include level of 

association with family or friends who use drugs or are involved in crime, and legal pressures to 

undertake treatment (NIDA, 2002). 

As the TC has become modified, including changes to program content and expected length of 

residency, there has been a great deal of debate as to what are the essential elements which define 

the TC, and therefore what are the elements that must be retained. Research indicates that 

modified TC programs show greater emphasis on professional staff as opposed to recovering staff, 

or paraprofessionals. This may also have lead to a corresponding reduction in reliance on 

‘community as method’ as well as reductions in group therapy (Melnick & De Leon, 1999; Melnick, 

De Leon, Hiller & Knight, 2000). It is also possible that a perceived shift from group to individual 

therapy has been the result of more complex presentations to the TC, particularly in relation to 

mental health issues. 

The question of what cannot be changed in the TC was first debated in the professional arena at a 

1991 meeting of the European Federation of Therapeutic Communities (EFTC). In response to this 

question, a number of recommendations were developed to inform the establishment of future TC 

programs (Broekaart, Kooyman & Ottenburg, 1993: 61‐62). These upheld the need to maintain self‐ 

and mutual‐help as pillars of the therapeutic process, in which the resident is the protagonist 

principally responsible for achieving personal growth towards a more meaningful and responsible 

life and upholding the welfare of the community. 

2.3. Young people 

Stubbs, Hides, Howard and Arcuri (2004) raise the issue of the appropriateness of residential 

treatment for young people, noting earlier research (Howard & Arcuri, 2003) which found that 



clients presenting to residential treatment with psychostimulant dependence were not dissimilar to 

those presenting with a primary dependence of alcohol or heroin. This was despite the fact that 

retention rates for young people presenting with psychostimulant use were low, with close to 60% 

leaving in the first 30 days of a 90 day program. 

However, clients presenting with psychostimulant use who completed at least six weeks of the 12 

weeks program, showed significantly less drug use from a self‐reported pre‐treatment baseline, at 

three‐month follow‐up. This is an important result, since psychostimulant users were more likely to 

have reported with greater mental and physical health problems, more financial problems, and in 

the three months prior to treatment, were more likely to have experienced a drug overdose, 

committed more property and person crimes and had more sexual partners (Stubbs, et.al., 2004). 

Similar results were found in an American study of young people admitted to a residential 

therapeutic community (Hawke, Jainchill & DeLeon, 2000). 

As with adult populations, residential treatment options are not indicated for clients with low to 

moderate levels of substance use/dependence (other than semi‐supported or short‐term residential 

programs of less than three months). Clients with severe substance misuse or dependence, usually 

requiring detoxification, and who have elevated health concerns (including mental health) and few 

social supports, may benefit from a modified therapeutic community program. This should include a 

range of interventions such as motivational interviewing, harm reduction strategies, cognitive 

behavioural therapies, family therapy and skills training (Stubbs, et.al., 2004). 

2.4. Correctional populations 

As drug abuse and crime are often linked, many people with substance dependencies are involved 

with the criminal justice system. Furthermore, international research indicates that chronic drug 

users are found in the greatest concentration in incarcerated populations (Chaiken, 1989; Leukefeld 

& Tims, 1988). In addition, the link between meth/amphetamine use and violence increases the 

likelihood of people with ATS related problems being in the criminal justice system. Information 

from the Australian Institute of Criminology Drug Use Monitoring in Australia (DUMA) collected 

between 2000 and 2002, showed Perth had the highest number of male detainees in Australia 

testing positive to amphetamines (33%‐42%), followed by Adelaide (31%‐38%), Southport (26%‐33%) 

and Brisbane (21%‐29%) (Jenner & McKetin, 2004). 

Since the 1960s, TCs have increasingly been established in prison settings, primarily in the UK and 

USA, which is where some of the most extensive research studies on TCs have been conducted. 

These studies have found benefits for prison‐based TC treatment in preparing inmates to return to 

the community and for creating a safer, better managed prison environment. Drug‐involved 

offenders have the best outcomes when they participate in community‐based TC treatment while 

transitioning from incarceration to re‐entry to the community (Leukefeld & Tims, 1988; Chaiken, 

1989; Rawlings 1999). 

In recent years prison‐based TCs in Australia and New Zealand have become members of the ATCA 

has accepted , as has CareNZ, which operates a number of prison TCs in New Zealand, and other 

prison TC programs are being established. Therefore, it is important to consider the needs of clients 

within these settings in the development of a treatment protocol for clients with ATS dependencies. 


3. Treatment approaches 


There are a number of significant challenges in treating ATS dependence and related problems. The 

evidence‐base to support the development and implementations of specific interventions has been 

limited, especially when compared to other substances, and particularly tobacco, alcohol and 

opiates. There is limited evidence to inform treatment protocols for managing withdrawal, there is a 

limited range of pharmacotherapies, and for treatment services, there may be a compounding need 

to address mental health issues associated with ATS use. 

The National Amphetamine‐Type Stimulant Strategy 2008‐2011 (2008) has identified a number of 

issues in relation to treatment interventions. Effective treatment for ATS problems will depend on 

the development of an evidence base, good access to treatment, and workforce and organisational 

development. It is noted that: 

• Many people affected by ATS use are poorly connected with services and retention rates are 

therefore low; 

• Many of the treatments used for other drug related problems have relevance for people 

affected by ATS use. However, there are gaps in knowledge about ATS specific withdrawal 

and treatment strategies; and 

• The infrastructure to support effective responses to ATS related problems is limited in some 

areas. This includes the lack of coordination of response among services, including law 

enforcement, AOD specialists and other health (including mental health) networks. 

Different strategies are needed to address the broad range of needs, contexts and patterns of use 

and related problems. These are outlined in Table 7: 

Table 7. Range of responses for diverse target groups 

TARGET GROUP RESPONSE 

The broad community Inform about ATS use and related problems 

Parents Inform about risks of ATS use, how to prevent such use, how to identify 

problems in their children and how to respond to problems as they arise 

Those at risk of using Prevent use. Build protective factors and reduce/address risk factors (e.g., 

in broad community; in school and TAFE/university communities) 

Those who use occasionally Design innovative strategies to access population group and to inform 

these groups of risks and how to seek advice and assistance. Provide 

opportunistic and brief interventions. Address contextual factors that 

influence use and increase risk 

Regular/Problematic users Address problems. Enhance access to treatment and retain in treatment 

Source: National Amphetamine‐Type Stimulant Strategy 2008‐2011 (2008): 11. 

Given the fact that therapeutic communities traditionally work with clients for whom substance use 

has become problematic and entrenched, it is particularly the last group, the regular/problematic 

users, who will be particularly targeted through therapeutic community, or tertiary treatment 

interventions. This will include the identification and management of cognitive impairment 



associated with ATS use; the management of co‐existing anxiety and depression; and the 

management of severely dependent ATS users who are resistant to standard interventions. 

3.1. Characteristics of methamphetamine users entering treatment 

The Center for Substance Abuse Treatment in the US funded the Methamphetamine Treatment 

Project to evaluate and compare treatment approaches for methamphetamine users. As part of this 

study, drug use patterns, history of physical and sexual abuse, history of suicidality and 

psychopathology were assessed in 1016 methamphetamine clients between 1999 and 2001 across 

eight sites (Christian, Huber, Brecht, et.al., 2007). Of the 1016 participants, 55% were female and 

45% were male. The mean age was 32.8 (SD=8.0 years) and participants reported using for a mean 

of 11 years (SD=7.7 years), with 5 of these years recognised as frequent or problematic use. 

The study found that participants struggled with psychological issues, including depression and 

anxiety symptoms. Twenty‐six percent had symptoms which were severe enough to have required 

admission to a psychiatric facility, 32% had been on prescribed psychiatric medications at some 

point in their lives and 19% reported visual or auditory hallucinations. Sixty percent of participants 

in this study had suffered from depression at some point in their lives, 34% admitted to thoughts of 

suicide and 21% had attempted suicide at some point in their lifetime (Christian, et.al., 2007). 

Another significant factor for many ATS users is sexual abuse, and this study found 20% of both men 

and women had been sexually abused. A total of 39% of the total sample, and 58% of the women 

also reported having been forced to engage in sex. Participants admitting to sexual abuse also 

demonstrated significantly more psychological distress and scored more highly on psychotic‐like 

thinking, anxiety, depression, suicidal ideation, and suicide attempts than those without a history of 

abuse (Christian, et.al., 2007). 

Baker, Boggs and Lewin (2001), in their study of 64 regular amphetamine users in Newcastle (NSW, 

Australia), found high levels of psychopathology, social dysfunction, criminal behaviour, poor health 

and high levels of unemployment. The Opiate Treatment Scale, amphetamine version of the 

Severity of Dependence Scale and the Contemplation Ladder (to determine stage of change) were 

administered. 

Although 40.6% of subjects reported being at the preparation or action phase, the majority of 

subjects were at earlier stages, indicating a need for a range of interventions to be available for 

users at different stages. It is suggested that clients in the precontemplation and contemplation 

stages may be best accessed via needle and syringe programs or primary health care, where brief 

interventions may be delivered with harm reduction goals (Baker, et.al., 2001). 

Currently, the National Drug and Alcohol Research Centre (NDARC) is conducting the first Australian 

longitudinal cohort study of dependent methamphetamine users. The Methamphetamine 

Treatment Evaluation Study (MATES) is examining: 

• Rates of psychiatric disorders and psychotic symptoms among people seeking treatment for 

methamphetamine dependence. This includes Major Depression, Panic Disorder, 

Agoraphobia, Social Phobia, and Generalized Anxiety Disorder; 

• The characteristics of those entering treatment for methamphetamine dependence. 

Information included in the study relates to abstinence rates, criminal involvement, general 

health functioning and contact with health services and the criminal justice system; 



• The differences between those entering treatment and dependent methamphetamine users 

who are not seeking treatment in terms of their level of drug use, psychiatric morbidity, 

criminal involvement and general health functioning; and 

• Factors predictive of abstinence, psychiatric morbidity, criminal involvement and contact 

with the health and criminal justice system. (Information from NDARC website at: 

http://notes.med.unsw.edu.au/ndarcweb.nsf/0/BA801522BAEF1BA9CA25723900384BCC?O 

penDocument). 

MATES is coordinated by NDARC with a second study site in Brisbane, which was conducted in 

collaboration with the Queensland Alcohol and Drug Research and Education Centre (QADREC). The 

report from the Brisbane study is available (Cogger, McKetin, Ross, & Najman, 2008) and provides 

important information in relation to outcomes, particularly as participating treatment agencies 

include therapeutic communities and agencies that are members of the ATCA. These are: Fairhaven, 

Goldbridge, Logan House, Mirikai and Moonyah Detoxification Unit. 

Participants in this study were 100 treatment entrants recruited from 15 Government and non‐ 

government services (including those listed) in Brisbane and the Gold Coast. Treatment modalities 

included were withdrawal management (inpatient and outpatient) (n=29), residential rehabilitation 

(n=55), the majority of which were therapeutic communities, and counselling (n=16). For all study 

participants, methamphetamine was the primary or secondary drug of choice; and there had been 

no inpatient meth/amphetamine treatment in the month prior. All participants were interviewed on 

entry (at baseline), and at three and 12‐months post‐entry (Cogger, McKetin, Ross, & Najman, 2008). 

The report from this study shows that all participants met the DSM‐IV criteria for methamphetamine 

dependence in the last year, with 44% reporting Major Depression and a further 45% reporting 

Substance‐Induced Major Depression. The report from this study shows the prevalence of Social 

Phobia was 31% in the year prior to baseline. According to the report, a further 22% had Substance‐ 

Induced Social Phobia, 31% met the criteria for Panic Disorder, and 58% had symptoms of 

Agoraphobia. Ten percent had Substance‐Induced Panic Disorder (Cogger, McKetin, Ross, & Najman, 

2008). 

The authors found that 83% of treatment entrants had experienced an episode of psychosis in their 

lifetime, and 47% had experienced a clinically significant symptom of either suspiciousness, unusual 

thought content or hallucinations in the month prior to treatment. Three quarters of the sample 

reported feelings of hostility in the month prior to treatment (Cogger, McKetin, Ross, & Najman, 

2008). 

The report of treatment outcomes from this study showed marked reductions in all measures of 

methamphetamine use at both three and 12 month follow up, with 61% abstinent from 

methamphetamine use at both three and 12 month follow‐up (compared with 2% at baseline). 

However, Major Depression was the same at 12 month follow‐up as it was at baseline (44%), 

although there was a significant decrease in Substance‐Induced Major Depression. The authors 

suggest the need to maintain supplementary treatment for comorbidity to maximise longer‐term 

treatment outcome (Cogger, McKetin, Ross, & Najman, 2008). 

Personal communication with the CEOs of the therapeutic communities taking part in the study and 

with Dr McKetin, shows that of the total number of participants (n=100), 65 were recruited from the 

five TCs of Fairhaven, Goldbridge, Logan House, Mirikai and Moonyah Detoxification Unit. Thirty‐ 

two percent of participants were female (N=21) and 68% were male (N=44). While unpublished data 

shows the TC sample did not differ in their characteristics from the overall sample, there were some 



important results in the comparison of the two populations (TC participants and others). 

Participants from the TC sample showed greater impairment when compared to the Other sample, 

with 91% scoring below 40 on the SF‐12, although this was not statistically significant. TC 

participants were also more likely to be unemployed than those from the Other sample, and this was 

statistically significant, with 86% of the Total sample unemployed, compared with 74% of the Other 

sample, and 92% of the TC sample (p


Of considerable interest for TCs is the finding that ATS users in this study showed a markedly greater 

level of impairment in overall global executive function and both its subcomponents of behavioural 

regulation and metacognitive abilities to manage attention and solve problems. The authors found 

impairment most evident in relation to impulse control; the ability to move freely from one 

situation, problem or activity to another as the situation demands; the capacity to monitor social 

behaviour; the ability to hold information in mind in order to complete a task; capacity to initiate a 

task and independently generate ideas; and being able to organise personal effects (Gunn & 

Rickwood, 2009). All these are areas of cognitive functioning which affect the person’s ability to 

perform within the TC and are particularly relevant in recovery from substance use. 

Over the past four decades the TC has become more refined. ‘Real work’ situations have begun to 

disappear from the traditional TC program. This is due to a number of reasons: many programs are 

now established in urban settings which do not provide opportunities for a full range of work 

projects; occupational health and safety issues and insurance concerns have prevented resident 

members from undertaking many of the maintenance tasks associated with traditional TCs; and 

there has been more concentration on the use of evidence‐based educational, psychosocial and 

counselling interventions that enable staff to work at a deeper level with clients, an important 

aspect to treatment as programs have reduced in overall length. 

However, as the aspects of executive functioning shown to be affected in this study relate to 

reflective functioning, which involves self‐monitoring and self‐evaluation of performance, impaired 

functioning in these areas is likely to inhibit reflecting on behaviour, the ability to make objective 

decisions, to learn to control impulses, and to learn from past mistakes (Weingartner et al., 1996, 

cited in Gunn& Rickwood, 2009). TCs rely heavily on group processes, self‐reflection and self‐ 

motivation as part of the treatment process (Gowing, Cooke, Biven, & Watts, 2002). Therefore these 

types of cognitive deficits are likely to be particularly relevant in TCs (Gunn & Rickwood, 2009) 

raising a number of issues in relation to program design. 

Furthermore, as younger drug users seeking treatment are more likely to be ATS users with 

associated problems of aggression and cognitive deficits (NDRI & AIC, 2007) there are further 

implications for TCs regarding the safety of staff and other clients. Gunn and Rickwood (2009) 

highlight the need for training in de‐escalation of aggression and the development and adaption of 

treatment protocols to account for cognitive impairments in executive cognitive functions, 

particularly those related to reflective processes. 

Although a number of CBT‐based interventions have been shown to be effective in working with this 

client group, particularly in outpatient settings (Baker, et. al., 2003; Baker & Dawe, 2005), this 

research suggests that modifications may be needed to make these therapies more appropriate. 

Many of the group processes, which are the hallmark of TC treatment, may also need to be 

modified. Completing treatment manuals (often independently), setting treatment goals, following 

rules, undertaking educational and work tasks, behaving appropriately and following rules, which are 

all part of living and socialising within the TC community, may be particularly difficult since these 

tasks rely heavily on executive functions, particularly those related to reflective functioning (Gunn& 

Rickwood, 2009). 

3.3. Pathways to treatment 

Substantial numbers of individuals with harmful or dependent substance use never seek or enter 

treatment (Teesson, Hall, Lynsky & Degenhardt, 2000) and concerns have been raised in relation to 

low rates of treatment utilisation, which are considerably lower than those only using opiates or 

those using both stimulants and opiates. Local data has estimated treatment penetration at 



between 6% and 11% (Ritter, Berends, Clemens, et. al., 2003). 

Methamphetamine users may prefer to manage their use on their own, with the support of friends 

and family, or with their GP. There are few resources to assist in self management and GPs are often 

not in a position to provide intensive interventions for complex problems, although numbers of 

people accessing primary care may be referred to psychologists through the Better Outcomes in 

Mental Health initiative. Both GPs and specialist services are likely to see methamphetamine users 

who have suffered from depression, and this may be the primary reason for first contact. Others will 

access services having experienced psychotic symptoms such as hallucinations and paranoia or 

behavioural problems, such as aggressive outbursts. These clients will require skilled clinicians and a 

range of resources in order to manage these complexities (Lee, et.al., 2007b). 

Methamphetamine withdrawal also appears to be quite different from the withdrawal syndromes 

associated with other drugs, such as opiates and alcohol. This has significant implications for 

treatment services, which are generally better oriented to manage opiate and alcohol withdrawal. 

Services need to offer treatments that meet the multiple and specific needs of methamphetamine 

users (Lee, et.al., 2007b). 

It is estimated that approximately 10% of methamphetamine users either become dependent 

and/or experience significant problems with their use (McKetin, McLaren, Kelly, et.al., 2005). Lee 

and colleagues (2007b) have suggested that methamphetamine users are often reluctant to enter 

treatment and may be suspicious of its effectiveness. It is therefore important that the first contact 

with this group of substance users, in whatever context they first approach treatment, is conducive 

to the establishment of a good relationship (Jenkinson, Johnston, McLean, et.al., 2008). 

Methamphetamine users are likely to enter treatment from a variety of avenues, and therefore 

multiple treatment options and pathways are necessary, including frontline services, such as 

emergency departments and police. Both General Practitioners and peer groups are also important 

sources for information and referral and may be good partners for specialist AOD services, both in 

relation to entry and exit points (Vincent, Shoobridge, Ask, et.al., 1999). 

3.4. Pharmacological interventions 

Development of pharmacotherapy for methamphetamine dependence is still in an early stage. 

Srisurapanont, Jarusuraisin & Kittirattanapaiboon (2001) in the Cochrane Database of Systematic 

Review, note that fluoxetine (Prozac, an antidepressant drug), amlodipine (Norvasc, an anti‐ 

hypertensive), imipramine (Tofranil, a tricyclic antidepressant) and despramine (also a tricyclic 

antidepressant) have been investigated in four randomised trials. Results showed all four drugs 

have very limited benefits for amphetamine dependence and abuse. Fluoxetine may decrease 

craving in short‐term treatment, and imipramine may increase the duration of adherence to 

treatment in medium‐term treatment. Apart from this, no other benefits could be found, suggesting 

these treatments have not been shown to be beneficial for the treatment of amphetamine 

dependence and abuse. 

Shearer and colleagues (2003) conducted a placebo‐controlled clinical trial of dexamphetamine 

replacement therapy for cocaine dependence. Results showed that treatment retention was 

equivalent between groups; however, outcomes favoured the treatment group with no 

improvements observed in the placebo control group. The proportion of cocaine‐positive urine 

samples detected in the treatment group declined from 94% to 56% compared to no change in the 

placebo group (79% positive). While the improvements were not significant between groups, the 

treatment group self‐reported a reduction in cocaine use, criminal activity, cravings and reduced 

severity of cocaine dependence with no within‐group improvements found in the placebo group. 



On the basis that chronic cocaine and methamphetamine use have similar neurobiological effects, 

Shearer (2008) considered the applicability of the principles of agonist pharmacotherapy to 

psychostimulant dependence. Dopamine depletion has been posited as the neurobiological 

mechanism in psychostimulant dependence (Wise, 1996; Dackis & O’Brien, 2001). Therefore, chronic 

psychostimulant use may disrupt dopamine function, resulting in decreased dopamine release and 

the reduction in the number of dopamine receptors (Volkow, Fowler, Wang & Swanson, 2004; 

Shearer, 2008). The therapeutic value of drugs that bind to receptors is illustrated in the treatment 

of heroin dependence through the use of the agonist, methadone. Buprenorphine is a partial opioid 

agonist, which acts as an agonist at lower doses and as an antagonist at higher doses (Julien, 2001). 

This review found that the agonist Mondafinil appears to be well tolerated and has limited liability 

for abuse. Therefore its use may be beneficial in carefully selected, monitored and motivated 

clients. However, the effectiveness of indirect agonists, including dexamphetamine and 

methylphenidate has not as yet been established (Shearer, 2008). 

Cruickshank, Montebello, Dyer, et.al. (2008) also conducted a trial of mirtazapine (Remeron), an 

antidepressant with sedative and anxiolytic properties as a pharmacotherapy for methamphetamine 

withdrawal. This was an outpatient, double‐blind, randomised placebo‐controlled trial conducted 

over a 14 day withdrawal period. Both groups were offered narrative therapy counselling. Results 

showed there were no significant differences between the mirtazapine and placebo group in terms 

of retention or on any symptom measure. The authors do, however, suggest that the use of 

Narrative Therapy as an intervention could be further examined (Cruickshank, et.al., 2008). 

3.5. The NSW Stimulant Treatment Program 

The Stimulant Treatment Program (STP) commenced in NSW in 2006 with a trial of two stand‐alone 

stimulant treatment clinics based in Darlinghurst, St Vincent’s Hospital and Newcastle, Hunter New 

England Area Health Service. The program was established to provide treatment for stimulant users, 

and particularly methamphetamine users. 

The aim of the STP is to: 

• Assist people using stimulants who want to reduce or cease use; 

• Help people who are abstinent to avoid relapse; 

• Establish ongoing clinical interventions for people with co‐morbid mental health and 

stimulant‐related problems; 

• Reduce the health, social and legal costs associated with stimulant use; and 

• Improve the health and social outcomes of people who use stimulant drugs. 

A preliminary evaluation of the STP was conducted from November 2006 to May 2007, and early 

findings released in October 2008. 

During the first six months, 214 clients and family members contacted the clinics across both sites. 

Almost all stimulant users were methamphetamine users (98%) and were self‐referred (52%), 

referred by medical and clinical services (28%) or by family and/or friends (20%). A total of 196 

clients were triaged for further treatment, with 115 completing a comprehensive treatment 

assessment. Eighty‐seven clients participated in ongoing treatment (Dunlop, Tulloch, McKetin, et.al., 

2008). Clients were predominantly male (69%) with an average age of 37 years (range 20 to 55 

years). Stimulant use was by injection (66%) or smoking (27%) and had been used on average for 9.6 

years (range 1 to 25 years). 



Most clients had a history of mental health problems (80%), with depression most common (70%), 

followed by anxiety (39%) and drug‐related psychosis (35%). Relatively high levels of distress were 

also reported, including hostility (83%), suspiciousness (83%) and hallucinations (53%). Nearly 50% 

of clients entering the STP had not previously attempted any form of treatment. At follow‐up 25% of 

clients stated it was ‘very important’ and 75% said it was ‘extremely important’ that the STP 

addressed stimulant drugs specifically, rather than illicit drugs in general (Dunlop, et.al., 2008). 

Treatment was provided within a stepped‐care framework. The primary treatment offered was an 

outpatient psychosocial intervention, applying a number of counselling approaches, including 

cognitive behavioural therapy (CBT), motivational interviewing and narrative therapy. On average, 

clients attended for four sessions (range 1 to 22). Three clients also received pharmacotherapy 

treatment of dexamphetamine, which was provided through twice‐daily dosing at St. Vincent’s 

Hospital. All these clients stabilised rapidly and adhered to treatment regimes, including attendance 

at regular counselling sessions. They reported improved health and social functioning and 

decreased use of methamphetamine. 

Only 24 clients were followed up at three months, providing a follow‐up rate of 21%, hence caution 

must be exercised in generalising results (Dunlop, et.al., 2008). However, within these limitations, 

results would indicate that significant and clinically important reductions were seen in drug use, 

severity of dependence, distress, mental health problems and crime. There were also significant 

improvements in social functioning. All but one participant (96%) reported ‘good’ to ‘excellent’ 

changes in their lives as a result of the STP (Dunlop, et.al., 2008). 

The treatment protocol provided was standardised across both sites and comprised a manualised 

CBT intervention developed by Baker, Lee, Claire, et.al. (2004) and reported on further in this 

literature review (Brief Interventions). Some elements of narrative therapy were also included in the 

treatment provided at St Vincent’s Hospital. 

Recommendations stemming from this study include further evaluation of the project and the 

development of a coordinated approach to STP clinics in NSW. 

3.6. The Methamphetamine Treatment Project 

Conducted over 18 months between 1999 and 2001, the Methamphetamine Treatment Project 

(MTP) is (to date) the largest randomised clinical trial of treatment approaches for 

methamphetamine dependence with 974 individuals participating in the study (Rawson, Marinelli‐ 

Casey, Anglin, et. al., 2004; Rawson, Gonzales, Marinelli‐Casey, Ang, 2007). 

MTP researchers randomly assigned participants at each of eight treatment sites into either the 

Matrix Model, or the program’s treatment as usual (TAU). The study design did not standardise TAU 

across sites, so each program offered different outpatient treatment models (including lengths of 

treatment ranging from 4 to 16 weeks). All TAU models, along with the Matrix Model, either 

required or recommended that participants attend 12‐Step or mutual‐help groups during their 

treatment, and all treatment models encouraged participation in continuing care activities after 

primary treatment. 

The Matrix Model is a manualised 16‐week psychosocial treatment method, comprising CBT groups 

(36 sessions), family education groups (12 sessions), and individual counselling (four sessions), 

combined with weekly breath alcohol testing and urinanalysis. 



No significant differences in substance use and functioning were found between TAU and Matrix 

groups at discharge and at 6‐month follow‐up. However, the MTP study found that the Matrix 

Model participants: 

• Had consistently better treatment retention rates than TAU participants; 

• Were 27% more likely than TAU participants to complete treatment; and 

• Were 31% more likely than TAU participants to have methamphetamine‐free urine test 

results while in treatment (Rawson, et. al., 2004). 

At 6‐month follow‐up, more than 65% of both Matrix and TAU participants had negative urine tests 

for methamphetamine and other drugs (Rawson, et. al., 2004). Injectors had the poorest treatment 

prognosis, poorer treatment engagement, greater drug use during treatment, lower completion 

rates, and more methamphetamine use at 12 months than smokers and intranasal users. On many 

treatment measures, smokers were almost as severely impaired as injectors, and in general, 

intranasal users were least impaired. Psychological and medical impairment, before and after 

treatment, was also highest among injectors (Rawson, et.al., 2007). 

As part of this study, Marinelli‐Casey and colleagues (2007) examined the treatment performance of 

a subsample of 287 adults from 1999 to 2001. Fifty‐seven of these participants were treated in 

outpatient programs in the context of drug court, while the remaining 230 were treated in an 

outpatient setting, but were not sent through drug court. Analyses of results revealed that drug 

court participation associated with better rates of engagement, retention, completion and 

abstinence, compared to outpatient treatment without drug court involvement. 

3.7. Cognitive and behavioural therapies 

Lee and Rawson (2008) conducted a systematic review of cognitive and behavioural therapies for 

methamphetamine users, focusing on the published literature from randomised trials conducted 

internationally. There are a number of therapies which are considered cognitive and/or behavioural 

in nature, including cognitive therapy (CT), cognitive behavioural therapy (CBT) and behavioural 

therapies, such as contingency management. 

One of the objectives of CBT is to identify and monitor thoughts, assumptions, beliefs and 

behaviours that are related and accompanied to debilitating negative emotions and to identify those 

which are dysfunctional, inaccurate, or simply unhelpful. This is done in an effort to replace or 

restructure these with more realistic and useful ones. CBT was primarily developed out of Behaviour 

Modification, Cognitive Therapy and Rational Emotive Behaviour Therapy and has become widely 

used to treat various kinds of psychopathology, including mood disorders and anxiety disorders and 

has many clinical and non‐clinical applications. 

CBT is therefore an umbrella‐term for psychotherapeutic systems that deal with cognitions, 

interpretations, beliefs and responses, with the aim of influencing problematic emotions and 

behaviours. It can be seen as a general term for many different therapies that share some common 

elements and theoretical underpinnings. 

CBT is widely accepted as an evidence‐ and empiricism‐based, cost‐effective psychotherapy for many 

disorders and psychological problems. It is often used with groups of people as well as individuals, 

and the techniques are also commonly adapted for self‐help manuals and, increasingly, for self‐help 

software packages. It is a form of ‘talk‐therapy’ that is used to teach, encourage and support clients 

to change unhelpful thinking patterns (Lee & Rawson, 2008). 



Within the AOD treatment area, CBT has been tested and utilised in relapse prevention (Marlatt & 

Gordon, 1985) and coping skills therapy (Monti, Abrams, Kadden & Cooney, 1989). The PsyCheck 

program, developed by Lee and colleagues (2007a) provides a CBT intervention for use in AOD 

services working with people with co‐occurring mental health problems. 

Lee and Rawson (2008) found a relatively small number of randomised control studies in the 

literature. Studies most commonly reported were studies of CBT and/or contingency management, 

with CBT trials showing reductions in methamphetamine use and other positive changes, even over 

short periods of time. The authors found it was not clear if gains associated with contingency 

management are sustained long‐term. 

3.8. Third Wave Therapies 

During the last two decades a number of therapies, under the name of the ‘third wave’ of cognitive 

behaviour therapy (CBT), have been developed. These include Acceptance and Commitment 

Therapy (ACT), Dialectical Behaviour Therapy (DBT), Cognitive Behavioural Analysis System of 

Psychotherapy (CBASP), Functional Analytic Psychotherapy (FAP), and Integrative Behavioural 

Couple Therapy (IBCT). They are grounded in an empirical, principle‐focused approach, and are 

particularly sensitive to the context and functions of psychological phenomena and thus tend to 

emphasize contextual and experiential change strategies in addition to more direct and didactic 

strategies (Hayes, 2004). 

Developed within a coherent theoretical and philosophical framework, Acceptance and Commitment 

Therapy (ACT) is a unique empirically based psychological intervention that uses acceptance and 

mindfulness strategies, together with commitment and behaviour change strategies, to increase 

psychological flexibility. Psychological flexibility means contacting the present moment fully as a 

conscious human being, and based on what the situation affords, changing or persisting in behaviour 

in relation to chosen values. 

Based on Relational Frame Theory 3 , ACT illuminates the ways that language entangles clients in their 

attempts to understand their own inner lives. Through metaphor, paradox, and experiential 

exercises clients learn how to make healthy contact with thoughts, feelings, memories, and physical 

sensations that have been feared and avoided. This helps the person to gain the skills to 

recontextualize and accept these private events, develop greater clarity about personal values, and 

commit to needed behaviour change. 

ACT gets its name from one of its core messages: to accept what is out of your personal control, 

while committing to do whatever you can to improve your quality of life. The aim of ACT is to help 

people create a rich, full and meaningful life, while effectively handling the pain and stress that life 

inevitably brings. It does this by: 

a) Teaching mindfulness skills to deal with painful thoughts and feelings effectively – in such a 

way that they have much less impact and influence over the person. 

b) Helping participants to clarify what is truly important and meaningful ‐ i.e. an examination of 

personal values ‐ then use that knowledge to guide, inspire and become motivated to change 

their life for the better. 

3 Relational Frame Theory is a psychological theory of human language and cognition, developed largely by 

Steven Hayes (who also developed Acceptance and Commitment Therapy) and Dermot Barnes‐Holmes. It is 

based on the philosophical roots of functional contextualism, and focuses on how humans learn language 

through interactions with the environment. 



As the underpinning philosophy is sympathetic to AOD treatment, there is a growing use of ACT 

within the substance use field, and some very preliminary studies have been carried out. 

Twohig, Shoenberger, & Hayes (2007) investigated the use of an abbreviated version of ACT with 

three adults who met the criteria for marijuana dependence. The treatment was delivered in eight 

weekly 90‐minute individual sessions. The effects of the intervention were assessed using a 

nonconcurrent multiple baseline across participants design. Self‐reported marijuana use, confirmed 

through oral swabs, reached zero levels for all participants at posttreatment. At a three month 

follow‐up, one participant was still abstinent and the other two were using but at a lower average 

level of consumption compared to baseline. Depression, anxiety, withdrawal symptoms, and 

general levels of experiential avoidance generally improved. 

Batten and Hayes (2005) provide information of an earlier study which utilised ACT in the treatment 

of co‐occurring post‐traumatic stress disorder (PTSD) and substance abuse. Both PTSD and 

substance abuse can be conceptualised as disorders with significant experiential avoidance 

components. ACT has been specifically developed for the treatment of experiential avoidance and 

provides the opportunity for treatment of both disorders simultaneously. 

There are other studies currently being undertaken that look specifically at the use of ACT with 

methamphetamine users. 

3.9. Brief interventions 

Srisurapanont, Smbatmai and Boripuntakul (2007) report on a brief intervention provided to 

students aged 14‐19 years who met the DSM‐IV diagnostic criteria for methamphetamine 

dependence or abuse. Participants were students in Chiang Mai in Thailand. In this study, 48 

participants were randomly assigned to receive either a Brief Intervention or Psychoeducation in 

blocks of six. (There were twenty‐four participants in each group). 

Because cognitive impairment due to severe methamphetamine withdrawal may have had an 

impact on treatment outcomes, the intervention was commenced only after the participant had 

returned a negative urine sample and had scored 10 or less on the Amphetamine Withdrawal 

Questionnaire (AWQ). Each participant of the Brief Intervention group received two weekly, 20‐ 

minute counselling sessions in the first two weeks. 

The participants in the Psychoeducation group received a 15‐minute session of education to improve 

their knowledge on the pharmacological effects and health consequences of using 

methamphetamine. On each visit each participant in both groups was paid a small sum (50 Thai 

Baht, or $2.23) to compensate for travelling costs. This was not considered to be of any influence on 

treatment outcomes. 

The study evaluated outcomes at baseline, week four and week eight (end point). At week four, 

seven participants had dropped out of the Brief Intervention and five out of the Psychoeducation 

group. The frequency and amount of methamphetamine use had decreased significantly in both 

groups. However, by week eight the Brief Intervention group showed a significantly larger decrease 

in days of use, although there was no significant difference between numbers of participants who 

returned positive urine tests. 

A further study conducted by Baker, Lee, Claire, et.al. (2004) utilised a randomised control trial with 

214 regular amphetamine users in the Greater Brisbane Region (Queensland) and Newcastle (NSW). 

The main finding of the study indicated that amphetamine users receiving two or more brief 



intervention treatment sessions significantly increased their likelihood of remaining abstinent from 

amphetamine use over time. 

Recommendations from this study include a stepped‐care approach, with the first stage the 

provision of a structured assessment of amphetamine use and related problems; self‐help material; 

and regular monitoring of amphetamine use and related harms. This would be followed by a brief 

intervention, comprising either two or four sessions of CBT, depending on the person’s severity of 

use and associated issues, including levels of depression. 

In Australia, the current ‘gold standard’ of treatment for methamphetamine use and dependency is 

a brief psychological intervention, developed and tested in Australia (Baker, Kay‐Lambkin, Lee, et.al., 

2003). This is a two or four‐session combination of motivational interviewing and CBT, which was 

found to significantly increase abstinence amongst dependent methamphetamine users. At six‐ 

month follow‐up, close to half (49.4%) the treatment group were abstinent, compared to only 27.1% 

of the control group who received only the self‐help information in booklet form. 

Participants in the study were 282 people, screened to take part between October 2001 and 

September 2002. Of these, 214 regular (at least weekly) users of amphetamines were randomly 

assigned to either an active intervention (two or four sessions of CBT in addition to a self‐help 

booklet) or control condition (self‐help booklet only). The self‐help booklet was developed by 

NDARC in 2001. 

The CBT intervention focused on developing skills to reduce amphetamine use. Four sessions were 

conducted individually and lasted 45‐60 minutes. In the two‐session intervention, the procedure 

and content was the same as that for the four hour intervention (Baker, et.al., 2003). At pre‐ 

intervention, subjects were a group of regular amphetamine users with long using histories, high 

dependence, injecting risk taking behaviour, polydrug use, depression, psychiatric illness and poor 

quality of life (Baker, et.al., 2003). 

In this study all groups, including the no‐treatment group, significantly reduced their substance use 

(Jenkinson, et.al., 2008). However, being in the intervention group was significantly associated with 

abstinence, which implies active therapy gave subjects an added incentive for abstinence. 

The brief treatment intervention, developed as a result of this research, is based on the assumption 

of the motivational enhancement therapy (MET) approach, which maintains that responsibility for 

change lies within the client (Miller, Zweben, DiClemente & Rychtarik, 1995). Under this model, the 

role of the therapist is to enhance the client’s own motivation and commitment for change through 

the five basic motivational principles of: 

1. Express empathy; 

2. Develop discrepancy; 

3. Avoid argumentation; 

4. Roll with resistance; and 

5. Support self‐efficacy. 

The main goal of the intervention is to reduce the level of drug use and harm, including mental and 

physical health, financial, social and occupational harms (Baker, et.al., 2003). The manualised 

approach provides guidelines for the delivery of sessions, including activities, worksheets and 

homework tasks. 


3.10. Stepped‐care 


Kay‐Lambkin (2008a), in her review of available literature of treatment strategies for 

methamphetamine users, found several approaches worth further investigation. These included 

assertive engagement strategies, flexibility in the provision of treatment and retention strategies 

and use of a multi‐focused intervention package, such as stepped‐care. This approach may be 

further enhanced by the use of new technologies as alternatives or supplements to face‐to‐face 

counselling. 

A stepped‐care model offers the opportunity for collaboration between services such as AOD, 

mental health, General Practitioners, ambulance and welfare agencies through a comprehensive and 

multi‐faceted approach to meeting complex client needs. Hence, the model offers an intervention 

which can encompass secondary and tertiary prevention measures, with the initial intervention 

targeted at the least intensive option. If little change is evident with this intervention, then 

interventions may be increased in intensity in steps. At the same time, with monitoring, an 

intervention may be ‘stepped‐down’ in intensity, depending on the needs of the client. 

This is a common model in clinical practice, and especially within mental health, where ‘step‐up’, 

‘step‐down’ services are provided to include an assertive outreach component to either intervene to 

prevent people moving into psychiatric care, or to assist patients to re‐integrate into the community 

following a period of hospitalisation. Many of these patients will have issues of co‐morbidity, 

including substance‐induced psychosis. This model requires clear clinical pathways between 

services, with effective case management strategies in place. Through this process, clients are not 

left to navigate the system alone, but are assisted through treating services and agencies. This 

collaboration can facilitate timely and appropriate responses, minimise barriers and improve client 

outcomes (Jenkinson, et.al., 2008). 

An example of a stepped‐care model is outlined: 

• An initial intake an assessment process identifies the individual priorities and needs of the 

client, including: 

• Assessing the type and frequency of methamphetamine or other drug use 

• Identifying any co‐occurring issues 

• Assessing the impact on client health and wellbeing 

• Understanding the goals of the client – are they wishing to reduce harms associated 

with use, or cease use? 

• Prioritising issues (intoxication, withdrawal, crisis) (Kay‐Lambkin, 2008b). 

The initial intervention is the least intrusive. This may be a brief intervention focusing on immediate 

goals for change and providing self‐help material. This may have the added benefit of engaging 

people into treatment by providing an early non‐threatening contact. 

• Monitoring and assessment would follow, and will provide the basis for developing a plan to 

either ‘step‐up’ or ‘step‐down’ the intervention. This might include: 

Altering the frequency of treatment sessions 

Reintroducing the strategies that were previously successful 

Introducing new strategies, such as motivational interviewing, contingency 

management, detoxification, medication and pharmacotherapy 

Altering the way the intervention is delivered, for example, using face‐to‐face 

sessions, computer‐based programs and self‐help materials 



• Modifying the intervention to focus on a single issue or, conversely, an integrated 

approach that addresses a number of issues simultaneously. This might include 

addressing both mental health and AOD issues simultaneously (Kay‐Lambkin, 

2008b). 

Monitoring of client progress is necessary to decide on future steps and final discharge from the 

stepped approach. This model can include a number of interventions, including TC treatment, if 

indicated. 

In many ways, most TCs utilise a stepped‐care model as part of their normal treatment modality. 

Clients are often managed in the community while on the waiting list, they are then progressed 

through detoxification to residential treatment, which includes a staged approach, with outpatient 

care and aftercare in halfway house accommodation, a feature. Managing possible relapse and 

providing an opportunity to re‐enter the community for a period of time, then moving back into 

aftercare services, is particularly valuable for clients with co‐occurring disorders. This flexibility is 

particularly necessary when ATS issues are prevalent and where mental health concerns are an 

issue. 

3.11. Online interventions 

In considering the apparent reluctance of methamphetamine users to attend traditional AOD 

services, their comparatively young ages and patterns of drug use, online options have become an 

alternative to more traditional treatment. Computer‐based therapy can be less confronting, and 

interactive interventions more engaging than face‐to‐face therapy for this difficult to engage group 

(Copeland & Martin, 2004). 

There are different forms of computer‐based therapy. These include posting a question, which is 

usually answered within a short space of time (e.g., two to four days). Examples of this include the 

Somazone site (Australian Drug Foundation: http://www.somazone.com.au ). Other options include 

real‐time chat services. This means that the client is able to make an appointment with a counsellor, 

and at the appointed time, both the client and the counsellor communicate at the same time, by 

typing. Chat software (like MSN) is used and counselling is between one client and one counsellor. 

Kay‐Lambkin (2008a) suggests that the benefits of motivational interviewing, contingency 

management and CBT strategies may be enhanced through the use of new technologies. Young 

people increasingly report the use of the internet to access education, support and health 

information, as well as for social interaction (Australian Bureau of Statistics, 2005). While few 

controlled trials have examined the use of computerised treatments for mental health or AOD 

problems, Lynch and colleagues (2003) provide evidence to suggest that methamphetamine users 

are supportive of accessing information via the internet. 

Information provided by Drug Info Clearinghouse (Pennay & Lee, 2008) notes that unpublished data 

from an implementation trial of live online counselling in Australia shows that 700 people engaged in 

online counselling in the first eight months of operation. Of this number, approximately one‐quarter 

were methamphetamine users. The majority were young (under 35 years of age) and chose to 

access the service anonymously (over 85%) outside of usual business hours. 

3.12. Abstinence incentives: contingency management 

Contingency management uses positive reinforcement to reward achievement of goals in treatment 

by applying a system of incentives and disincentives to help people meet their goals for recovery 



from substance use. A recent meta‐analysis identified 34 well‐controlled treatment conditions—five 

for cannabis, nine for cocaine, seven for opiate, and 13 for polysubstance users—representing the 

treatment of 2,340 patients. Psychosocial treatments evaluated included contingency management, 

relapse prevention, general cognitive behaviour therapy, and treatments combining cognitive 

behaviour therapy and contingency management. The strongest effect was found for contingency 

management interventions when combined with CBT interventions (Dutra, Stathopoulou, Basden, 

et.al., 2008). 

Contingency management remains a hotly debated issue, particularly in relation to the value of urine 

testing, but evidence suggests that contingency management may be an effective treatment 

strategy or adjunct to psychosocial treatments for methamphetamine use (Roll, Petry, Stitzer, et.al., 

2006). In this study, 113 participants who were diagnosed with methamphetamine abuse or 

dependence were randomly assigned to 12 weeks of treatment or treatment plus contingency 

management. This comprised urine testing (for illicit drugs) and breath samples (for alcohol). The 

reinforcers were plastic chips or tokens, some of which could be exchanged for prizes. The number 

of tokens increased each week, but was re‐set to one after a missed or positive sample. Those in the 

contingency management group returned significantly more negative samples and were abstinent 

for a longer period of time. 

Rawson and colleagues (2006) compared three groups: 1. contingency management; 2. CBT; and 3. 

Combined CBT‐contingency management for methamphetamine and cocaine users. In this study, 

the contingency management condition provided vouchers, which could be redeemed for cash. 

Participants in the contingency management group who provided three clean samples each week 

were able to earn $1200 over the 16‐week trial period. Those in the CBT group received a 16‐week 

intervention, but no vouchers, while participants in the combined CBT‐ contingency management 

group received both the voucher and CBT intervention. 

All groups showed significant reduction in use, with the contingency management group showing 

significantly increased retention and reduced stimulant use during the treatment period. However, 

there was no significant difference between the groups at follow‐up (Lee & Rawson, 2008). 

The National Institute for Health and Clinical Excellence (UK) sets out guidelines for the use of 

contingency management in National Health Service AOD services, citing results of 25 trials of 

contingency management involving over 5000 patients (Petry, 2006). In the formal trials, incentives 

included vouchers (exchangeable for goods such as food); cash rewards (of low monetary value – 

commencing at £2; prizes (including cash and goods) and clinic privileges (such as non‐supervised 

methadone dosing). All incentives were shown to be effective. 

3.13. Conclusion 

There is reason for optimism in relation to treatment interventions. While Shearer (2008) and 

Srisurapanont and colleagues (2001) point to the need for further research before replacement 

therapies can be considered useful for meth/amphetamine users, there is a good deal of evidence in 

favour of psychosocial interventions. At the same time, there is some support for the use of 

dexamphetamine as an agonist treatment intervention (Shearer, 2008). 

Lee and Rawson (2008) show that methamphetamine use is responsive to treatment, and Rawson 

and colleagues (2007 & 2008) provide information from the Methamphetamine Treatment Project 

detailing outcomes from both a Cognitive Behavioural Therapy (CBT) and Treatment As Usual (TAU) 

approach. This review is further supported by the systematic review conducted by Lee and Rawson 

(2008). What the literature does seem to indicate, is that CBT interventions delivered using a 

treatment manual can increase abstinence rates. Contingency Management also shows some 



promise. These approaches may be best combined utilising a stepped‐care approach, which may 

include some period of residential treatment. 

Findings from the Brisbane site of the Methamphetamine Treatment Evaluation Study (MATES) are 

particularly promising (Cogger, McKetin, Ross, & Najman, 2008), since this incorporated five agencies 

that are members of the ATCA, and therefore are currently providing interventions which have been 

found to be beneficial in the treatment of clients with methamphetamine dependence. According to 

the report of the study, treatment outcomes showed marked reductions in all measures of 

methamphetamine use at both three and 12 month follow up, with 61% abstinent from 

methamphetamine use at both three and 12 month follow‐up (compared with 2% at baseline). 

Major Depression was, however, the same at 12 month follow‐up as it was at baseline (44%) 

although there was a significant decrease in Substance‐Induced Major Depression. The authors 

suggest the need to maintain supplementary treatment for comorbidity to maximise longer‐term 

treatment outcome (Cogger, McKetin, Ross, & Najman, 2008). 

Baker and colleagues (2003) have developed a brief CBT intervention, which has been trialled and 

found to be effective. At the same time, the Matrix Model, utilised in the Methamphetamine 

Treatment Project, and also shown to be effective, provides a longer CBT program (16‐week 

psychosocial treatment method) comprising CBT groups (36 sessions), family education groups (12 

sessions), and individual counselling (four sessions). This is combined with a contingency 

management intervention of weekly breath alcohol testing and urinanalysis. 

What is important to understand in the adoption of a CBT approach, is that clinical trials conducted 

on CBT interventions include a manualised treatment approach. Many therapists would argue they 

use CBT, both in individual and group interventions. However, not all would use a manualised 

approach. If we are expecting to get similar results in our practice to those achieved through clinical 

trials, it is important that therapists and clinical workers utilise the CBT program as developed and 

trialled. This includes the worksheets and tasks developed as part of the approach. 

Other models worth investigation are the stepped‐care model (Kay‐Lambkin, 2008a & 2008b) and 

the use of on‐line interventions. These may be combined with a variety of interventions, including 

motivational interviewing and contingency management. There are possibilities for combining a 

number of these interventions within a therapeutic community model, whilst maintaining the 

efficacy of the TC. 

However, of critical importance to this discussion and to the development of a treatment protocol, 

are the findings from the study conducted by Gunn and Rickwood (2009) since this is a 

contemporary study, undertaken with four of the TCs that are part of the current consultation. This 

study found markedly greater level of impairment in overall global executive function and both its 

subcomponents of behavioural regulation and metacognitive abilities to manage attention and solve 

problems. As this impairment is most evident in relation to impulse control; the ability to move 

freely from one situation, problem or activity to another as the situation demands; the capacity to 

monitor social behaviour; the ability to hold information in mind in order to complete a task; the 

capacity to initiate a task and independently generate ideas; and being able to organise personal 

effects (Gunn & Rickwood, 2009), the implications for TC programs must be considered. 

Ironically, a move from work‐focussed and experiential TC programs to more educational and 

didactic programs, will not suit this client group, at least not in the first stage of treatment. This is 

not to say that CBT and other cognitively‐based education and treatment interventions should be 

sacrificed, but it does point to a very great need for balance within the TC and a reconsideration of 

activity‐based interventions, including recreational programs. 



The aspects of executive functioning shown to be affected in this study relate to reflective 

functioning, which involves self‐monitoring and self‐evaluation of performance, impaired functioning 

in these areas is likely to inhibit reflecting on behaviour, the ability to make objective decisions, to 

learn to control impulses, and to learn from past mistakes (Weingartner et al., 1996, cited in Gunn& 

Rickwood, 2009). Therefore there is a need to consider how the resident member of the community 

can be guided through the process of learning and reflecting, decision‐making and impulse control in 

order to gain not only the benefits of treatment, but most importantly, the ability to remain in 

treatment. 




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Section 2: 

Report of Consultations 





1. Summary of Therapeutic Community Consultations 

The consultation process undertaken for this project was extensive, involving representatives from 

29 organisations, representing more than 30 therapeutic communities in Australia and New Zealand. 

The process of consultation was commenced at the Australasian Therapeutic Communities 

conference in Byron Bay in September 2008, when Mr James Pitts, CEO Odyssey House McGrath 

Foundation, provided an overview of the project to delegates and invited participation. From the 

outset, one of the key principles was the distribution of the final treatment protocol to all TCs in 

Australasia. 

Following the conference, letters were sent to Chief Executive Officers and senior managers of all 

therapeutic communities in September 2008, inviting input into the project through the 

development of the literature review and asking for information about any existing interventions 

which the TCs had found useful in working with the client group. 

The first of the consultations took place on the Gold Coast on 20 October 2008, and was followed by 

Sydney, Melbourne, Perth, Canberra, Auckland and Adelaide. A total of 57 people attended the 

consultations, and the Director of Aranda House in Alice Springs took part through an individual 

meeting. To assist in this process, information drawn from the literature review was distributed to 

all TCs prior to the consultations. This greatly assisted in establishing the prime areas of concern, 

shaping the report of each consultation under specific headings. 

1.1. Principal drug of concern 

All TCs reported high populations of ATS users. With few exceptions, ATS was identified as the 

principal illicit drug of concern by TCs participating in the consultations. In all TCs, the three main 

drugs of concern were most usually identified as alcohol, ATS and cannabis; although heroin was 

nominated as the second illicit drug of concern after ATS at Odyssey, McGrath Foundation (NSW). 

The widespread use of ATS reported by TCs across Australia was interesting, given the fact that 

Australian statistics show highest use in the reporting period 2000 – 2005 in Western Australia, 

followed by ACT and Tasmania (see Figure 2 at page 14 in this report). In general, the concerns from 

the Perth and Canberra consultations reflected the national statistics, but there was also high 

reported usage in Queensland, New South Wales and South Australia, although it was somewhat 

apparent that individual TCs have different experiences of population groups, depending on their 

overall treatment focus. For instance, Mirikai on the Gold Coast attracts and works with a younger 

and somewhat more chaotic group of substance users than other Queensland services. Mirikai has 

been successful in gaining both mental health and AOD funding, and has met the quality service 

standards for each sector. Therefore Mirikai is recognised as working with a younger and more 

chaotic population of substance users, many of whom have high and/or low prevalence mental 

health disorders. 

In Perth, while Cyrenian House reported high populations of ATS users, the experience was not the 

same at Palmerston. Furthermore, where ATS users where resident at Palmerston, many of the 

complex behaviours that other TCs reported were less evident, and this may be related to the fact 

that at Palmerston clients are involved in physical activity in working on the farm, therefore 

providing a release for some of the more poorly controlled behaviours experienced by other TCs. 

Data in relation to principal drug of concern, mental health status and psychiatric diagnoses was not 

provided by all TCs. Where this was available and is reproduced within this report, the concerns 

raised by TCs, particularly in relation to comorbidity are evident. Depression and anxiety are the 



major mental health issues reported by all TCs. While this was not a surprise, what was somewhat 

more surprising, was the incidence of low prevalence disorders, including bipolar disorder and 

schizophrenia among TC populations. 

1.2. Assessment process 

The assessment process was seen by all TCs as being more complex, with a need to collect more 

information, especially relating to MH history and presentations. This can be time consuming as it 

requires more follow‐up and more focus on chronic drug use than type of drug, together with 

assessment of suicide risk, self‐harm, violence and eating disorders. The assessment and early 

treatment phases were seen by all TCs as the most vital in gathering information and gaining the 

support of other services in the community, and most importantly, mental health services. The 

majority of clients coming into treatment where ATS use is a presenting issue, have had prior 

involvement with mental health services. 

Most agencies reported this stage of pre‐admission has been extended as it takes longer to gather 

the necessary information, and to ensure that the person has been stabilised, either as a result of 

detoxification, or on prescribed medications. This has been a universal shift for TCs over the past 

two decades as more clients are coming into treatment on a range of prescribed medications – once 

a reason for excluding people from TC treatment. Although all TCs were cognisant of the fact that 

there were no guarantees that a person would not decompensate and experience a psychotic 

episode once in treatment, all required prospective residents to have been stabilised prior to entry 

into treatment. In addition, clients in this stage are often demanding, with personality disorders, 

including narcissistic and anti‐social personality types, influencing the way in which they will react to 

methamphetamine and other ATS use. 

Managing the waiting list and providing support during that time has therefore become an 

important consideration. At Karralika, the Early Birds Program has been funded to assist clients who 

are on the waiting list and requiring support prior to entering the program. This is conceptualised as 

an early intervention program, which includes active case management in consultation with other 

community‐based and government services. 

Finding strategies to engage with clients has also become a consideration, and at Kuitpo this has 

been creatively managed through sending text messages via mobile phone to remind people to 

attend appointments. The use of text messages is contemporary, and is used by a variety of 

businesses and services to help people to maintain diary commitments. It also recognises the fact 

that while people who use our services will almost always have a mobile phone, they may not have 

the credit necessary to make a call or access the message bank. The use of text messages has 

assisted compliance and is well supported by Kuitpo clients. 

There was an acknowledgement amongst all programs that the assessment and earlier phases of 

treatment have had to change in order to cope with this population group. The assessment process 

itself has become extended, and the nature of the waiting list has of necessity had to change to 

support people to enter treatment, rather than expecting clients to exhibit a high degree of 

motivation. Acknowledging motivation as a fluctuating state, and using motivational interviewing to 

assist clients to make a decision for treatment is seen as a legitimate intervention in the assessment 

stage. In New Zealand, there is often a difficulty in balancing outside and internal risks, especially 

those presented by gangs, in deciding the timing of a person’s entry into the community. Part of this 

is also the concern in balancing the needs of the individual in relation to those of the wider TC 

community. 



Hence, assessing the balance of clients in the TC has become an important issue. All programs in the 

consultation raised the issue of the number of clients with chaotic behaviours who could be handled 

at any one time. This was not an issue of exclusion, but of balance, realistically recognising that the 

balance could easily be ‘tipped’ within the community, especially in the early stages of treatment, 

when most complex behaviours could be expected to emerge. All TCs reported the first stage of 

treatment (variously known as Stage 1, Induction, Orientation, Assessment Phase etc.) as usually 

lasting between four to six weeks, therefore numbers within this phase will be smaller, and this in 

turn emphasises any degree of complexity experienced by residents. For TCs who operate this 

phase in a separate facility, the lack of role models to moderate behaviour and to provide a sense of 

what is accepted and expected in relation to a person’s behaviour, is an issue. While specific 

programs and interventions may be provided separately to people in this first phase of treatment, 

having clients reside within a household that includes older and more mature clients (in terms of 

treatment maturity) will provide the opportunity for modelling of behaviours and peer support. 

TCs have introduced new programs including waiting list support, early intervention and day 

programs (e.g., The Peppers) together with detoxification to assist the transition into treatment, and 

to provide an opportunity for a stepped‐care approach, which is particularly valuable where a 

person experiences an episode requiring intensive support or a period away from the wider TC 

community. 

1.3. Violence, physical effects and effect on TC, staff and families 

All TCs in the consultation reported increased concerns in relation to violence, threats of violence 

and aggression amongst this client group. The Woolshed reported a significant incident, which has 

resulted in new policies and protocols being developed to protect staff and residents, and includes 

calling the police to escort a client off the property where there is a fear of violence. Other 

programs agreed that there has been a cost to staff and programs, with higher rates of staff burnout 

and an increased need for clinical supervision, employee assistance programs and other supportive 

interventions, particularly as there is a real potential for the staff team to be split by this client 

group, as staff often disagree about disciplinary action and treatment expectations. 

While there was an acknowledgement of a need for TCs to be more tolerant and compassionate, and 

to practice tolerance and latitude, conversely there was a view that TCs needed to be clear about 

their expectations of behaviour, especially in relation to violence or threats of violence. The need for 

boundary setting was emphasised, while at the same time appreciating that impulse control as part 

of executive functioning, was often a considerable issue of concern for this client group. 

The Woolshed has introduced a process of contingency management, modelled on the ‘star chart’ 

which provides rewards for Junior (Stream one) residents, who receive a star each time they follow 

the resolve process and confront a fellow resident regarding their inappropriate behaviour. On 

receipt of three stars, they are able to gain a reward – such as a movie pass. Senior residents are 

able to train to become mediators, and will receive a ‘mediator licence’. If a person is selected by 

others to assist them as a mediator to resolve an issue, they are again provided with a reward – such 

as a sleep in on a Friday morning or a bubble bath. While staff were concerned that this form of 

contingency management might be construed as somewhat condescending, it has been well 

accepted by the community. Earlier relaxation of boundaries which allowed clients more freedom 

has now been replaced by more balance, which has resulted in more safety within the community. 

The use of contingency management is part of this balance and is well supported in the literature. 

The use of this process at The Woolshed provides a creative response, especially as the focus is on 

the learning of new skills in communication and mediation to resolve issues. 



The use tools, such as a ‘therapeutic discharge’, which allows the person to re‐enter the program 

sooner than if they were given a usual disciplinary discharge, is being used by a number of TCs. In 

some cases this means the person is discharged and immediately readmitted, sometimes having 

been walked off and back onto the property, in other cases the person may be asked to leave for a 

period of time, but given various opportunities, including outpatient support, while in the 

community. All TCs agreed that while there is a need to explain rules and expectations around 

behaviour, the fact that this client group has been shown to have deficits in relation to impulse 

control (Gunn & Rickwood, 2009) means there is a need for constant dialogue around this issue. 

Additionally, it is acknowledged by TCs that many clients now entering treatment are in need of 

habilitation, rather than rehabilitation, and many have not been taught or have been provided with 

role modelling to help them to gain the necessary skills or ability to monitor and manage behaviours. 

The ‘lack of words’ or language was raised by a number of TCs, particularly in relation to young 

people within this client group, who may therefore be unable to communicate with others in the 

community in a non‐threatening manner. This may also be a result of learned behaviours, particularly 

if the person has found that being aggressive or threatening within the family, school and society will 

provide sought‐after results. Residents are also aware of the physical consequences, the wear and 

tear on their bodies, that result from violence and aggression. They often do not like the effects on a 

personal level and are very often aware of what it is doing to their families. Often families are 

reluctant to have their relative back in the house because of the violence which they have exhibited. 

Hence working with families to educate and to heal the family unit may be necessary. Sometimes 

the person may have limited choices when they leave the TC as a result of emotional, and 

sometimes, physical damage which has been inflicted on the family. There is also and increased risk 

of domestic violence as a consequence of ATS use, often resulting in PTSD. 

Conversely, some TCs raised the concern that sometimes clients are in denial or unaware of the 

consequences of their use, especially the combined effects of polydrug use. Often there will also be 

aggressive paranoia, and it may therefore be difficult to engage the person in treatment and to 

develop a therapeutic alliance. There was an added concern raised by TCs about incidents of 

extreme violence, particularly by males, prior to entry into treatment. This includes violence in 

which they have become involved as both perpetrators and victims and often results in clients 

entering treatment with untreated injuries, and particularly head injuries, leading to a concern in 

relation to the person’s ability to function on a cognitive level. One of the treatment issues for some 

people is the need to deal with anti‐social behaviours and influence over others. Sometimes people 

are well known in the criminal world and will influence the treatment of others. In this regard, the 

primary addiction may be crime. 

1.4. Mental Health issues 

The increased incidence of comorbidity was seen as raising the need for more individualised work, 

which in turn places greater stress on other aspects of the program. While there is a concern around 

the relationship between mental health and AOD use (which came first, will symptoms abate when 

drugs are withdrawn?) the need to address the presenting issue was strongly supported by all TCs. 

This may result in enduring mental health issues emerging during the treatment process, often 

resulting in the need for mental health intervention. All TCs acknowledged the need for closer liaison 

with mental health services, although a number of TCs in the consultation acknowledged the need 

for improved relationships in order to provide better service delivery and support. 

As clients are often not able to process information and may have poor cognitive skills, there was an 

acknowledgement of the need for ‘time out’ within the program and a requirement for more 

individualised treatment. However, there was a concern that this may result in shifting the focus of 



TC treatment, and overcompensating for clients whose behaviours could be problematic. This was 

especially highlighted by TCs where requirements for prosocial behaviours had been clearly 

articulated, most often resulting in residents learning to modify behaviours with peer support and 

mediation. 

More clients are entering treatment on prescribed anti‐psychotic medications, sometimes following 

a psychotic episode, and at other times because of an enduring mental health problem. While the 

continued use of prescribed medications may be imperative for successful treatment, a reduction in 

the level of prescribed medications may also be required, especially as clients stabilise and detoxify 

from illicit drug use. There were some expressed concerns about possible over‐diagnoses of clients, 

which may result in inappropriately high levels of medication at the time of admission. Particular 

concern was expressed about the number of people who are given a diagnosis of Bipolar Disorder. 

This may not be an appropriate diagnosis where this has been given in the context of drug use. Some 

clients have also been diagnosed and prescribed medications at a young age, and in some cases 

these clients have not taken their prescribed medications, often resulting in self‐medicating with a 

range of illicit drugs and alcohol. 

Many clients are also concerned about continuing their medication use, and this may be the 

motivation to seek treatment. Often an issue of concern for TCs are the clients who ‘take themselves 

off’ their prescribed medications so that they can be ‘like others’ in the program. Increasingly for 

residents coming into treatment on psychiatric medications, there is a re‐emergence of symptoms 4‐ 

6 weeks after entry. 

TCs in the consultation noted that people have a shorter drug using career with methamphetamine, 

in particular. This is because extreme consequences may be seen much sooner. Therefore a person 

using methamphetamine for one year may have the same physical problems as someone who has 

been using heroin for a much longer period of time. The consequences of ATS use are also not as 

easy to pinpoint, and although physical and psychological effects may differ, psychological problems 

are usually more profound. There may also be just one prime consequence of ATS use – and this 

may be an admission to a psychiatric ward. 

Programs noted a need to monitor anxiety at all stages of treatment, and while there is a high 

prevalence of depression and anxiety amongst ATS users, TCs also noted an increased number of 

clients presenting with diagnoses of schizophrenia and bipolar disorder. There were a number of 

reports of people finding difficulty in settling, often exhibiting symptoms of anxiety and paranoia. 

Cutting and self‐harming behaviours are also of concern. The person’s intention may not be hurt 

themselves, but an attempt to get help. Other physical injuries associated with ATS use resulting in 

hospital admissions, may also be evident. 

The lack of sexual boundaries which had sometimes been a part of a person’s behaviour prior to 

entering treatment was also raised during the consultations. While not a gender‐specific issue, 

nevertheless for a number of women entering TCs this has become a major treatment concern, the 

consequence sometimes including sexual assault and sexually transmitted infections. Of concern 

from a treatment perspective therefore, are issues relating to sexual assault, including PTSD and 

significant issues relating to shame, guilt and grief. 

A number of TCs were fortunate to have the services of a psychiatrist and/or clinical psychologist, 

who were able to assist in diagnoses and to support staff through clinical advice, education and 

supervision. However, not all TCs were able to access this support, even with the additional benefit 

of funding through the Improved Service Delivery initiative. This has often left TCs feeling 

unsupported and inadequate and has raised the level of stress amongst staff members. Staff training 



has become more important, with all TCs acknowledging the need for staff to have a greater 

understanding of mental health issues. Most TCs had either embraced the PsyCheck model, or were 

in the process of undertaking training. All had included a mental health screen as part of the 

assessment process. 

Education on mental health issues for others in the community was also noted as being important. 

The need for others to be aware of possible symptoms and behaviours so that they can support their 

peers was highly supported by TCs in the consultation. This has not replaced the concern for 

confidentiality around mental health problems, and the decision for confidentiality or disclosure 

remains the choice of the client. However, the provision of education at a broader level was seen by 

TCs as important within the context of the community. 

1.5. Relationship with Mental Health services 

As noted, some TCs have been fortunate to have the services of a consultant psychiatrist, resulting in 

better transition into the program, increased support at the program level, and more coordination at 

the re‐entry stage. Some TCs have Memoranda of Understanding in place with mental health 

services, and this has generally resulted in far better coordination of services, although it was noted 

that at times this could still be problematic – especially as TCs were often perceived as offering a 

level of safety and treatment which was not always the case. Consistently, those in the consultation 

talked about the concern to balance the needs of the individual against those of the community. 

Therefore, while there were real concerns about discharging clients with mental health problems, at 

times this decision had to be made in order to protect others in the community. 

The need for a sessional psychiatrist in consultancy role to provide consistency of treatment was 

raised a number of times during the consultancy. This allows a person who is placed on medication to 

be followed up consistently – to monitor treatment effects, how the person is progressing, and to 

review medications. There was a concern about duty of care within TCs and the need for someone 

who is legally able to take care of the person, especially in relation to psychiatric issues. At post‐ 

treatment there may be problems with people with complex mental health issues moving out of area 

and the need for the development of a shared care approach to treatment was consistently raised by 

TCs. Once again, this raised the concern for practitioners who are engaged to work with the TC to be 

sympathetic to aims of TC, and to have an understanding of its processes. The need to look carefully 

at referral processes was highlighted, as was the ability to work in partnership with mental health 

services to provide pathways for treatment, and the opportunity for earlier intervention and de‐ 

escalation of a crisis situation. 

Some concerns in relation to psychiatric support had more to do with the system than with the TC. 

For example, a scarcity of psychiatrists in a number of areas, and in particular, Adelaide, Canberra 

and Wagga Wagga, were seen as impacting significantly on the TCs ability to provide targeted 

support to programs. 

There was a strong recommendation for the development of Memoranda of Understanding between 

TCs and mental health services, to include both adult and, where applicable, child and adolescent 

teams, and especially crisis teams. Although The Woolshed is a Government service, the concerns 

raised by the TC were much the same as other NGOs, a lack of coordination between AOD and 

mental health and difficulty in accessing mental health and psychiatric support being of major 

concern. However, even where services did have protocols in place, there was a very real need to 

maintain communication and coordination and for shared education for both services – the TCs so 

that they had a better understanding of how to deal with mental health issues, and for the mental 

health and other medical services to gain an understanding of the way in which TCs operate. This 



would help to develop a better appreciation of both the strengths and limitations of the model in 

working with this client group. 

1.6. First stage of treatment 

The first stage of treatment in all programs is conceptualised as being between four to six weeks in 

duration, although many noted that at times this needs to be extended to provide enough time for 

the person to stabilise and ‘settle into’ the day‐to‐day operation of the TC. All agreed that this was 

the point of most concern in working with clients with ATS use. The use of the ‘buddy system’ within 

TCs is universally used, WHOS has refined this so that new residents are matched with a buddy who 

will understand the problems the person may be facing in relation to their mental health and lack of 

cognition and impulse control, and therefore provide reassurance and role modelling. This has 

assisted new residents to settle into the program, and provides a sense of support and hope. 

There was an acknowledgement of the need for flexibility, although this was not seen as either a 

relaxation of the boundaries or an invitation to rule breaking. There was some amusement about 

early TCs which considered a person to be looking out the window as not being connected to the 

treatment process or to have been deemed to have ‘split the program’. Similarly, someone falling 

asleep in a group or leaving a group or session without permission, may have resulted in discharge in 

early TCs. Flexibility to allow a person to ‘go off the floor’, to take a bath, to lie down or to have 

‘time out’ was seen as being both important and necessary to allow the person to adjust, especially 

in the early stages of treatment. 

The use of contingency management was highlighted and supported by a number of TCs in the 

consultation, usually relating to rewards for the person’s prosocial behaviour. The system 

introduced at The Woolshed provided another perspective on the use of this strategy, particularly as 

it concentrates on the development of peer support and mediation skills amongst the resident 

population, leading to greater self‐management and internal locus of control, rather than external 

systems. Odyssey Vic particularly noted this shift in treatment approach over the past 7‐8 years, 

with greater emphasis on self‐regulation, as distinct from external control and inflexible application 

of rules. 

Ironically, as TCs have modified their treatment programs to include more psychoeducation 

interventions, there has been a tendency to reduce the amount of time residents spend in 

traditional work programs. There are a number of reasons why this has happened, including the 

impact of Occupational Health and Safety and insurance requirements which have prevented many 

of the ‘real work’ activities from being undertaken, together with a realisation that shortening 

program length has required consideration of the need for interventions that address the person’s 

treatment issues being introduced earlier within the program. Added to this is the conceptualisation 

of the TC within a harm minimisation framework, providing a greater opportunity for education 

which addresses the possibility of a person’s continued and/or modified drug use, rather than the 

expectation of an abstinence‐only model. 

1.7. Treatment interventions 

The community‐as‐method remains the hallmark of TCs. Within this approach, the use of group 

counselling and peer support continue as primary treatment tools within the TC. However, all TCs in 

the consultations acknowledged a widening of interventions, with individual counselling and case 

management also included. A number of programs had also adapted interventions for use within 

the TC, and this included an adaptation of the PsyCheck model for use in groups by WHOS and 



Cyrenian; the Funky Monkeys group for clients with mental health problems at Mirikai and ‘Diggits’ 

Dual Diagnosis Program at Odyssey House, NSW. 

Meditation and Mindfulness groups were well supported in the consultations, particularly as they are 

useful for helping to quieten the mind and assist people to become centred. Tai Chi and Yoga were 

also considered to be useful. The need for activity through exercise and work programs was 

acknowledged as being important for this client group. Arts and crafts were also highly endorsed, 

with a number of programs, and notable Karralika, The Woolshed and Kuitpo, including art therapy 

and arts program as part of the overall program. Drama, drumbeat, music, performance and poetry 

and creative writing were also widely endorsed by TCs, providing recognition of the fact that a range 

of interventions are required to meet all needs. The need for multiple ways of accessing feelings and 

expression was highlighted, and a recognition that drug use is not always about escaping feelings, 

but also about accessing them. 

TCs use a range of interventions and resources – including CBT, ACT and Mindfulness‐based 

interventions. The use of Motivational Interviewing was also highly endorsed. A variety of group 

therapy interventions and support, often incorporating materials to assist clients to deal with 

problems stemming from shame, guilt, grief, denial and other issues, are widely incorporated within 

TC programs. With improved knowledge of mental health problems and a better understanding of 

the issues surrounding ATS use and comorbidity, TCs noted that clients are better able to support 

those who are experiencing mental health problems. 

1.8. Treatment protocol 

Recommendations from TCs included the development of Tip Sheets to assist staff, clients and 

families to understand some of the issues associated with ATS use, management of withdrawal and 

complex and aggressive behaviours; an intervention that would complement and extend existing 

interventions; and one which included CBT, ACT, Mindfulness and Motivational Interviewing 

strategies. As it is often the family who is making the initial contact, having material which provides 

support and psychoeducation was considered to be a valuable resource. 

TCs noted that they were now offering different groups and interventions for different population 

groups and issues. This includes anger management programs, groups for survivors of domestic 

violence, parenting programs, Wisdom Groups (for residents over 40 years of age), special youth 

groups or activities (for those under 25 years of age), dual diagnosis and art therapy sessions. 

Therefore, the idea of bringing particular groups of residents together for specific interventions or 

activities was not generally considered to pose too many problems, although the notion of closed 

groups had not been embraced by all TCs. 

Stepped care and contingency management strategies are often used by TCs, but many had not 

thought of these strategies in these terms. For example, all TCs provide a stepped care approach to 

treatment, including supportive re‐entry to the community. There was an acknowledgement of the 

need for flexibility around possible lapses and relapses, especially if these are accepted within the 

Stages of Change model. A process of bringing people back into a supported treatment phase of the 

program from a halfway house or re‐entry stage following relapse, rather than discharging them 

back into the community, had been adopted by many of the TCs taking part in the consultation. 

Finally, a protocol that is targeted at the first stage of treatment but would also be adaptable to 

some use within the assessment phase, particularly as there is more need to work with clients who 

are on a waiting list as this period has been extended out, was endorsed during the consultations. 



1.9. Postscripts from Prague: Perry Fletcher 

Feedback from the 1st Global Methamphetamine Conference: 

15 & 16 September 2008 

The Canberra Institute of Technology 

The Centre for Health, Community and Wellbeing 

1.9.1. Introduction 

An association between drug use and risk behaviour (HIV transmission) does not imply causality. 

Regional and global illicit drug reports are often incomplete, based on anecdotal reporting, as well as 

prevalence estimates. However, according to the United Nations Office of Drugs and Crime and the 

World Health Organisation, more individuals worldwide now use stimulants than opiates and 

cocaine combined. 

Methamphetamine abuse (use) has been found to be as receptive to treatment as other addictive 

drugs. Effects can include increased energy and alertness, decreased need for sleep, euphoria and 

increased sexuality. The duration and severity of a typical withdrawal from methamphetamine 

remains unclear. However, across the world, prevention and treatment options for 

methamphetamine users are not as available as heroin or alcohol treatment methods. No 

pharmacotherapy is available for the management of methamphetamine withdrawal and at the 

moment there are no specific pharmacological treatments available for treating methamphetamine 

overdoses. 

In terms of production, formula or recipes for methamphetamine production are widely available. 

Methamphetamine production is a relatively simple process, especially when compared to many 

other recreational drugs. (Oceania) Australia and New Zealand continue to produce significant 

amounts of methamphetamine and the production of Amphetamine‐type stimulants is a world‐wide 

issue where distributors are constantly finding new markets. Methamphetamine has replaced 

amphetamines without users being aware of it. Locally it is being used in conjunction with other 

more traditional drugs and is also included in the manufacture of party drugs, such as ecstasy. 

Globally, methamphetamine has become an immensely popular drug, second only to marijuana. 

However, there are specific risk behaviours arising from use by particular user groups and this can 

influence the direction of treatment and prevention from an individual sense. 

What needs to be considered is that methamphetamine is not a new drug, but importantly it has a 

wide range of different impacts for different populations. Therefore, strategies for future treatment 

and prevention delivery need to incorporate integrated services rather than the parallel services 

evidenced in the past. 

Currently the 2008 Global ATS Assessment suggests that in a sense there is a moral panic and an 

emerging consensus amongst experts that stimulant use is a unique and complex problem that 

presents a significant challenge to existing policies and strategies (Source: Conference advertising 

material), “yet the development of appropriate and effective responses to stimulants lags. In most 

cases treatment and prevention are inappropriately modeled on opiate and alcohol treatments 

ignoring the physical properties of the drug itself. Methamphetamine use patterns vary widely and 

effective responses must be tailored widely to the unique needs of regions, cultures and individual 

users”. 



Some Issues raised at the conference: 

1. The difficulty of measurement as, unlike hectares of plant based crops which can be spotted 

and measured using satellite and ground survey, ATS production facilities are much harder 

to detect. 

2. Secondly, is the simplicity of the ATS supply chain. The precursor chemicals needed to make 

ATS are produced by the tens of thousands of tonnes worldwide for legitimate industrial 

purposes. Methamphetamine can be produced by using off‐the‐shelf ingredients and easily 

obtainable recipes (the internet). 

3. Thirdly, is the link between ATS supply push and demand pull. ATS can be made in a 

household residence, or at least in the neighbourhood of distribution. 

Louisa Degenhardt, in her plenary session, delivered an excellent paper which reflected both global 

and individual methamphetamine use. Methamphetamine intoxication presents complexities for 

clinicians. Some of the questions that need to be asked are why has there been so little emphasis on 

methamphetamine? Does it need a specific focus? Should this examine prevention and patterns of 

use, harm, HIV and mortality? Does it need unique policy, treatment and research strategies? What 

is very clear, and this was mentioned by several speakers, is that methamphetamine is a 

stimulant/euphoric and this in itself may answer the need for all of the preceding questions to be in 

the affirmative. 

1.9.2. Methamphetamine and HIV Prevention: Current Challenges 

Louisa Degenhardt and Bradley Mathers contend there are four current challenges. These are: 

1. HIV prevention itself and the current challenges surrounding this. 

2. The epidemiology of methamphetamine. 

3. Methamphetamine and intravenous use. 

4. Prevention/reduction of HIV and other harms. 

A theme that emerged here was a common belief that methamphetamine users are being 

marginalised in relation to HIV treatment. When I consider the term “marginalisation” I see this as a 

term that is often applied to drug users and many others in society. It emphasises vulnerability in 

specific groups. However, methamphetamine or any other drug use, involves an element of self 

determination. This is combined with outcome effects, such as invincibility and disinhibiting 

behaviours. To me the concept of “marginalisation” becomes blurred. I also felt that there was an 

emphasis on causation of specific behaviours from methamphetamine use. 

Kapilla covered the biological, psychological and the behavioural patterns of use, relapse and 

recovery in gay men. There was an emphasis on behavioural relapse and a discourse emerged from 

the paper that was relevant to the group involved. Firstly, in Boston, methamphetamine users in 

this group experience euphoria, alertness and energy release. Sex had increased pleasure/loss of 

inhibition, and weight loss. 

1.9.3. Prevalence and Patterns of Use 

It is believed that it is only a matter of time before smokers of methamphetamine switch to injecting 

and naturally manufacturing will turn to more injectable, purer methamphetamine. The experience 

in Asia and SE Asia shows a significant increase in HIV transmission as a result of the changing 

patterns of use. The major consensus was that in most countries where methamphetamine is being 

used, it is concentrated amongst at‐risk populations. 



Another theme that emerged was episodic binge using (sessions). It was argued that patterns of 

daily use over a period of time are hard to maintain. It was also argued that an element of psychosis 

may be contributable to sleep deprivation. 

On a local level, it would be interesting to discuss the anecdotal evidence emerging that 

methamphetamine users are poly‐drug using in order to decrease methamphetamine use, or 

alternatively, to be able to have sustained sessions of methamphetamine use. What is clear is that 

many users have available ‘pharmacies’ amongst their associates which allows them to create 

‘leveling out’ phases in their use. 

There has been very little research into methamphetamine use and mortality. The clearly identified 

risk behaviours in some specific groups will require an increase in funding for a wide range of 

treatment and prevention services. 

1.9.4. The Duality of Methamphetamine Use and Disinhibition 

What becomes clear, is that the drug effects of disinhibition and aphrodisiac facilitates potential risk‐ 

taking and longer periods of risky sexual activity with longer windows for infection of STIs and HIV. 

This is a major concern in high risk sex worker industries, with SE Asia highlighted. 

Occupational patterns of use also need to be considered, with a predilection for the stimulant effect 

of methamphetamine desired by workers within other industries, including those not only involving 

sex work. Manual labour, transport and hospitality industries are some of these. 

1.9.5. Pharmacology of Methamphetamine 

In his paper Meds for Meth. Addicts, John Mendelson explored the possibilities of 

pharmacotherapies for methamphetamine addiction. Issues raised in this presentation included: 

• There was a lack of specific molecular target. 

• Methamphetamine induces cognitive impairment. 

• For the addiction life cycle, at which part of the process should intervention occur? 

• How does the pharmacology of methamphetamine impede drug development? 

• Most addictive drugs have a short half‐life whereas the effects of methamphetamine may 

last up to 12 hours in duration. 

• Successful agonist therapies (such as Buprenorphine in opiate dependency) need to remain 

longer in the system. Therefore a drug with a similar chemical structure to 

methamphetamine would be required. 

• Terbutaline (an asthma drug) and Dobutanine were chemically similar but not useful and yet 

to be tested. 

• The toxic effect of methamphetamine may make it hard for those who are dependent to 

stay in recovery. 

Dr. Alex Wodak, Director of the Alcohol & Drug Service at St. Vincent’s Hospital Sydney, NSW, 

presented a paper reporting on the results of substitution treatment from 1995‐2006. In his paper, 

he suggested that sedatives dominate policy, research and treatment, and that stimulants have been 

ignored. However, there has been a steady increase in consumption of Methamphetamine with a 

60% increase in psychosis from 1999‐2003. 

He supervises two pilot clinics with an emphasis on a separate identity from main stream services. 

These pilot clinics are service oriented, rather than research oriented. Six participants in these trials 

had substitution therapy over the reporting period and were stabilised rapidly with strictly 



controlled dosing. The program follows a stepped care approach with clear baselines for entry. 

Results showed significant improvement in mental health, social and family life. 

Dextroamphetamine (D‐Amphetamine, and also known as dextroamphetamine sulphate, 

dexamphetamine, Dexedrine, Dexampex, Ferndex, Oxydess II, Robese, Spancap #1, and, informally, 

Dex) is a psychostimulant which has been used as a therapy in limited trials. It was emphasised that 

dexamphetamine was mainly used with people with severe dependency, such as the use of 2 grams 

or more a day. Methamphetamine and dexamphetamine have similar chemical compounds, making 

dexamphetamine a possible amphetamine substitution therapy. Dr Alex Wodak talked of the 

positive effects of the use of dexamphetamine in extreme circumstances. However, clearly there is a 

need for associated support services. 

Dexamphetamine substitution is only needed for treatment of a refractory minority. (It should be 

noted that 60 grams of dexamphetamine is a large substitution dose). It appears effective and safe, 

but needs a better sustained release option, which is currently not available in Australia. Many 

come seeking dexamphetamine treatment but because of delays accessing this, they apparently 

successfully undertook a treatment intervention without the use of dexamphetamine. 

The key finding was that non‐pharmacological treatment attracts, retains, and benefits many 

stimulant users. It is simple, inexpensive, effective and needs to be widely implemented. 

From my perspective, it seems that a window of opportunity exists: 

• It seems apparent that there is a need for innovative public health interventions that 

recognise the unique responses and drug using patterns of specific groups. 

• There is a clear need for high levels of biopsychosocial interventions. 

• Programs should be integrated rather than parallel. 

• Provision of a sustained release dexamphetamine should be made available in Australia for a 

small percentage of clients. 

There was little discussion on co‐morbidity at the conference. Methamphetamine clients respond 

well to intense treatment that is emotionally supportive and non‐judgmental. Whether there needs 

to be an identity approach around ‘meth users’ is debatable as many users in Australia were heroin 

users prior to commencing methamphetamine, and indeed many still are. There is also the major 

issue of binge using and polydrug use, which has the potential to distort treatment. 

Nationally HIV infection notifications may increase because of identified areas of risk, such as those 

identified earlier. There is also need for concern in relation to increased use, and particularly 

injecting use, in Asia. There is the potential for significant impact if Australian tourists engage in 

risky behaviours whilst overseas. However, the adoption of harm reduction strategies provides 

positive opportunities for change for methamphetamine users. 

1.9.6. Treatment, withdrawal, medications and interventions 

In his outstanding presentation, Richard Rawson spoke of the complexities of providing treatment 

for methamphetamine users. He identified that some of the clinical challenges were due to the 

existence of conditions of anhedonia and dysphoria existing with users particularly during 

withdrawal. These conditions are also accompanied by severe craving for the drug. Part of the 

problem of relapsing to methamphetamine is the severity of the unpleasant emotional and cognitive 

impairments that may also continue months after cessation of use. There was consensus that 

methamphetamine use may coexist with persistent psychotic disorders for some groups but the 

general consensus was that methamphetamine use does not cause disorders such as schizophrenia. 



Psychosis can be transitory, developing with methamphetamine use and continuing after use and 

possibly cessation of use. 

Due to the lack of clinical trials in regards to methamphetamine treatment it was a revelation for me 

at the conference to find some outstanding results in regards to non‐clinical treatments. From Russia 

to Australia it is clear that holistic programs that embrace a wide range of non‐clinical interventions 

that include emotional and cognitive support of clients are having excellent success rates with 

amphetamine clients. 

A Russian study that could have been titled from Russia with Love, studied outcomes from intense 

abstinence based live‐in support services that encompass a wide range of cognitive and relaxation 

interventions, such as yoga. Results showed that cognitive impairment measured on admission 

improved dramatically after only two months of this kind of support. 

There was an argument, which came mainly from American sources, for the use of naltrexone 

implants for the treatment of Amphetamine‐type stimulants. Closely linked to this was the finding 

that oral naltrexone and anti‐depressants improved rates of abstinence. However one trial for 

naltrexone implants (1000mg of naltrexone per implant) excluded anyone with any psychiatric 

history. 

It appears (and to me this is a highlight of my findings from the conference) that methamphetamine 

users may have a high potential for change with high levels of support/counselling interventions. In 

fact only a small number will benefit from amphetamine substitution therapy. 

What is difficult to measure is the lasting effect of diminished cognitive functioning from prolonged 

methamphetamine use. Research has shown that injectors have the most significant 

disorders/problems. These may include: 

• Paranoid reactions; 

• Protracted memory impairment; 

• Depressed dysthymic reactions; 

• Hallucinations (mainly auditory); 

• Psychotic reactions; 

• Rapid addiction; and importantly, 

• Anhedonia (the inability to gain pleasure from enjoyable experiences). 

Methamphetamine use may co‐exist with persistent psychotic disorders for some groups, but again, 

the general consensus from the conference was that methamphetamine use does not cause 

schizophrenia. 

Apart from evidence that there are difficulties for some users in retaining positive outcomes from 

treatment, there have been some varying results of replacement therapy with dexamphetamine. 

The UK experience over 30 years has shown unreliable results with some scientific validity lacking. 

What is clear is that there isn’t a need for long‐term interventions such as methadone. What is clear 

and is also significant with alcohol/cocaine interventions, is that there needs to be a shift from 

parallel treatments/interventions to those that are integrated. 

Richard Rawson spoke of the success of Contingency Management. The premise behind 

Contingency Management is to utilise reinforcement procedures systematically to modify 

behaviours of substance users in a positive and supportive manner. Recent meta‐analysis of 

contingency management in drug programs showed that it has a large effect. These contingencies 

are delivered based on abstinence and attendance goals and can take the form of vouchers or 



privileges. They have been used with drug addictions as well as dual diagnosis. Overall, contingency 

management has been found to be a useful and cost effective addition to drug treatment. 

1.9.7. The relationship between methamphetamine use, anger and aggression 

There has been little research into the relationship between methamphetamine use, anger and 

aggression. Melissa Claire, a clinical researcher from The University of Newcastle, NSW, found 

several key points from her research and clinical dealings with methamphetamine users. These key 

points are: 

• There were high levels of psychiatric distress with clients who used methamphetamine. 

• She queried whether the anger was trait anger (and that the clients had angry 

personalities). 

• There was a clear need for peer acceptance amongst clients. 

• Poor social skills and lack of confidence in meeting the demands of other people were 

observed. 

• Those who experienced personality deficits reported that methamphetamine boosted 

self‐esteem. 

• There needs to be an understanding of the relationship between anger as a precipitator 

of violence and outcomes of her research included the recommendation that anger 

screening be included as part of the assessment process. 


1.9.8. References 


Borodkina, O. (2008). Social Aspects of Methamphetamine Injection in Russia. Adiktologie No 2 

supplementum, Journal of Prevention, Treatment and Research of Addictions, Sdruzeni. 

Claire, M., Lewin, J., Lee, N., Baker, M., & Carr, V. (2008). Why do Substance Users Choose 

Methamphetamine and How Does this Impact on Treatment: The Relationship Between 

Methamphetamine Use, Anger and Aggression: An Expression of Self. Adiktologie No 2 


Degenhardt, L., & Mathers, B. (2008). The Global Methamphetamine Picture: Existing evidence on 

Worldwide Use and Association with HIV. Adiktologie No 2 supplementum, Journal of Prevention, 

Treatment and Research of Addictions, Sdruzeni. 

Douglas, J., & Nice, M. (2008). Global ATS Situation Assessment/Global Synthetics Monitoring: 

Analyses Reporting and Trends Programme. Adiktologie No 2 supplementum, Journal of Prevention, 


Mendelson, J. (2008). Meds for Meth. Addicts: An Exploration of the Challenges and Opportunities 

to developing Pharmacotherapies for Methamphetamine Addiction. Adiktologie No 2 


Rawson, R. (2008). The Methamphetamine Epidemic in the U.S: Speed, Crank, Crystal, Ice and Tina 

and the Public Health Consequences. Adiktologie No 2 supplementum, Journal of Prevention, 


Wodak, A. (2008). Dexamphetamine Substitution Treatment for Stimulant Users. Adiktologie No 2 


Zabransky, T. (2008). Methamphetamine in the Czech Republic. EU Pervitin Deviance or Laboratory 

of EU Drug Future. Adiktologie No 2 supplementum, Journal of Prevention, Treatment and Research 

of Addictions, Sdruzeni. 





2. Information from Therapeutic Community Consultations 

2.1. Report of Gold Coast Consultation 

Fairhaven 

Goldbridge 

Logan House 

Mirikai 

The Buttery 

WHOS Najara 

Prevalence and related issues 

• Mirikai is working with young people primarily who often have positive symptoms of psychosis. 

Amphetamines 

28% 

Prescription 

1% 

Cannabis 

25% 

Figure 4. Mirikai & Oasis ‐ Primary Drug of Choice 

Anti‐social PD 

6% 

Schizophrenia 

4% 

Poly‐substance 

6% 

Schizo‐affective 

6% 

ADHD 

4% 

Dep/anxiety 

7% 

Borderline PD 

7% 

Aspergers 

2% 

PTSD 

2% 

Figure 5. Mirikai ‐ Mental Health Primary Diagnosis 

Morphine 

3% Heroin 

13% 

Depression 

32% 

Bipolar 

13% 

Drug induced 

psychosis 

9% 

Alcohol 

30% 

Estimated 60% of intake at Mirikai have ATS use, this includes 28% who nominate ATS as their 

primary drug of choice, and others who are polydrug users, including ATS use. 

Anxiety 

2% 

These percentages are based 

on primary diagnosis only. 

Many clients have a 

secondary and/or other 

diagnosis as well, which adds 

to the complexity. 



• Goldbridge reported the principal drug of concern was Cannabis (28.40%) followed by 

Amphetamine‐type substances (15.98%). The principal licit drug of concern was Alcohol 

(15.38%) 

Table 8. Goldbridge ‐ Main Drug of Concern: 2007‐2008 

CANNABIS 48 28.40% 

AMPHETAMINE‐TYPE SUBSTANCES 27 15.98% 

ALCOHOL 26 15.38% 

HEROIN/OPIOIDS/METHADONE 26 15.38% 

ECSTASY (MDMA) 15 8.88% 

BENZODIAZIPINES 9 5.32% 

COCAINE 8 4.73% 

OTHERS (SOLVENTS/HALLUCINOGENS/POLYSUBSTANCES 6 3.55% 

LSD 4 2.37% 

TOTALS 169 100.00% 

Table 9. Goldbridge ‐ Mental Health Status of Clients: At Assessment 2007‐2008 

AFFECTIVE/ DEPRESSION/ BI‐POLAR 52 30.77% 

ANXIETY 31 18.34% 

PTSD 10 5.92% 

PERSONALITY DISORDERS 10 5.92% 

EATING DISORDERS 3 1.77% 

PSYCHOSIS 2 1.18* 

SCHIZOPHRENIA 1 0.60% 

TOTAL 109 64.50% 

• 109 clients met the diagnostic criteria (ICD‐10) for a Mental Health Disorder. 

• Affective and anxiety were the most common mental health problems co‐occurring with a 

primary substance‐use disorder (misuse or dependence). 

• WHOS Najara estimates 70% of clients presenting with ATS use. 

• The Buttery notes a relatively low prevalence of ATS presentations, at about 16%. 

• Logan House estimates around 33% of residents presenting with ATS use issues. 

Assessment process 

• Mirikai often does a pre‐assessment within the hospital setting. Psychiatric history, reports and 

comprehensive information collected. 

• If the person is in hospital, Mirikai will do joint case management session with mental Health 

staff. This will be followed by full clinical assessment and contingency plan developed. 

• Within Mirikai, person is referred to Dual Diagnosis Worker and a plan is developed for the TC 

which will provide necessary support. MH nurse will also do a risk assessment on admission. 

• During assessment phase of the program, Mirikai residents will be booked in to see the 

psychiatrist who consults on site. If necessary, medication will be prescribed and current regime 

monitored. 

• Some residents will become ill where symptoms do not resolve. 

• Weekly review meetings are put in place once the person is in treatment – these comprise 

psychiatrist, psychologist, Dual Diagnosis worker, TC Worker and nurse. 

• Goldbridge includes MH information in assessment and also concentrates on more individual 

assessments. Need for more work around the assessment process, realistically assessing what 

program can manage within constraints. Acknowledged that if the person has positive 



symptoms they may need to be screened out and referred elsewhere, as program may not be 

able to constructively address issues. 

• Fairhaven will have initial contact through assessment, when drug histories are established. 

• Mental Health issues are not always disclosed at assessment, and therefore only become 

apparent once the person is admitted. 

• WHOS does not do anything specific around assessment – there is phone assessment that is 

comprehensive, and this is followed by second assessment on admission. 

• If there is a MH history or evidence of self‐harm, WHOS will seek MH report. If there are 

significant problems, and the person cannot be stabilised, they may not be accepted into the 

program and referral will be made. If there is a long MH history, then an attempt will be made 

to work in conjunction with MH. Noted that the Crisis Team has been very responsive. 

• The Buttery also undertakes a telephone assessment and will accept residents with affective 

disorders, but does not take people with major psychiatric disorders. These people will be 

referred to other programs (e.g., Endeavour House). 

• At The Buttery, type of drug use is not focused on in explaining behaviours. A MH history is 

taken, and psychiatrist brought in to assess and possibly prescribe. 

Violence, physical effects and effect on TC, staff and families 

• Issue noted by Goldbridge is physical space limitations within facility. This makes it difficult for 

people to have “time out”. 

• There is sometimes a lack of staff understanding of issues and treatment strategies. 

• Noted by Goldbridge that high levels of paranoia may result in reactivity to point where person 

becomes violent. 

• Therefore there is a need for a modified program in response to client presentation. 

Mental Health issues 

• Mirikai noted cases may be very difficult and complex. Needs to be accepted that not 

completing the program may not be a sign of failure. 

• Need for flexibility. 

• If it becomes apparent that diagnosis is more permanent, then Mirikai will attempt to engage 

family in ongoing care. This includes getting the family to see the psychiatrist and attend Family 

Support Groups. 

• Noted by Fairhaven, that MH issues may become apparent through behaviours in first weeks of 

treatment, necessitating ongoing assessment and review. 

• Issues may not be ATS related, but often cannabis and other polydrug use. 

• WHOS noted that sometimes there are issues with people who have high needs, especially 

those on medication, who may not be able to fit within the program. 

• WHOS does have a nurse, but no MH professionals, although staff have some MH training. They 

are beginning to embrace MH issues, but are also more likely to utilise outside supports. 

Screening is undertaken through the use of PsyCheck and K10. 

• Logan House noted higher level of anxiety amongst ATS users, also depression. This is 

addressed in the context of treatment‐interfering behaviours. 

Relationship with Mental Health services 

• Mirikai has MOU in place with MH. Has also recently gained accreditation under National 

Mental Health Standards. 

• Mirikai staff have also undertaken studies in MH (inc. Diploma in Mental Health) as well as AOD. 

• Need for common language between MH and TC and understanding of the constraints and 

possibilities each can offer. 



First stage of treatment 

• Residents at Mirikai have a Buddy – but there are some exemptions in first weeks to encourage 

the person to settle in, e.g., Time to go for a walk instead of attending group. If the person 

becomes overwhelmed, they may go to bed early. 

• There is a formal diagnosis and full psychological evaluation (inc. personality testing) carried out 

at Mirikai. 

• Mirikai adopts a crisis management approach – including medication. 

• Others in TC receive information and education about diagnoses and how this is being managed. 

Therefore other residents are aware of treatment issues and provided with information about 

what they can do to assist another resident. 

• Acknowledged that it is very often very stressful for other residents and support and 

information is provided on group and individual basis. 

• At Fairhaven, there is a re‐assessment after three weeks within treatment program. At this 

point the person may be retained in the early program stage and assessed through GP and 

provided with psychologist referral. 

• Individual case management and review takes place at Fairhaven. 

• At WHOS, resident is expected to comply with program, but PsyCheck screen will be undertaken 

and intervention provided. Medicare referrals are used to outside psychologists. 

• At Logan House, the Induction Phase is designed to minimise levels of distress, interfacing with 

the doctor, and more emphasis on physical and mental health. 

• More residents will exhibit internalising behaviours, rather than externalising, and this may be 

moderated by the older peer group. 

• Logan House has an early and functional assessment – behaviours explored and categorised, 

externalised for the community – providing juxtaposition between subjective and objective. 

There is a high level of clinical interventions sitting behind this. 

• Logan House also concentrates on the behaviour, rather than the person – what are the things 

that will lead you to walk out of here or be discharged – how can these behaviours be 

minimised? 

Treatment interventions 

• Mirikai special group – “Funky Monkeys” – concentration on issues of anxiety. Not only ATS 

users but others included where MH issues are a concern. 

o Allows residents to relax and talk about issues. 

o Arts based rather than feelings based groups. When issues are resolved, person will then 

go back into main TC. 

o Twice weekly there is Psychoeducation – e.g., Assertiveness training, encouragement to 

address underlying issues. Also outings incorporated into the program, recognising that 

program is quite intensive for this group of people. 

• Mirikai has Home Groups, and people will return to these once they become well. They will be 

taken back to “Funky Monkeys” if clinical symptoms deteriorate after discussion at Clinical 

meeting. 

• At Mirikai, if the person is not doing well at the end of Stage 2, they may be stepped into one of 

the halfway houses (Clarity Houses) which have been developed with MH funding and managed 

by the Dual Diagnosis Worker. 

• Mirikai has halfway houses, including Clarity Houses. Also provides a six week Minimal 

Intervention Program (MIP) when relapse occurs or person becomes mentally unwell. If this 

occurs, the contingency plan will be redeveloped. 

• Mirikai prefers people to move into HWH in clusters, provide support to each other and receive 

ongoing support from Dual Diagnosis Worker and psychologist (who they continue to see under 

Medicare). 

• These people may need to be in transitional care for some time. 



• Noted by Goldbridge that staff may have limited training in MH. 

• Awareness of creating another “sub‐group” within the treatment setting. 

• Need for modified groups, which are less intensive and confrontational. 

• Need to find a balance – it is easy to tip the balance if too many clients with complex needs are 

in treatment at one time. 

• Concentration on Living Skills and experiential learning at The Buttery, complex issues are 

addressed in parallel with the community. 

• Concerns raised by Logan House include: 

o Anxiety issues, resulting in low attention span. 

o Need to take care of basics – relapse prevention, personal hygiene, why are we here? 

o Treatment provided as ROCK and ROLL – which translates as: 

Recovery Recovery 

Orientation Ownership 

Concepts Living the 

Knowledge Learning 

• Logan House groups are inclusive for all residents – noted that stimulant use is associated with 

anxiety and alcohol use with depression. 

• There is also an “In‐Out” house which provides time out where necessary for a period of time 

and is a staff supervised community house. 

Treatment protocol 

• Treatment protocol developed in context of Community‐as‐Method. 

• Currently there are several things that TCs do that support good practice – 

o Individual treatment plans – may have more CBT and Acceptance Commitment Therapy 

(ACT). 

o Those with diagnosis of Borderline Personality Disorder (BPD) access Dialectic Behaviour 

Therapy (DBT). 

o At Mirikai, approach used by whole team. 

o Behavioural management used to tailor consequences. 

o AHOS have designed a four session PsyCheck Group, rather than using it as individual 

intervention. This concentrates on identifying unhelpful thoughts and includes relaxation 

to address anxiety and depression. 

• Group format seen as an essential element of protocol. 

• Peer support necessary. 

• Manual developed for first stage (3‐6 weeks) of treatment. 

• Need to respond to symptoms, including brain damage. 

• Therefore there is a need for quite basic information in first weeks, e.g., personal hygiene, diet, 

dealing with cravings, stress management. 

• Harm minimisation focus – improve circumstances, focus and not be confused. 

• Contingency management principles – Walk About Money (WAM) and other privileges for 

positive behaviour. 

• Noted that ACT often better than CBT, Mindfulness very useful to consider, need to be focused 

on group intervention. 

• Basic management skills and emotional regulation. 




2.2. Report of Sydney Consultation 

Blue Mountains Recovery Services 

Odyssey House 

Selah Farm 

WHOS 



• Odyssey House reported alcohol identified as the primary drug for residents entering the 

residential program, ATS identified as primary illicit drug. 

• Odyssey House noted higher degrees of paranoia, anxiety and depression and difficulty for 

residents to focus on treatment needs. 

Alcohol 

Amphetamine Type Substances 

Heroin 

Cannabis 

Methadone 

Benzodiazepines 

Buprenorphine 

Cocaine 

Morphine 

Inhalents 

Ice Speed 

0 20 40 60 80 100 

Figure 6: Primary Substance Use of Clients Admitted into the Odyssey House NSW TC 

Cannabis 

Alcohol 

ATS 

Benzodiazepines 

Heroin 

Ecstasy 

Cocaine 

Buprenorphine 

Morphine 

Methadone 

0 10 20 30 40 50 60 70 

Figure 7: Secondary Drug of Choice Identified by Clients entering the Odyssey House NSW TC 



Figure 8. Odyssey House NSW ‐ Comparison 2006/2007 with 2007/2008 Primary Substance Use 

identified upon admission to the TC: Percentage of the Total Admissions 

Clients admitted without a Dual Diagnosis – 56% 

Clients admitted with a Dual Diagnosis – 44% 

Figure 9. Clients Admitted to the Odyssey House NSW TC: July 07 to June 08 with a Dual Diagnosis 

Depression 

Schizophrenia 

Schizophrenia 

4% 

Bi Polar 

Anxiety 

Psychosis 

BPD 

PTSD 

Bi Polar 

4% 

1 

0 20 40 60 80 100 

Other 07/08 ‐ 5% Other 06/07 ‐ 6% Methadone 07/08 ‐ 6% 

Methadone 06/07 ‐ 8% Cannabis 07/08 ‐ 18% Cannabis 06/07 ‐ 15% 

Heroin 07/08 ‐ 19% Heroin 06/07 ‐ 19% ATS 07/08 ‐ 23% 

ATS 06/07 ‐ 20% Alcohol 07/08 ‐ 29% Alcohol 06/07 ‐ 32% 

Depression 

33% 

Anxiety 

2% 

Schizoaffective 

Disorder 

2% 

No Diagnosis 

55% 

Figure 10. Grouped by Diagnosis/Drug use – Odyssey House NSW 


OCD 

0% 

Psychosis 

0% 

1 

No Diagnosis 

Depression 

Bi Polar 

Schizophrenia 

Anxiety 

OCD 

Schizoaffective 

Disorder 

Psychosis 

0 20 40 60 80 100 120 140 160 180 200 

Alcohol ATS Heroin Cannabis Ecstasy Cocaine Methadone Codeine Morphine Benzodiazepines

ALCOHOL 

ATS 

CANNABIS 

METHADONE 

HEROIN 

MORPHINE 

ECSTASY 

BUPRENORPHINE 

CODIENE 

COCAINE 

8 

7 

4 

1 2 

2 

1 

17 

15 

1 3 

11 

1 

Figure 11. Grouped by Drug Use / Diagnosis: Odyssey House NSW 


33 

3 

2 11 

8 

• Blue Mountains Recovery Services (BMRS) reported approximately 30‐40% of clients presenting 

to treatment have ATS use. The major concern is their inability to settle within the program, 

sometimes resulting in unsafe and violent behaviours. 

• Selah Farm noted that 30% of residents attend with issues relating to ATS use. 

• Salvation Army noting 16% across all services are presenting with ATS noted as primary drug, 

48% have MH problems. 

• WHOS currently undertaking research project. Note around 800‐900 admissions per year where 

ATS use an issue. 

o 2005‐06: 60% Regional and 30% in Metro identified ATS use. 

o 2006‐07: 44% Regional and 27% Metro identified ATS users. 

o 2007‐08: 43% Regional and 25% Metro ATS users. 

o ATS use linked with clandestine laboratories and bikie gangs. 

o ICE is drug causing most of the concerns. Heroin users also presenting with ATS use and 

99% are injecting. 


• Assessment process seen as being more complex, need for more information, especially relating 

to MH history and presentations. 

• This can be time consuming as it requires more follow‐up. 

• More focus on chronic drug use than type of drug. 

• Treatment population reflective of wider population, e.g., Salvation Army noting Townsville 

program serves more transient population. 

• These are high maintenance clients, need to distribute over caseworkers and fewer clients 

where there are complex issues. 

• Need to be abstinent for 3‐4 weeks before diagnosis made. 


• Residents are aware of the physical consequences – wear and tear on the body, violence and 

aggression. They don’t like the effects on a personal level and are very often aware of what it is 

doing to families. 

• People have often been homeless because of a range of issues, often related to behaviours, and 

as a consequence will also have greater physical problems. Sometimes they are unable to be 

admitted because of physical problems. 


2 

1 0 10 20 30 40 50 60 

Depression Schizophrenia BiPolar Anxiety Psychosis PTSD BPD 

3 

10 

1 

4 

11



• There is a greater need for more individualised work, and this in turn puts greater stress on 

other aspects of the program. 

• Concern around relationship between MH and AOD use – which came first, will symptoms abate 

when drugs are withdrawn? 

• Selah requesting MH reports prior to the person being admitted into program. 

• WHOS noted that where MH issues were underlying drug use, these will not fully resolve and 

will need to be addressed. Where MH problems are secondary to drug use, then the person will 

usually stabilise after approximately two months in treatment. 

• ATS use has always been prevalent, but there has been a significant increase in general 

population, and this relates to increased MH problems. 

• Not the same level of cognitive skills and therefore more need for “time out” within the 

program. 

• More individual treatment required. 


• Need to build relationships with MH services. 

• Some programs, e.g., Odyssey House, have psychiatrist as consultant to program. 

• Important to develop MOU and to develop relationship with services. 

• More concentration on comorbidity – programs generally developing structures and 

relationships as part of Improved Services delivery model. 


• BMRS note a need to change way they do case management, more social work interventions – 

need to engage doctors and medical services. There is more health care that is not program‐ 

focused. Therefore getting people to focus and undertake program can be difficult. 

• Odyssey reported that the initial assessment phase of the program was the most difficult, but 

that if residents could move through this they are likely to settle into the program. This is the 

point where most leave treatment, however they generally return and are more settled on the 

second treatment attempt. 

• Odyssey has psychologists who will identify and assess through psychological testing ATS users 

and those with complex needs. There is an emphasis on peers working with these residents and 

helping to “pull them through”, especially as they generally take longer to settle. 

• There is a need to make minor adjustments to the program and consider memory loss, lower 

attention span. 

• Where necessary, residents are able to leave group and to return when settled. If they remain 

they often become disruptive to other group members. 

• Where the first stage of Odyssey House is usually four weeks, this may be extended to six weeks 

for ATS clients. 

• WHOS also noted lack of ability for residents entering treatment to focus. 

• WHOS Hunter Valley introduced some new interventions to hold new clients – including 

matching buddies (i.e., resident who had been an ATS user matched with ATS user entering 

program). This provides opportunity for identification and understanding of how the person is 

feeling and what they might be experiencing. 

• More ATS users leave the program early, but WHOS finding that if they remain for 30 days they 

are more likely to complete the program. 

• Allowed to go off the floor and to have some acknowledgment of physical problems – take baths 

etc. Need to have less cognitively‐based information and more physical work in early stages. 




• Odyssey House has introduced “Diggits” – Dual Diagnosis Program. The main focus is on MH 

problems and how to manage these. 

o Program is run by psychologist, group meets weekly and addresses a different issue each 

week. 

o This assists residents to cope in the main therapy groups, and provides more support. 

o There is acceptance of MH problems and the issue of relapse. 

o The need to remain on medications is also addressed. Noted that often residents want to 

be like others – and will therefore take themselves off medications prematurely. 

• WHOS have adapted PsyCheck into group model as four week (four sessions) intervention. 

Residents attending PsyCheck groups not labelled. Staff have become more confident in 

screening, and as a consequence there are better retention rates. 

• WHOS also seeks outside treatment for residents with low prevalence disorders. 

• Everyone is mainstreamed, but there are “add‐ons” where necessary at an individual case work 

level. 


• More people needing aftercare support and longer time in HWH. They may be harder to place 

elsewhere, they want recovery and want to stay in treatment. 

• Need for more aftercare services. 

• Need to accept slips and relapse – this is not a reason to bring people back into the program, but 

to provide additional support at HWH and aftercare stage. 

• Best to look at this in the context of where they are – may need a “symbolic” discharge, address 

the issue and put the person back into aftercare. 

• There is a need to explain and persuade staff why the program needs to change to adopt a more 

flexible treatment approach. 

• Adjust ATS/MH interventions rather than adjust program – maintain expectation on 

participation, even though person may need extra consideration – time out, baths, walks etc. 

• Need to inform the community – ask staff and residents, what can we do for this population? 




2.3. Report of Melbourne Consultation 

Odyssey Vic 

YSAS 

YSAS – Birribi 

Windana 



• Numbers presenting for treatment where ATS use nominated as primary drug not immediately 

available, other than Birribi with a reported rate of approximately 3%. 

• Windana and Odyssey Vic reported fairly low numbers, although it was noted by all programs 

that ATS was used within the context of polydrug use. 

0.35 

0.3 

0.25 

0.2 

0.15 

0.1 

0.05 

0 

Figure 12. Windana: Total percentages ‐ presenting drug of concern on admission 2006‐2007 

0.4 

0.35 

0.3 

0.25 

0.2 

0.15 

0.1 

0.05 

0 

Figure 13. Windana: Total percentages ‐ presenting drug of concern on admission 2007‐2008 



• YSAS noted many young people will use sporadically, but more likely to nominate Ecstasy as part 

of regular use. 

• Those who come into treatment with any amphetamine use are likely to be more chaotic and 

will take longer to settle down. These people are also at greater risk. 


• Program stages are noted as being more important with this group – detoxification prior to 

treatment. 

• Noted by Odyssey Vic that it is important to “ground” people, but that they will then become 

quite stable over time. 

• Claims by some that it takes up to 12 months for cognitive functioning to properly return. 

• Noted by YSAS that there is a substantial group of young people with MH issues, not necessarily 

related to ATS use, although Ecstasy users experience mood swings which do not seem to 

stabilise for about two months after entering treatment. 

• Also noted by Windana that thinking is often “scrambled” and that people will take some time 

to settle. 

• Services become stretched if too many people with ATS use problems are admitted into the 

program at one time. 

• Odyssey Vic acknowledged that the program is increasingly responding to MH issues, and that 

assessment may be difficult. Constant monitoring is needed and the formulation of a diagnosis 

should be delayed until symptoms have abated. 

• There is a need to respond to MH issues and to recognise issues of dual diagnosis. 


• Need to consider how much we are prepared to tolerate, remembering that someone else may 

be at the receiving end of the person’s behaviour. 

• We may end up with protecting the perpetrator rather than the victim. 

• May need to be flexible in relation to some MH conditions and parents and children entering the 

program. 

• YSAS noted a need to educate staff to expect more challenging behaviours and to alter response 

in relation to consequences for “acting out” behaviours. 

• Windana noted need for staff to be more tolerant and compassionate, and to practice tolerance 

and latitude. 

• There was need for gradual modification of staff attitudes. 


• Because residents need to be monitored and may need more reassurance, more tolerance is 

also required. Hence, Windana noted need for latitude and this may require more individual 

case management. There is always the need to balance this within the TC. 

• There is a risk of shifting the focus, and overcompensating. 

• Issues often relate to personality disorders, rather than drug type. 

• Use of solvents experienced by YSAS. This causes brain damage and 4‐6 weeks into the program 

this group may become difficult to manage. Difficulty in multi‐tasking. 

• Young people more likely to use cannabis and alcohol as primary drugs. 

• If MH issues are concern, the person may see a psychiatrist soon after entering the program, but 

may then be monitored for some time before a diagnosis is made. 

• One of features of TCs for people with MH issues was more frequent but shorter groups. 

• In a smaller TC it is difficult to cope with different groups. There is a need for a wider curriculum 

and this may be difficult to manage. Need for separate focus groups. 




• Many of YSAS clients have been engaged with MH through Child and Adolescent MH Services 

(CAMHS) from age of 12 and 13 years. 

• There is a need to maintain strong MH relationships. 

• Both YSAS and Odyssey Vic have had need to call crisis Teams. 


• YSAS reported many young people struggle with grounding on first entry to the program. 

• Odyssey Vic also noting that this population group is more difficult to stabilise in the initial 6‐8 

weeks of the program. They may also need constant reassurance. 

• Most important to provide differentiating treatment approaches in first three months of 

treatment. 

• More tolerance needed, but again this is an issue of balance. 

• Less punitive response which facilitates community to regulate and seek other treatment 

options. 


• Treatment environment has become modified with different populations seeking treatment. 

• More flexibility, however if people are to remain, the general rules still need to be applied. 

• Need to make allowances for comorbid presentations and MH conditions. 

• Noted by Odyssey Vic that there has been a shift over the past 7‐8 years with greater emphasis 

on self‐regulation, distinct from external control and application of rules. There is value in this 

approach. 

• Odyssey Vic noted Motivational Interviewing and motivational therapies – and wondered how 

useful they might be in retaining people in treatment? 

• Need to cut down on the frequency of groups and include more individual counselling. 

• Needs to be an acceptance of MH problems, many people will want to come off their 

medications “to be like everyone else”. This needs to be assessed and monitored. 

• Odyssey Vic developing a project through Richmond office called Eclipse Project which focuses 

on ATS and MH issues. Aimed at working with families and young people by engaging key 

agencies. 


• Need for Tip Sheets that give some advice for staff and residents. Need to be less rigid, but 

balanced boundary setting. 

• Youth do not always respond well to CBT. 

• Youth may also experience difficulties in handling the TC structure, and will need help to cope. 

• Noted that TCs have different groups for different populations – e.g., parenting, alcohol, 

Wisdom Groups (over 40s), Young Adults. Any group for ATS or MH clients should be adjunct to 

general community. 

• There is a need to be constantly organic, and for the community itself to wrestle with many of 

these issues. 

• Windana noted the need for appropriate use of staff to guide the process. 

• Rewards may be given in form of vouchers – contingency management. This could be a mug, 

Sanity voucher, lunch out for group etc. 

• Psychoeducational material can be adapted and used on an ad hoc basis. 

• Need for collective sharing of load amongst staff. 

• Multiple interactions. 

• Facilitation of process and capacity to share load. 




2.4. Report of Perth Consultation 

Cyrenian House 

Palmerston Farm 

Serenity Lodge 



• Cyrenian House staff reported that amphetamines and alcohol were the major drug issues 

reported by clients entering programs. 

• Information collected on admission from 2007‐08 shows amphetamines was reported by 207 

females and 325 males as principal drug of concern. This was followed by alcohol, which was 

reported as principal drug of concern by 137 females and 183 males. 

• The person’s drug use issues may be further compounded by the use of cannabis, which is often 

used to self‐medicate and manage a mental health condition. 

• ATS is much more of an issue for young people, especially as drug effects are more instant. 

Number of clients 

350 

300 

250 

200 

150 

100 

50 

0 

Figure 14. Cyrenian House Principal Presenting Drug by Gender 2007‐2008 

9 

8 

7 

6 

5 

4 

3 

2 

1 

0 

Figure 15. Cyrenian House Principal Drug of Concern 2007‐2008 

Female 


Male


• Client group crosses all occupations – Army, Navy, chefs, nurses, and hairdressers. 

• High use of ATS in WA (highest in Australia) – mines, truck drivers, less social activity, more 

manufacturing in WA, closer to Asia, less cocaine. 

• Greater availability. 

• If using drugs and working at mines, will need to make sure use something which leaves system 

rapidly. Party drugs. 

• Often recreational use, with users not going on to dependent use. 

• HIV rates and sexualised behaviours, domestic violence. ICE use and pornography. 

• Difficulties with boundaries – lack of shame leading to greater sexualised behaviours. 


• The assessment process may be extended as related mental health issues and both previous and 

current mental health treatment need to be investigated. Therefore it often takes longer to 

admit a client to treatment and to develop treatment plans. 

• There needs to be more assessment time, and programs admit smaller groups of clients in first 

stage of treatment as group will be more demanding and need more staff attention and time. 

• Profile of people who are using ATS towards more extreme end. Lack of self‐esteem, often 

leading to self‐medication. 

• Preparation work is essential need to know the limits and possibilities of the TC. 

• There are many physical health and psychiatric complications for people, and therefore a need 

to be more in touch with medical services. 

• Damage for drug use may be worse, but often clients more willing to engage in treatment – 

higher motivation. 

• Concern re lack of strategies about how best to work with Indigenous clients within the TC. 


• The use of amphetamines (ATS) has ramifications for the TC population, for clients, children and 

staff. In particular, the program noted a number of OH&S issues stemming from ATS use. 

• Noted there is often higher staff turnover and burnout when dealing with ATS users. Need for 

supervision as ATS users will often split the staff team – there is a need to work together and to 

communicate treatment plans. 

• Staff are often unable to respond to demands and it is extremely important to get people to be 

realistic and self‐regulating from the outset. 

• There is an increased history of violence, and sometimes this may be in more subtle forms. 

• Clients are often in denial or unaware of the consequences of their use, especially the combined 

effects of polydrug use. 

• Often there will also be aggressive paranoia, and it will be difficult to engage the person in 

treatment and to develop a therapeutic alliance. 

• Often families are reluctant to have their relative back in the house because of the violence 

which they have exhibited. Hence there are sometimes limited choices for the person when 

they leave the TC. 

• Also noted was the link between ATS use and domestic violence and resulting PTSD. 


• There is an increased number of people being admitted to treatment with a mental health 

diagnosis. Sometimes symptoms will resolve once the person settles into treatment and has 

ceased drug use for a period of time. 

• Another related issue is ATS psychosis. As a consequence more clients are entering treatment 

on prescribed anti‐psychotic medications. Sometimes the continued use of prescribed 



medications is imperative for successful treatment, however, many clients are concerned about 

continuing use, and this may be the motivation to seek treatment. 

• Increasingly residents coming into treatment on psychiatric medications, often there is a re‐ 

emergence of symptoms 4‐6 weeks after entry. 

• The TC environment provides a certain amount of protection. 

• Usually takes around 4 weeks in treatment before the effects of drugs wear off and the person is 

at baseline. 

• People have a shorter drug using career with methamphetamine in particular. This is because 

extreme consequences are much quicker, therefore a person using methamphetamine for one 

year may have same physical problems as someone who has been using heroin for much longer 

period of time. 

• Consequences of ATS use are not as easy to pinpoint, physical and psychological effects may 

differ, but psychological problems will be more profound. There may be just one prime 

consequence – and this may be admission to the psychiatric ward. 

• Need to monitor anxiety at all stages of treatment. 


• There is a need to engage in a dialogue with psychiatrists to educate them about drug effects 

and treatment issues. 

• Also seeing second generation of drug users, young mothers coming into treatment will often 

have drug using parents. 

• Issue of psychiatric medication again highlighted – people coming into treatment often 

“zombied” and unable to function. In these cases medications need to be reduced to a 

functional level. This calls for more dialogue between Mental Health and the TC – with 

contingency planning to include the MH provider essential. Also needs to be a clearly 

articulated MH plan and MOU in place with MH providers. 

• Level of functionality is an issue, TC may be safe place for withdrawal. Preferable to have people 

enter treatment on medication, rather than to withdraw themselves prior to entry. Often TC 

having to deal with rebound effect once they are in treatment. 

• TCs are excellent places for people to understand when they can reduce from medications – and 

this should not happen within first 6 weeks of treatment. 

• Again noted that the relationship between TC and practitioner is vital. 

• Post‐treatment, there are problems with people moving out of area with complex MH problems 

in the development of shared care approach. 

• Need for sessional psychiatrist in consultancy role to provide consistency of treatment. When 

person is placed on medications can be followed up consistently – monitor treatment effects, 

how the person is progressing, review of medications. There is a duty of care – someone who is 

legally able to take care of the person, especially in relation to psychiatric issues. 

• It is important that any practitioners who are engaged to work with the TC are sympathetic to 

aims of TC, including use of group therapy. Need to look carefully at referral process. 


• Need for person to settle – easy to get information overload. Therefore more concentration on 

activity and education only provided when person has had a chance to settle. 

• Understand that people will be chaotic , therefore only basic concepts understood in early 

stages of treatment. 

• Use of role play valuable – residents may have increased emotional outburst. This will often 

create chaos, especially as behaviour will often attract an audience, there is a need to become 

more accountable. 

• Evaluations show that keeping group separate to main resident group is useful for reducing 

disturbance. 



• Working on preparation for treatment is very useful, provides healthy grounding and provides 

more settled environment. 

• Residents often want to be treated differently in order to feel normal. Processes by which 

behaviour is monitored and gratification delayed are very important. There needs to be staff 

supervision and setting of boundaries. 


• PsyCheck has been developed as group modules, rather than one:one treatment intervention. 

• However, some ATS users struggle to connect with PsyCheck and then become anxious. 

• Meditation and Mindfulness groups work well with ATS users – quietens the mind. 

• Tai Chi and Yoga also useful. 

• Cognitive functioning is an issue – need to be more lenient in approach, but at the same time 

maintain boundaries. Avoid shaming. 

• This is a paradox – balance between special needs around cognitive skills, but at the same tome 

maintain need for people to follow processes. 


• Overlay framework already in place. 

• Need to keep people engaged until they “land”. 

• Should concentrate on the assessment and first stage of the TC. 

• Can’t assume that ATS and MH issues are always linked. Clients with complex needs and MH 

concerns may be the result of other drug use. 

• Need to ask behavioural questions (i.e., what behaviours is the person noticing) and ideas of 

reference rather than diagnoses questions. 

• Mostly MH issues will be high prevalence disorders of anxiety and depression rather than low 

prevalence disorders. 

• For new clients – useful to have information that will explain what they might be experiencing in 

the early stages of treatment and withdrawal. Need to know that it won’t be like this forever, 

that they will improve. 

• Strengths‐based intervention important. 

• There are also advantages in working with this group – they are younger and less entrenched in 

their drug use. 

• PsyCheck is a useful model. 

• Also use of CBT techniques – e.g., ABC and Thought Diary. 

• Creative and expressive therapies also very useful. 

o Drumbeat with young people 

o Drama 

o Performance 

o Poetry and creative writing 

• Multiple ways of accessing feelings and expression. Need to understand that drug use is not 

always about escaping feelings, but about accessing them. 

• Often an education gap – need to consider enrichment of lives. 

• Staff (clinical, reception and administration) should undertake cultural sensitivity training; 

organisations should proactively support this. 


2.5. Report of Canberra Consultation 

Canberra Recovery Services 

Karralika, ADFACT 

Peppers, Wagga Wagga 

Ted Noffs Foundation 

Wollongong Crisis Centre 



• Karralika noted that in looking at recent statistics, 68% stated they had tried 

methamphetamine, and 40% stated it is their first drug of choice. 

• This client group tends to be younger, often it is their first intervention, and they have become 

quite chaotic very quickly. This means that they will often take some time to settle down, which 

has resulted in the first Induction Stage of the program often needing to be extended from 6 

weeks to 8 weeks. 

• The principal drug of concern leading people to seek treatment is alcohol. 

• Most clients admitted have a poly drug use history and ICE/SPEED are either drugs of concern, 

or if not, drugs of choice. 

Table 10. Karralika ‐ Principal Drug of Concern on Admission 

ALCOHOL 36 HEROIN/OPIOIDS 26 

AMPHETAMINES 23 CANNABIS 21 

• From July 2007 to June 2008, 110 individuals were admitted to Karralika. Of the 110, 49 had 

Mental Health issues. This means approximately 45% of the 110 clients admitted for treatment 

had a mental health diagnosis. The most common mental health diagnosis was depression. 

Table 11. Karralika ‐ Mental Health Status of Clients: At Admission 

DEPRESSION 23 ANXIETY 7 

SCHIZOPHRENIA 4 PSYCHOSIS 5 

PERSONALITY DISORDER 2 BI‐POLAR 5 

SELF HARM 2 POST TRAUMATIC STRESS 1 

• Peppers also seeing people coming in with methamphetamine use, in combination with other 

drug use. 

• Peppers also noting that some people entering treatment with ATS use are really unwell, 

requiring more mental health management, and sometimes, hospitalisation. 

• The principal drug of concern leading people to seek treatment was alcohol 

• Amphetamines were the most common illicit drug which people reported as the major drug of 

concern leading clients to seek treatment. This is a change from cannabis being reported as the 

major illicit drug of concern leading people to seek treatment. 

Table 12. The Peppers ‐ Principal Drug of Concern on Admission 

ALCOHOL 44 CANNABIS 25 

AMPHETAMINES 28 HEROIN/OPIOIDS 11 

• 60% of clients entering Peppers have mental health issues, diagnoses of bipolar disorder 

becoming more prevalent. 



Table 13. The Peppers ‐ Mental Health Status of Clients at Assessment 



PERSONALITY DISORDER 3 BI‐POLAR 8 

SELF HARM 3 POST TRAUMATIC STRESS 1 

• 78 clients had a mental health diagnosis at assessment. 

• Depression and anxiety were the most commonly diagnosed mental health problems. 

Table 14. The Peppers ‐ Mental Health Status of Clients on Admission 



SELF HARM 1 BI‐POLAR 2 

• 23 or approximately 50% of the 44 clients admitted for treatment had a mental health diagnosis. 

The most common mental health diagnosis was depression. 

• Wollongong Crisis Centre (WCC) also seeing people with polydrug use, including 

methamphetamine and other ATS use. 

• WCC noted that 4 years ago there were more people presenting who needed mental health 

interventions. Better screening as part of the assessment process has resulted in better 

coordination of care. People aren’t being screened out, but are receiving better support pre‐ 

treatment, therefore resulting in better care. 

• Canberra Recovery Service (CRS) seeing around 60% with polydrug use and 40% alcohol use. Of 

the polydrug users, around 20% have ATS use. 

• Clients have often been using over short period of time, but have more cognitive damage and 

greater MH and comordity issues. 

• More individualised treatment and case management approach utilised. 

• Ted Noffs Foundation (TNF) noted few young people presenting with ATS use, although there is 

some use of ecstasy and ICE. Primary concerns for TNF are cannabis and alcohol. There have 

been no presentations of young people with opioid use in the past year. 


• All services agreed that the relationship with Mental Health Services was paramount to 

successful treatment outcomes. 

• Karralika (ADFACT) has a Memorandum of Understanding with MHACT, which particularly 

focuses on CATT response, joint case management approach and ongoing MH support. 

• All agreed that the assessment process was very important, particularly the gathering of 

information from referral sources. 

• WCC noted that the screening process had become more important in gathering information 

around MH issues. If the person was unable to enter the program immediately, they were able 

to be supported in the community before entering the TC. 

• TNF also identified MH issues during the assessment process, with co‐location with the STEPS 

(Youth Step‐up, Step‐down Service) providing a partnership in addressing comorbidity issues. 

• TNF also noted that it has been more difficult to retain ATS users in treatment, with many 

leaving once detoxification has been completed. 



• Peppers provides a Day Program and home detoxification, with greater flexibility allowing 

clients to move between the TC and Day Program. Clients may require short‐term use of 

benzodiazepines in order to settle symptoms. 

Violence and effect on TC, staff and families 

• Some aggression noted, but all TCs reported few incidents of violence. This was seen in part as a 

result of better care coordination with MH services, particularly with crisis teams. 

• There is a need for clear boundary setting. 

• Sometimes behaviours are a result of inappropriate levels of medication – which may not be 

evident until the illicit drugs have been completely withdrawn. 

• Staff can often be “absorbed” by ATS users, who can be very demanding of staff time and 

energy. 

• Need to be very clear about what time we can offer as staff “right now” and be clear about 

when they can be seen again. Tasks given in between time to support the person. 

• Need to ensure that as staff we don’t become reactive to crisis and that it can be contained. 


• A high prevalence of depression and anxiety was noted amongst ATS users, however programs 

also noted a higher number of clients presenting with diagnoses of schizophrenia and bipolar 

disorder. 

• Programs reported that some people found difficulty in settling, often exhibiting symptoms of 

anxiety, paranoia and a difficulty in setting boundaries. 

• Stronger partnerships with MH services had resulted in better coordinated care. 

• Clients who become unwell may need to enter hospital or psychiatric services for a period of 

time in order to stabilise, and then return to the TC, often with medication to help them settle 

down. 

• Flexibility and “time out” important. 

• Often other members of the community intolerant of ATS users’ behaviours and other MH 

issues. 

• Concern about over‐diagnosis and inappropriately high level of medication at the time of 

admission. Particular concern expressed about the number of people who are given diagnosis of 

Bipolar Disorder. This may not be appropriate diagnosis where this has been given in the 

context of drug use. 

• Some clients have been diagnosed and prescribed medications at young age, in some cases they 

have not taken their prescribed medications, often resulting in self‐medicating with a range of 

illicit drugs and alcohol. 

• TNF noting young people coming in to treatment who have already been given MH diagnoses. 

• MH concerns often emerge in the context of detoxification. 

• Some pre‐existing conditions begin to emerge when the person enters treatment. 

• WCC also noted issues with ATS users with cutting and self‐harming behaviours. The intention 

may not be hurt themselves, but an attempt to get help. There may also be other physical 

injuries associated with ATS use resulting in hospital admissions. 

• Karralika also noted increased self‐harming behaviour – once again primarily through cutting. 

• Numbers of people entering treatment who would meet diagnostic criteria for Borderline 

Personality Disorder. Most often associated with trauma. 


• Working in partnership with MH services has provided pathways for treatment, providing an 

earlier intervention and de‐escalation of the crisis. 



• Peppers noted difficulty in gaining support from psychiatrists, with none resident in Wagga 

Wagga, this means that psychiatrists need to fly in to the community. There is support from GP 

and a psychologist on staff. MH Worker also employed by Peppers. 

• MH training calendar available to staff to access training. 

• Karralika also has psychologists, comorbidity and health worker on staff. 

• WCC has psychologist three days per week, a MH/AOD Nurse whose role includes the upskilling 

of staff and early identification of MH problems. 

• WCC includes a holistic approach to treatment, which concentrates on settling and grounding 

the person, and includes meditation and strategies to assist the person to learn how to de‐ 

escalate symptoms. 

• TNF working with Child and Adolescent MHS (CAHMS) with a Protocol in place to moderate and 

monitor medications. 

• All staff learning to understand the interactions of particular drugs and to see the effects on the 

person’s health and wellbeing. 

• Also a need to work with and educate GPs. 


• All TCs noted that the first stage of treatment is often very difficult for ATS users, who may be 

very unwell and physically sick during this period. 

• Impulse control often poor during this phase, clients may be aggressive and impulsive. 

• There is a need for clear boundaries and guidelines. 

• Karralika noted this could be a very difficult time for ATS users, and that as a consequence they 

could often be very demanding on staff time. 

• There is a need to be flexible in approach to groups – sometimes the person is unable to remain 

focused and may become agitated or anxious. 

• This may mean the person needs to leave the group, to walk, go back to bed, shower or bath, if 

they become anxious or distressed. 

• There is a need for individual treatment plans and education. 

• Contingency management approaches utilised, with rewards for positive behaviour and ability 

to understand and maintain boundaries. 


• With improved knowledge of MH problems and a better understanding of the issues 

surrounding ATS use and comorbidity, all clients are better able to support those experiencing 

MH problems. 

• Karralika noted more positive outcomes for all clients with better understanding and more 

community involvement with clients with MH symptoms. 

• Greater flexibility needed, and education around way people may act, e.g., poor communication 

skills or way of expressing feelings may result in behaviours which could be seen as 

inappropriate or threatening. They “may not have any other words”. 

• From another perspective, this may mean the person is not able to hide their feelings and is in 

fact therefore more honest in the expression of feelings. 

• There is a need for accurate handover information, particularly between treatment staff and 

psychologists, mental health and comorbidity workers. Often this is important in helping staff to 

better understand what is happening for clients. 

• Peppers utilising CBT‐based interventions, with all staff trained in use of CBT. 

• SMART Recovery, AA and NA all utilised as support structures. 

• Greater emphasis on expending energy in a positive way through sport, gym, and other 

activities. This also includes workskills training, such as horticulture programs. 



• Need for more physical activities and less educational programs in earlier stages. Cognitive 

functioning often very poor. 

• Also a number of issues with memory, and strategies often need to be introduced to assist 

memory. 


• There is a greater need to educate other clients about MH issues and possible effects of ATS use. 

• Stepped care approach supported, with TCs either already utilising halfway houses or in the 

process of establishing these (Peppers). 

• Peppers noted value of MH First Aid Training and are now looking at introducing this for clients 

as well as staff. 

• Information provided to clients, and available around the facility for people to access. 

• Use of Recovery Model for MH as well as AOD issues. 

• Karralika staff using PsyCheck. 

• Need for the person to take greater personal responsibility. 

• Need to tailor individual programs – e.g., crime, ATS, cannabis etc. 

• All TCs noted that a variety of tools would be useful, emphasis on holistic approach that helps 

staff work with people at specific program stages. 




2.6. Report of Auckland Consultation 

Odyssey House Auckland 

Higher Ground Trust 



• Higher Ground has noted a change in presentations and prevalence between 2002 and 2009. In 

the period 2002‐2003, 120 clients presented with Pure Methamphetamine use or ‘P’ 

dependency. Of this number, 65% (78) presented as preadmissions and 35% (42) were 

admitted to the program. 

• Of the 78 who did not enter the program, one group were incarcerated, a second group entered 

treatment at a later date, and a third group were referred to other agencies after being 

assessed by Higher Ground. 

• Numbers of clients presenting with methamphetamine dependency in 2007‐2009 has reduced, 

largely as a result of new legislation that has seen Methamphetamine reclassified as a Class A 

drug, which now carries a significant gaol sentence. 

• This has also led to a change in the age of ‘P’ clients, with a reduction in the number of clients in 

the 25‐35 age group presenting for treatment. 

• Staff of Higher Ground believe it is likely this group is perhaps becoming involved with the court 

system – and may therefore be receiving gaol sentences. 

• The ‘P’ clients are younger than opiate dependent clients admitted to Higher Ground. In 2002, 

the average age was 31, but is now 28, and continuing to fall. The majority of clients are male 

(62%), presenting with ‘P’ dependency. 

15 

10 

5 

0 

20‐24 25‐29 30‐34 35‐39 40‐45 46‐50 

Figure 16. Age of clients with Methamphetamine use admitted to Higher Ground 

• There is an increase in numbers of young women (under 25 years of age) who are presenting to 

Higher Ground. Many of these young women are on charges or at the point of being charged. 

Many have come from abusive relationships and have more aggressive and chaotic behaviours. 

• Both programs also recognising issues of sexualised behaviours, putting people at risk. 

• Of the total number of clients admitted to Higher Ground with ‘P’ dependency, 81% were 

European, 17% Maori and 2% Pacific Islanders. 

• Education level of clients entering Higher Ground is high, with 78% having reached 5 th form 

school level or above. 



• Higher Ground observe a number of people coming into treatment with higher level 

qualifications and skills. ATS may have been essentially used to increase energy and 

wakefulness for study or other activities, however use has become out of control. 

• This also means that many of these people are not regular users, they may be higher 

functioning and may also have more resources, including family supports. 

7th Form, 38% 

Figure 17. Education level of clients with Methamphetamine use admitted to 

Higher Ground 

• A higher level of education and pre‐treatment employment status also results in more people 

returning to the workforce post‐treatment. 

UNEMPLOYED 

43% 

6th Form, 21% 

Tertiary, 2% 

N/A, 17% 

5th Form, 21% 

EMPLOYED 

57% 

Figure 18. Employment Status of Admitted Methamphetamine Clients: 

Higher Ground 

4th Form, 

5% 

• This is not the experience of Odyssey House Auckland, who are more likely to be working with 

an older group of clients with more entrenched problems. 

• Most clients coming into treatment are polydrug users, who may also have problem gambling 

behaviours. 

• Many clients will have criminal charges and gang involvement: both these groups respond well 

to the therapeutic community method. 


NO CRIME 

45% 


Figure 19. Criminal Activity Identified of Admitted Methamphetamine Clients: Higher Ground 

• The five most prevalent drugs of concern for people entering Odyssey Auckland in 2008 

were alcohol, cannabis, methamphetamine and amphetamines. Odyssey also provides 

statistics on use of nicotine. Higher use of both methamphetamine and amphetamines are 

reported by adults than young people in Odyssey, whereas more young people than adults 

report use of alcohol and cannabis. 

Percent clients using 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

89.1 

Alcohol 

73.6 

71 

Figure 20. Odyssey Auckland ‐ Principal Drugs of Concern 2008 

DEALING 

31% 

OTHER CRIME 

24% 

Top 5 Problem Drugs 2008 

91.2 

Cannabis 

63.8 

59.2 

73.9 

Nicotine 

56.9 

54.1 

36.8 

33.3 

8.1 

6.9 

0 


10.9 

Methamphetamine 

Amphetamines 

Youth 

Adult 

All clients



• Preadmission and the early stages of treatment are seen as the most chaotic period. This needs 

to be seen as part of the withdrawal process. 

• During the preadmission stage, the person may be supported by telephone contact and, where 

possible or necessary, referral to short term supported accommodation prior to entry. 

• At Higher Ground, the assessment processes include telephone contact and face‐to‐face 

interview when the person will come in with a support person or family member. Part of this 

will be to determine if Higher Ground is the best program for them, or if they should be 

referred to another service. 

• People who are still in employment may choose Higher Ground because it is a short‐length 

program (18 weeks). Therefore if the person is relatively high functioning, has the support of 

their employer, and is therefore able to take the time from work, they will have support to 

undertake the treatment program, and a job to go back to after treatment is completed. 

• In contrast, Odyssey tends to work with clients who are less functional. 

• Clients in this stage are often demanding, with personality disorders, including narcissistic and 

anti‐social personality types, influencing the way in which people will react to 

methamphetamine. 

• At Odyssey House the assessment process begins with first contact at the admissions centre. A 

risk is completed at this time. An appointment is made for an eligibility assessment which can 

be either face to face (at Admissions or in the prisons) or by phone. If people are accepted for 

treatment some detoxing may be required before admission to the service. 

• Often clients have not slept for some time and their bodies are therefore adjusting. 

• During this stage clients can be demanding, bringing irritation and entitlement into their 

interactions with others. 

• There is often a difficulty in balancing outside and internal risks, especially those presented by 

gangs, in deciding the timing of a person’s entry into the community. Part of this is also the 

concern in balancing the needs of the individual in relation to those of the wider TC community. 


• There was a concern raised by TCs about incidents of extreme violence, particularly by males, 

prior to entry into treatment. This includes violence in which they have become involved as 

both perpetrators and victims. 

• This often results in clients entering treatment with untreated injuries, and particularly head 

injuries, leading to a concern in relation to the person’s ability to function on a cognitive level. 

• Clients will often talk of inflicting violence on others, and these behaviours need to be 

contained on entry to the program. 

• As part of this, there are often emergent issues of PTSD. 

• Young women are also noted as sometimes presenting as aggressive and chaotic in their 

behaviours. 

• There is a need to be very clear about Cardinal Rules and the consequences of behaviours if 

rules are broken. 

• Odyssey noting that one of the treatment issues for some is the need to deal with anti‐social 

behaviours and influence over others. Sometimes people are well known in the criminal world 

and will influence the treatment of others. In this regard, the primary addiction may be crime. 

• People who are demanding of own needs will often lack patience and may be quick to make 

complaints about alleged delays in meeting needs, particularly health needs (e.g., for dental 

treatment). This may be through internal or external processes. 


• TCs noted a number of mental health issues for clients presenting to treatment. 



• Odyssey has a psychiatrist who works across the adult programs, including the Dual Diagnosis 

Program. Therefore the Crisis Team will only be called in times of crisis or emergency. 

• At Odyssey all clients are assessed by the psychiatrist on admission and medication 

management provided if necessary. 

• Dual Diagnosis Program provides a different stream from the outset of treatment. 

• Sometimes clients will enter one of the Odyssey House programs and be transferred to another 

facility if it is in the clients' best interest, treatment wise. (Clients with Axis I diagnosis are 

spread throughout all adult facilities). 

• Higher Ground doesn’t normally accept people on psychotropic medications, but they will need 

a letter from their doctor saying they are able to come off their medications in order to enter 

the program. 

• At Higher Ground, an assessment will be made by the Clinical Psychologist, and if they are 

identified as being at risk, a Risk Management Plan will be developed. If there is a concern 

about self harm, contact will be made with Mental Health. 

• The concern for TCs is, “What does the person need now? Is the community at risk? Does the 

person need to be moved on? Do they need to be contained?” 


• There are ongoing concerns around dual diagnosis, and therefore the need to maintain 

professional and working relationships with Mental Health, particularly the Crisis Teams. 

• The main diagnoses are Major Depressive Disorder, Bipolar and drug‐induced psychosis. 

• In Odyssey mental health issues are managed by the psychiatrist. 

• Some young people presenting with early onset psychosis (prodromal phase). 

• Crisis Team may be required if client suddenly becomes unwell or suicidal and is unable to 

guarantee their safety. 


• Higher Ground noted an increased number of young women entering treatment, with 

methamphetamine use providing a pathway into addiction. 

• There is also a higher proportion of gambling observed amongst methamphetamine users, and 

also an increased number of people who are dealing. 

• This, along with the Preadmission stage, is seen as the most difficult time for clients with ATS 

use. 

• Issues of anger need to be addressed; generally clients are able to admit problems and 

behaviours which have resulted. 

• Use of methamphetamine is not sustainable – even gangs are actively trying to stop their own 

members from using. 


• The need for activity through exercise and work program is acknowledged as being important 

for this client group. 

• Both Odyssey and Higher Ground have gymnasiums and sports programs as well as work 

therapy programs, in line with TC modality. 

• For younger populations who have a level of education, have not ‘burned the bridges’ with 

family members, and may be at university or in employment, moving on from the program is 

easier. Family involvement is a very important component of TCs. 

• TCs use a range of interventions and resources – including CBT, a variety of group therapy 

interventions and support, Hazeldene materials focused on shame, guilt, grief, denial and other 

issues. 

• For many people, becoming addicted has resulted in becoming involved with people with whom 

the person may not usually associate. 



• Contingency management utilised – rewards through weekend leave, time out (Higher Ground). 

• Odyssey House has an assessment phase, followed by a treatment planning group where 

treatment goals are formulated. After this, clients move into the treatment phase which is 

structured in four levels. Each level has a developmental task which when accomplished moves 

them on to the next level. Level 4 is considered the re‐entry level and concentrates on 

preparing the client to reintegrate with the wider community. Finally when all re‐entry are 

tasks are realised the client is proposed for graduation from the program. 


• Recognise the preadmission and first stage of treatment as the most difficult, especially as 

people do not have the same means of coping (drugs). It therefore makes sense to focus 

attention at this stage. 

18 

16 

14 

12 

10 

8 

6 

4 

2 

0 

PHASE 1 PHASE 2 PHASE 3 

Figure 21. Exit Stage of Methamphetamine Clients: Higher Ground 

• Data from Higher Ground shows high attrition rate at Phase 1, particularly as a result of a shift 

in the initial external pressure which brought the client into treatment. Discharge usually 

resulting from self‐discharge or planned behaviours that result in staff discharge. 

• However, if clients are able to stabilise and move into Phase 2, it appears that they will 

internalise motivation and this in turn improves retention rate. 

• Important to include a variety of tools – including CBT intervention, information for clients and 

staff. 

• CBT and MI – changing thought patterns, negative scripts and lifestyle patterns. ABC and 

Thought Diary. 

• Mindfulness strategies – visual forms of engaging. 

• It is often the family who is making the first contact, therefore it would be useful to include 

information for families on what they might expect to see happening to their relative as they 

are going through the withdrawal and rehabilitation process. 

• Same information may be applicable for other clients so that they know what to expect while in 

treatment. 

• Also part of staff orientation – information to assist basic understanding. 

• Consider other forms of engaging clients – use of narrative, reframing experience – strengths 

based. 


2.7. Report of Adelaide Consultation 

Kuitpo Community: UnitingCare Wesley Adelaide Inc. 

The Woolshed 



• Kuitpo noted increasing numbers of clients entering the community with ATS use problems. 

This is particularly evident amongst women coming into the community, especially within 

the Family Program. 

• The association with body image and eating disorders was specifically highlighted. Many of 

the women are using amphetamines to reduce weight, and then finding their weight 

‘balloons’ on entering the community when amphetamines are no longer used and initially 

unhealthy eating habits return. Part of the process of treatment is therefore consideration 

of body image, nutrition and treatment for eating disorders. 

• In a ‘snapshot’ conducted in the first two weeks of November 2008, Kuitpo found almost 

20% of clients (7 of 36 clients) entering the community nominated amphetamines as the 

primary drug of concern. This was the most prevalent illicit drug of concern. 

• This figures increase within the family program (which can accept three single parents and 

their children within self‐contained cottages). Estimated 70% of women entering the family 

program have ATS use, and this may pose considerable problems where children are 

concerned. 

25 

20 

15 

10 

5 

0 

Figure 22. Kuitpo Community: ‘Snapshot’ of Principal Drug of Concern, first two 

weeks in November 2008. 

• The Woolshed noted 98% of clients entering treatment presented with polydrug use, with 

the primary illicit drug of concern being amphetamines. This had been evident over the past 

two years. 

• Heroin and other opiate use have reduced, although still an issue for older clients entering 

treatment. Polydrug use includes alcohol, amphetamines and cannabis. 

• Both agencies agreed that many clients started out partying, and that use of amphetamines 

in combination with alcohol, often escalates. 




• The Woolshed noted that the prevalence of mental health problems had increased amongst 

clients presenting with ATS use. Therefore the assessment process is often extended, as 

more information, particularly in relation to the person’s past psychiatric and mental health 

is collected. 

• Assessment of suicide risk, self‐harm, eating disorders and other mental health concerns is 

needed, and there is a greater need to engage other services that have been involved in the 

person’s care and treatment, including previous or current psychiatrists and psychologists. 

• The assessment process has therefore become more detailed and thorough. 

• The Woolshed and Kuitpo are concerned that the person entering treatment has been 

stabilised, with no current psychotic episodes. 

• Both agreed that clients are now more likely to have a history of violence and anger 

management is therefore a part of the treatment program in order to teach the skills 

needed to manage anger. 

• The Woolshed is now more likely to use the tool of ‘therapeutic discharge’, which allows the 

person to re‐enter the program sooner than if they were given a usual disciplinary discharge. 

This has become a necessary skill, because although No Violence rules are explained, 

someone new into the program may not have been there long enough to gain the necessary 

skills or ability to monitor and manage behaviour. 

• Kuitpo agreed with this concern, with impulse control being an issue, particularly in the early 

stages of treatment. Alongside this, is the fact that many residents in the early stages of 

treatment are being ‘habilitated’ rather than ‘rehabilitated’ and often do not have verbal 

skills or language to express themselves. Therefore, they may use threatening language 

while not intending to act out any violence. 

• It has therefore been necessary to educate all the community about the use of language and 

communication skills. 

• Kuitpo noted clients are now more often on prescribed medications to manage issues of 

comorbidity. 

• The Woolshed noted increased violence or threats within the community had become a 

concern and were all ATS related. There had also been increased incidence of psychosis 

amongst newer residents. 

• Need to give some time for symptoms to resolve before entering the community. 

• Kuitpo noted that clients attending appointments had become an issue due to chaotic 

lifestyles, and are now using mobile phone text messages to send reminders for people to 

come in for appointments. This is working very well, and is more effective than leaving 

phone messages as clients rarely have enough credit on their phones to access message 

bank or return calls. 


• The issue of violence was seen by both agencies as being of very real concern, especially 

given their rural locations. 

• The Woolshed have had to make significant changes to protect staff and other clients after a 

life threatening incident where a staff member was trapped in a room with someone who 

was behaving in a violent manner This incident had required police intervention to remove 

client from premises. Nil report made to police re: threat. 

• This has resulted in a policy and the development of procedures with the police in relation to 

a discharge where violence or threatening behaviours may result. The police now come 

onto the property prior to the discharge taking place, and will escort the person away from 

The Woolshed. This has been used four or five times and has resulted in a safer and calmer 

discharge situation. 



• Kuitpo has not had an episode of violence associated with ATS use, however, both agencies 

agreed there is a lot more emphasis on the rules around violence and threats of violence 

prior to the person being accepted. 

• Kuitpo noted again the issue of clients being unable to effectively communicate or ‘find the 

words’ to articulate feelings without aggression. Clients also presenting with significant 

histories of violence. 

• Although the programs accept the fact that people may be unpredictable, and that episodes 

of psychosis will occur, there has been a real need to establish safety for staff and other 

clients, and particularly where there are children (Kuitpo) involved in the program. 

• As much as possible, both programs try to establish that mental health concerns have been 

addressed and that the person is stable, which may mean on medication, prior to entering 

the communities. 

• Decompensation after entry is a concern, and this may result from a variety of factors, 

including other personalities within the community. 

• The need for clients within a TC to be able to socialise and manage within a community 

setting, means that it is sometimes extremely difficult for ATS users to fit within the TC. 

There is often a lack of boundaries and histories of abusive relationships. 

• The other issue raised in relation to the TC, is that healthy confrontation and support to 

change behaviours is a hallmark of the TC, and doing this is often perceived as being difficult 

or unsafe in relation to unpredictable and somewhat volatile clients. Therefore there is an 

issue of others keeping secrets and not supporting others in the change process. 

• The Woolshed has introduced a ‘reward system’ as part of their contingency management, 

which is an adaptation of the ‘star chart’. 

o Junior (Stream one) residents receive a star each time they follow the resolve 

process and confront a fellow resident regarding their inappropriate behaviour. On 

receipt of three stars, they are able to gain a reward – such as a movie pass. 

o Senior residents are able to train to become mediators, and will receive a ‘mediator 

licence’. If a person is selected by others to assist them as a mediator to resolve an 

issue, they are again provided with a reward – such as a sleep in on a Friday morning 

or a bubble bath. 

o While staff were concerned that this form of contingency management might be 

construed as somewhat condescending, it has been well accepted by the 

community. 

o Earlier relaxation of boundaries which allowed clients more freedom has now been 

replaced by more balance, which has resulted in more safety within the community. 

o Use of contingency management part of this balance. 

• Noted that the new generation of drug users are more inclined to be presenting with ATS 

issues, and therefore more modelling of behaviours is required so that others are able to 

learn more prosocial modes of behaviour. 

• Often people haven’t had the chance to modify behaviours even within the home situation, 

where aggression has often been the norm – and where people have learnt that it works! 

• Ironically, part of the issue is seen as resulting from a shift in social attitude where people 

have been validated and serviced by a variety of community services, therefore often 

resulting in a sense of entitlement which have sometimes validated antisocial behaviours. 

• Need for clear information, setting of boundaries and understanding that sometimes poor 

cognition skills will require information to be concise and understandable. Also a greater 

need for reinforcement. 




• Kuitpo reported depression and anxiety as being most prevalent mental health concerns. A 

‘snapshot’ of clients in treatment in the first two weeks in November 2008, showed 92% had 

a formal mental health diagnosis. 

Bipolar Disorder 

6 

Borderline Personality Disorder 

Anxiety 

18 

4 

3 

PTSD 

Figure 23. Kuitpo Community: ‘Snapshot’ of most prevalent mental health concerns, 

first two weeks in November 2008. 

• The Woolshed also reported high incidence of comorbidity, with an estimated 96% 

presenting with a range of mental health issues. 

• Initially The Woolshed was required through staffing limitations to take no more than three 

complex clients at any one time. This is no longer something which can be given 

consideration, given the range of presenting mental health concerns. 

• Both programs agreed finding the balance was an issue, too many clients within the program 

at any one time causes concerns and changes the dynamics of the community. 

• Clients with personality disorders also a consideration, as many exhibit manipulative 

behaviours. 

• The Woolshed noted there had been a shift in focus with a mental health group now being 

run on a fortnightly basis to address issues and to provide Psychoeducation. 

• Kuitpo also providing weekly groups, through the Improved Service Delivery initiative. 

• Staff in both programs now receive training in mental health as well as AOD, and 

consequently have a broader skills base. 


• The Woolshed noted a real need for policies to be in place to deal with psychotic episodes 

and other mental health issues. Because of their location, access to services has been an 

issue of considerable concern. They find themselves caught between Rural and Flinders 

areas, and stand the chance of being tossed between services – with each one stating they 

are the responsibility of the other. 

• The Woolshed also raised the issue that mental health and other medical services are 

inclined to take the view that since the person is already in treatment with The Woolshed, 

that they are safe and receiving the necessary treatment, and are therefore a low priority in 

terms of additional intervention. 


24 

Depression


• This has meant that in order to receive the necessary treatment, the person has had to be 

discharged from The Woolshed, and transported to hospital in order to receive a better level 

of care. In this way, they are seen sooner and there are no assumptions made that since 

they are already at The Woolshed, then everything will be fine. If the situation is safe, a staff 

member will transport. At other times, an ambulance may be required. 

• Kuitpo raised similar concerns, noting that gaining crisis intervention was often very difficult, 

as they are also caught between area health services – this time Rural and Southern. 

• It is also difficult for both programs to gain support of mental health, as they are unable to 

refer into mental health. Referrals are required to be undertaken by General Practitioners 

or other medical services, and although The Woolshed is a government‐managed service 

under Drug and Alcohol Services South Australia (DASSA), access to a psychiatrist and other 

mental health services, remains an area of concern. 

• Neither agency has access to a psychiatrist to support the program, although Kuitpo has a 

General Practitioner, who provides considerable support, including the provision of weekly 

education groups to the community. 

• There is an apparent shortage of psychiatrists and psychologists in Adelaide in general, and 

this has further impacted on the programs, both in terms of the support needed within the 

program, and also for clients once they have re‐entered the community. 

• There is an issue of safety for the rest of the community, programs are not able to restrain 

clients who become psychotic or aggressive, and therefore there is a very real need for 

support from mental health and, at times, the police. 


• Kuitpo provides an adult and a family program, and is able to accept up to 20 clients over 

the age of 21 years. They are situated on a 32 hectare property and clients reside within one 

of five, four‐bedroomed cottages. There are an additional three cottages for single parents 

and their children, with each family having a separate house. 

• The first stage of treatment lasts four weeks. The overall program length is 20 weeks. 

• The Woolshed is also set in a rural location, on a 70 acre property in the Adelaide Hills area. 

Residents live in one of three log cabin houses. Age range is 16 ‐ there is no upper limit. 

• Both programs agreed that an intervention aimed at the first stage of treatment would be 

beneficial, since this is the stage in which people are most chaotic and require a targeted 

intervention. 

• Clients within the Kuitpo family program often remain only six to seven weeks, therefore an 

intervention which could be used with this group is considered very useful, especially as 

women in the family program have the highest use of ATS within the Kuitpo Community. 

• The Woolshed also noted that since the assessment phase has been extended out for many 

clients, an intervention that could be used at this point would be useful. 


• Currently both programs use a range of treatment interventions, which include group and 

individual counselling. CBT, Acceptance and Commitment Therapy, Motivational 

Interviewing and Relapse Prevention strategies are incorporated into both Kuitpo and The 

Woolshed. 

• Art therapy is a significant part of both programs, and Kuitpo has a trained art therapist and 

teachers as part of the staffing complement. 


• The need for a treatment protocol which consolidates and complements existing program 

interventions was highlighted. 



• This would provide consistency within the program and reinforce information provided 

through other psychosocial interventions. 

• A protocol that is targeted at the first stage of treatment but would also be adaptable to 

some use within the assessment phase, particularly as there is more need to work with 

clients who are on a waiting list as this period has been extended out, in part because of 

more requirements on beds, and in part to allow staff to gather information and to provide a 

time for stabilisation prior to entry. 


2.8. CONSULTATIONS: List of Contributors 


Gold Coast 20 October 2008 

Facilitator Lynne Magor‐Blatch 

Kerri Wrench Fairhaven Dave Warby Logan House 

Rod Sheppard Fairhaven Mary Alcorn Mirikai 

Robbie Ferris Goldbridge Lucy Prieto Mirikai (DD Worker) 

Steve Green Goldbridge Barry Evans The Buttery 

Ivor Shaw Logan House Chris Clair WHOS Najara 

Sydney 20 November 2008 

Facilitator Lynne Magor‐Blatch James Pitts 

Bob Mohler Blue Mountains Recovery Services Terry Hooker Odyssey House 

Shane Nancarrow Blue Mountains Recovery Services Jennifer McGaulley Selah Farm 

Debi Ingram Odyssey House Garth Popple WHOS 

Steph Lean Odyssey House Gabrielle Campbell WHOS 

Melbourne 24 November 2008 


Eric Allan Odyssey Vic Meridy Calnin Odyssey Vic 

Annette D’Amore Odyssey Vic Richard Castle Odyssey Vic 

Jessica Walshe Odyssey Vic Charlie Stewart YSAS 

Kay Welsh Odyssey Vic Yvonne Devey YSAS ‐ Birribi 

Laura Petrie Odyssey Vic Antigone Quince Windana 

Perth 3 December 2008 


Carol Daws Cyrenian House Malvina Limb Cyrenian House 

Charl Van Wyck Cyrenian House Mitch Peasley Cyrenian House 

Eleanor Baptist Cyrenian House Shonna Grant Cyrenian House 

Gabby Cohen Cyrenian House Rachel Rea Palmerston Farm 

Kayla Nilsen Cyrenian House Susan Morrison Palmerston Aftercare 

Donna Stambulich Cyrenian House Women’s Program David Lonnie Serenity Lodge 

Canberra 10 February 2009 


Bob O’Heir Canberra Recovery Service Brendan McCorry Peppers, Wagga Wagga 

Michael Barrow Canberra Recovery Service Geoff Fairhall Karralika, ADFACT 

Anna Bruseker Wollongong Crisis Centre Therese Power Karralika, ADFACT 

Michelle Abernethy Wollongong Crisis Centre Brett Pridmore Ted Noffs Foundation 

Auckland 25 February 2009 


Pat Williams Odyssey House Auckland Stuart Anderson Higher Ground Trust 

Ann Powell Odyssey House Auckland Shane Howell Higher Ground Trust 

Emily Giles Odyssey House Auckland 

Adelaide 30 April 2009 


Sarah Watson Kuitpo Community Amanda Hulst The Woolshed 

Carol Gannon Kuitpo Community 





Section 3: 

Results of Trial of 

Treatment Protocol 




Results of Trial of Treatment Protocol: First Study 


A short trial of the Treatment Protocol was conducted in May‐July 2009, with clients of Mirikai in 

Queensland and Cyrenian House in Western Australia. These two programs were chosen as both 

reported significant ATS use amongst clients presenting for treatment. Western Australia has 

reportedly the highest incidence of ATS use in Australia. Mirikai is a youth program with high 

prevalence of ATS use and comorbidity amongst the client group. Cyrenian House includes both an 

adult mixed gender program and a women and children’s program, known as the Saranna Women’s 

and Children’s Program. 

As a result of the trial, a number of refinements were made to the materials. This largely comprised 

of providing additional information around the use of Tip Sheets and Worksheets, and some changes 

to the way in which some of the sessions were presented. 

Training was conducted with the two programs prior to the introduction and trial of the Treatment 

Protocol. This training was conducted by the principal author at Mirikai on 22 April 2009 and at 

Cyrenian on 1 May 2009. Attendees at both workshops included the facilitators who conducted the 

trials, together with other staff from both residential and outreach services. 

The Treatment protocol is divided into seven sessions: 

Session 1: Building motivation for change 

Session 2: Understanding and coping with cravings 

Session 3: How thoughts influence behaviour 

Session 4: Understanding feelings: Mind/Body Connection 

Session 5: Learning how to deal with anxious thoughts and feelings 

Session 6: Understanding and acknowledging core beliefs and values 

Session 7: Relapse Prevention 

These sessions may be delivered flexibly, e.g., the first two sessions might be used in a pre‐ 

treatment or assessment phase and the following five within the TC, all might be delivered within 

the TC setting, or the final session (Relapse Prevention) presented as part of a group of three 

sessions with Sessions 1 and 2 in an outpatient setting or separately prior to discharge. For the 

purposes of the Trial, both TCs were asked to deliver all sessions within the TC and, if possible, utilise 

a closed group model – i.e., all participants would where possible receive all sessions. 

1.0. Information on participating Therapeutic Communities 

1.1. Mirikai Therapeutic Community 

Mirikai, local Aboriginal meaning "a place of peace" is a specialist residential alcohol and other drug 

treatment program that works on a Therapeutic Community model. Its goal is to enhance the 

capacity and commitment of clients to achieve, as well as maintain an optimal level of personal and 

social functioning free from harmful drug use and to assist residents to achieve and maintain a 

personally satisfying and socially responsible lifestyle free from harmful drug use. 

Clients entering Mirikai are aged 18‐29 years old and have complex problems associated with their 

drug use, including mental health problems. They may be referred from health, welfare and 

community organisations, or they may self‐refer. Each stage of the Mirikai program takes between 

six to eight weeks to complete. Successful completion of each stage is a necessary pre‐requisite for 

progress onto the next. The last stage, re‐entry to the community through one of the commitment 

houses, lasts around six months, depending on the individual. 



For clients with a dual diagnosis, tailored educational and social activity programs have been 

developed to support them through the program. 

1.1.1. Program Stages 

Assessment and Admission ‐ During the first three weeks after arrival, all residents are thoroughly 

assessed. The program works closely with other services such as mental health services, dentists, 

sexual health services, hospitals, Centrelink and legal services to meet each individual’s specific 

needs and detoxification is provided through the program. Clients attend a Beginner’s group ‐ called 

Thoughtful Conversations, specifically designed to help them fit into the program. 

Safety Net ‐ This is a six week intensive living and life skills program consisting of basic health and 

hygiene, self esteem, anger management, communication skills, relapse prevention, stress 

management, therapy and sports program. Art and drama are also a major part of this program. 

Treatment ‐ During this stage of the program there is a strong emphasis on teamwork and 

developing the ability to trust others. Residents learn the skills to make positive relationships and to 

change their belief systems. They begin to learn how to be responsible for their actions by helping 

other people, and maintaining the daily running of the program. 

Re‐entry ‐ In this stage, there is an emphasis on work based future planning. Residents live in a 

commitment house (supported accommodation), to test these new found skills before moving back 

into the community. 

1.2. Cyrenian House 

The Cyrenian House Residential Program operates as a Therapeutic Community (TC) and is located 

in a semirural setting in the outer northern suburbs of the Perth Metropolitan area. The program 

encourages a personal exploration of attitudes and behaviours in relation to alcohol and/or drug use 

and focuses on the development of self‐awareness and self‐responsibility as a result of engagement 

with the Therapeutic Community. 

The Cyrenian House TC consists of four stages. Completion of Stage 1 and 2 are necessary to 

graduate from the program. This may take up to 3‐4 months. Residents are strongly encouraged to 

apply for Stages 3 where they are able to put into practice the skills and awareness that they 

developed in Stage 1 and 2 and become role models for the younger residents. Stage 4 gives 

residents the opportunity to slowly re‐enter and readjust into the wider community with the 

advantage of being part of the program, while at the same time developing outside networks and 

preparing for exit into the community. 

The Therapeutic Community provides a safe environment for an exploration of new lifestyle choices. 

Unique opportunities exist for participants to explore and identify issues in depth with the 

development of practical strategies designed to support the individual in the long term. 

The program contains various components including: 

• education groups 

• counselling 

• therapeutic group work 

• art activities ‐ to promote creative and holistic developments 

• music 

• recreation activities 

• community responsibilities 



1.2.1 Saranna Women's & Children's Program 

Saranna provides a residential treatment program for women with dependent children who are 

affected by alcohol and other drug issues. The service addresses the current inequality of service 

access for women with young dependents and facilitates family reunification and strengthening. 

The residential treatment service comprises part of the Therapeutic Community. Women and their 

children form an integral part of the community, living in self contained cottages whilst engaging in a 

daily program of recovery. 

The objectives of Saranna are to provide a drug and alcohol free environment for women and their 

children whose lives have been negatively impacted through drug using behaviour; to develop 

effective networking systems through shared case management implemented through a range of 

community services and agencies; and to ensure that client management incorporates an effective 

through‐care plan to reduce the possibility of relapse. 

1.2.2. Program Stages 

The Cyrenian House Program stages are: Stage 1 (0‐6 weeks), where the focus is on orientation to TC 

process as well as assessment and evaluation. At the end of three weeks, the resident’s suitability 

for the TC is assessed by staff and residents. During this first six weeks residents are introduced to 

basic issues in the recovery process such as communication, relapse prevention, self esteem and 

health and lifestyle. 

Stage 2 (6‐12 weeks) focuses on full participation in the TC. Residents are introduced to deeper 

issues, such as family of origin, grief and loss, and intimacy. 

During Stage 3 (3‐6 months) the focus is on leadership and role modelling in the TC. Residents put 

into practice what they have learned in earlier stages. This stages also provides an opportunity to 

address areas such as relationships, spirituality and identity. 

Stage 4 (6 months +) is the re‐entry stage where residents focus on areas such as housing, education, 

work and future prospects. Residents must be engaged in a community project as a means of ‘giving 

back’ to the community and can choose to stay for up to, and over, 12 months. 

(Throughout the program residents are exposed to various groups such as music, art, Psycheck, 

gender, feelings, yoga, meditation and social activities.) 

2.0. Characteristics of participants 

Participants were asked a number of questions to gather demographic information. This included: 

sex, age, length of residence in the TC, the stage of the program in which they were currently 

enrolled, the number of years of ATS use, their primary drug of concern and the length of time in 

which they had been abstinent. 

The number of participants across both locations attending each of the sessions varied from 14 (first 

session) to six (Session 7). Two participants attended all sessions at Mirikai and only one participant 

recorded attending all sessions at Cyrenian. Mirikai did not conduct the final session on Relapse 

Prevention. 

Ages of Mirikai participants ranged from 18‐33 years with a mean age of 23.78 years. There was 

little difference between ages of males and females attending groups at Mirikai, with males ranging 



in age from 23‐33 years (mean = 23.98 years) and females ranging in age from 18‐28 years (mean = 

23.53 years). 

Length of residence for Mirikai participants ranged from 1‐240 days, with a mean of 55.38 days. The 

majority of participants were in the Safety Net phase of the program, which is a six week intensive 

living and life skills program consisting of basic health and hygiene, self esteem, anger management, 

communication skills, relapse prevention, stress management, therapy and sports. Other 

participants were in the Assessment phase, which is the first stage of three weeks following 

admission, during which time a thorough assessment is conducted and health and treatment issues 

determined. One person was in Stage 2, progressing to Stage 3 of the treatment program whilst 

undertaking the ATS Treatment Protocol. 

Ages of Cyrenian participants ranged from 21‐42 years with a mean age of 30.51 years. Males 

attending the Cyrenian groups ranged in age from 21‐42 years (mean = 33.01 years) and females 

were between 22‐40 years (mean = 25.24 years). 

The Cyrenian group had been in treatment longer than those attending the Mirikai group, as the trial 

of the Treatment Protocol was not restricted to those in the first stages of treatment. Length of 

residence for Cyrenian participants ranged from 45‐240 days with a mean of 113.35 days. In 

comparison, the Mirikai group had been in treatment for an average of 55.38 days and ranged in age 

from 18‐33 years with a mean age of 23.78 years. 

The majority of the Cyrenian group were all in Stage 2 (30 participants over the seven sessions) or 

Stage 3 (36 participants) of the program, and one participant who attended one session only 

recorded being in Stage 4. Clients in Stage 2 have typically been at Cyrenian for 6‐12 weeks; Stage 3 

residents have been in the program for 3‐6 months; and Stage 4 residents for more than 6 months, 

and in the re‐entry stage. 

2.1. Substance use 

The ATS Treatment Protocol is specifically designed for use with clients with ATS use. That said, it 

was acknowledged by all participants in the training sessions that the materials were also suited to 

other drug using populations, and that within the context of therapeutic community programming, it 

would not always be possible to separate out the ATS users from other substance users. It was also 

acknowledged that the majority of clients entering treatment are polydrug users, and that while ATS 

use may not be the principal drug of concern, it is likely to be one of a number of drugs used by the 

person over their drug using career. 

Participants at Mirikai had used ATS on average for 9.57 years prior to entering the TC. This ranged 

from 5‐18 years of ATS use. Fifty‐nine participants took part in the trial over the six sessions. 

Principal drugs of concern were listed as Alcohol (15 participants), Cannabis (18 participants), ATS 

(10 participants), Benzodiazepines (7 participants), Heroin (7 participants) and Poly drug use 

(excluding ATS, 2 participants). Fifty of the Mirikai participants stated they had used ATS. 

Length of abstinence from alcohol and other drug use generally followed length of time in the 

program, although there was some variation. This ranged from 4‐120 days with a mean of 55.31 

days. At Mirikai the variation was due to readmissions following a lapse where the person’s total 

length of residence was recorded, although the person may have been placed at a different program 

stage. 



Participants at Cyrenian had used ATS on average for 9.83 years prior to entering the TC. This 

ranged from 5 weeks to 20 years of ATS use. However, one participant stated using amphetamine 

but giving no details as to length of usage, and another two stated they had not used ATS but gave 

‘Amphetamine’ as the principal drug of concern. 

Sixty‐seven participants took part in the Cyrenian trial. Principal drugs of concern were listed as 

Alcohol (21 participants), Cannabis (4 participants), ATS (14 participants) with a further 8 listing ‘Poly 

drug use’ and specifically including ATS, Heroin (9 participants) and Poly drug use (not specifying 

amphetamine or other ATS, 9 participants) Two participants stated ‘Don’t know’ in response to this 

question. All but two of the Mirikai participants stated they had used ATS. Unlike the Mirikai 

participants, no‐one recorded use of Benzodiazepines. Eleven participants stated they had not used 

ATS, although, as noted previously, ‘Amphetamines’ were noted as a principal dug of concern on 

three occasions, although no period of usage was recorded. 

Mean length of abstinence from alcohol and other drug use at Cyrenian House was 114.39 days and 

ranged from 56‐240 days. This compares to a total period of residence of 45‐240 days with a mean 

of 113.35 days. This is an interesting issue, since it points to the fact that clients are often entering 

treatment either without first entering a specialised withdrawal unit prior to the TC or are being 

detoxed within the TC itself. In the majority of cases the length of residence and the length of 

abstinence were the same. 

3.0. Measures 

3.1. Participant questionnaires 

Participants were asked a number of questions relating to the material in each of the sessions. This 

included specific questions relating to the particular session (e.g., in Session2, which dealt with 

Cravings, participants were asked (a) Did the session explain cravings in a way that was 

understandable? and (b) Did it give you strategies to cope with cravings?). Other questions asked: 

• Were the Worksheets helpful? 

• Were the Tip Sheets informative? 

• Were the activities helpful? 

• What did you like most about today’s session? 

• What did you like least about today’s session? 

• Do you think any part of the session needs to be changed? 

• If you thought we needed to make some changes, in what way should it be changed? 

• Any other comments? 

The final evaluation asked participants which of the Worksheets, Tip Sheets and Activities they had 

found most helpful. Participants were also asked: What did you like most about the session? and 

What did you like least about the session? The final questions asked participants if they thought the 

session needed to be changed, and if so, in what way? A section was also provided for general 

comments and feedback. 

Questionnaires for Sessions 4‐6 also asked participants if they were able to complete the homework 

tasks provided in the period between that and the preceding session, and whether these were 

considered to be helpful. 



3.2. Facilitators’ questionnaires 

Facilitators were asked to complete an evaluation questionnaire after each session and a final 

evaluation at the completion of all sessions. At Mirikai six of the seven sessions were presented, 

with the final Relapse Prevention session not conducted. Facilitators were asked the following 

questions at the completion of each session: 

• Were the Worksheets helpful? 

• Were the Tip Sheets informative? 

• Were the activities helpful? 

• What do you think the participants liked most about today’s session? 

• What do you think the participants liked least about today’s session? 

• Please give us some feedback on the session from your perspective – was it easy to 

deliver? 

• Do you think the information was pitched at the right level? 

• Do you think any part of the session needs to be changed? 

• If you thought we needed to make some changes, in what way should it be changed? 

• Any other comments? 

Questions specific to each session were also asked: 

Session 1 

• Do you think the session helped participants to look at why they might need treatment? 

• Do you think the participants were able to understand the material? 

Session 2 

• Do you think the session explained cravings in a way that was understandable? 

• Do you think it gave participants strategies to cope with cravings? 

Session 3 

• Do you think the session helped participants to understand how thoughts influence the 

way we act? 

• Do you think the participants were able to understand the material? 

Session 4 

• Do you think the session helped participants to understand the connection between mind 

and body? 

• Do you think the participants were able to identify with the feelings that were discussed? 

Session 5 

• Do you think the session helped participants to understand and recognise anxious 

thought patterns? 

• Do you think the participants learnt some strategies to help them deal with anxious 

thoughts and feelings? 

Session 6 

• Do you think the session helped participants to identify their values? 

• Do you think the participants were able to identify the things that are important to them? 

Session 7 

• When do you think it would be helpful to do this session? (You can tick more than one 

box) 



As part of a Pre‐treatment intervention 

In the TC 

Just before leaving the TC 

• Do you think the participants were able to identify their relapse dangers? 

• Were they able to develop a coping plan? 

Questionnaires for Sessions 4‐6 also asked if participants were able to complete the homework tasks 

provided in the period between that and the preceding session, and whether these were considered 

to be helpful to participants. 

4.0 Results 

4.1. Participants’ response 

Of the total 59 participants over all the Mirikai sessions, 43 participants (72.88%) rated the material 

as helpful in addressing the specific topic. Forty‐seven participants (79.66%) stated they believed 

they had learned strategies which were helpful in addressing the issue addressed by the session 

(e.g., strategies to deal with cravings, strategies to deal with anxious thoughts and feelings). A total 

of 46 participants at Mirikai (77.97%) stated the Worksheets were helpful and 54 (91.53%) stated 

the activities were helpful. Tip Sheets were not provided with all sessions, where they were 

provided, 33 of the 36 participants in these sessions (91.67%) stated they were helpful. 

Of the total 67 participants taking part in all the Cyrenian sessions 51 participants (76.12%) rated the 

materials as helpful in addressing the issue presented by each of the sessions. Sixty‐four participants 

(95.52%) stated they had learned strategies which would be helpful in addressing the issue 

presented by the session. The Worksheets were considered helpful by 55 participants (82.09%), 55 

(82.09%) participants considered the Activities were helpful. Once again, Tip Sheets were not 

provided with all sessions. Where they were, 36 of the 44 participants (81.82%) thought they were 

helpful. 

As the Cyrenian participants did not complete the final evaluation, they did not report overall on the 

intervention, and therefore did not provide information on the Worksheets, Tip Sheets and Activities 

which they found most helpful. However, a number of these were highlighted on individual session 

evaluations. 

Participants across both sites (Mirikai and Cyrenian) rated the following Worksheets most highly: 

• Unhelpful thinking patterns 

• Those in the first two sessions dealing with motivation for change (Decisional Balance and 

Lifestyle issues causing problems in my life) 

• Those dealing with understanding thoughts and feelings (Managing your Feelings in 

Recovery and Understanding how we experience Feelings) 

• The ACT Sheets (i.e., Vitality vs. Suffering Worksheet and Vitality vs. Suffering Diary). 

The most helpful Tip Sheets were identified as: 

• The Bridge Concept 

• Some facts about Cravings 

• The Bull’s Eye 

A number of participants stated that all Worksheets and Tip Sheets were helpful, one person stating 

that “I learnt so much” from the Tip Sheets. 



The most helpful Activities were given as those included in: 

• Session 4: Understanding feelings: Mind/Body Connection – and particularly the relaxation 

exercise 

• Session 6: Understanding and acknowledging core beliefs and values – and particularly 

identifying personal values (The Values Card Sort) 

Others noted that all activities had been valuable in increasing knowledge and that it had “brought it 

to my attention, in front of me to see”. 

The question, What did you like most about the session? elicited responses from all participants. 

While many responses related to specific activities and materials in each of the sessions, participants 

also highlighted the social environment and involvement of other participants, group interaction, 

sharing and learning new things. Participants also highlighted the way in which the sessions were 

conducted, with a number of positive comments directed towards the facilitators at both Mirikai and 

Cyrenian. 

In Session 1, participants stated they most liked the following: 

• Time to answer all questions and kept us involved 

• Social environment and broader picture it presented 

• The discussion groups, group interaction, listening to others, sharing 

• Teachers good, learnt a lot about myself 

• Mapping out why I’m here 

• Weighing up pros and cons of using 

• Getting a broader picture of my addiction and its trappings 

• Realising there is nothing that great or worthwhile to continue drugs 

• They made me feel alright and my problem could be fixed 

• Awareness around denial 

• Realisation, awareness around what makes me tick 

• Reaffirmed where I came from 

• Where I’m at today 

Participants in Session 2 most liked: 

• How to identify a craving and understand how long they would last, determining the 

difference between cravings and triggers 

• The stray cat and idea of surfing the wave (Some facts about Cravings 

Tip Sheet) 

• Understanding and dealing with triggers 

• Group interactivity 

• It was applicable to my past (cravings checklist) 

• Gave me the idea that cravings are manageable 

• The Acceptance Commitment Therapy (ACT) worksheets and activities 

In Session 3, the things most liked in the session were: 

• Learning about thinking styles and the way in which we act 

• Talking about the “my past and feeling comfortable about it” 

• Homework task (The Vitality vs. Suffering Diary, which was given as a homework task at the 

end of Session 2) 

• The Raisin Exercise – a Mindfulness exercise 

• The ABCs exercise 

• Reflecting 


• About Vitality and Suffering and Mindfulness activities 


Session 4 participants most liked the following: 

• Sharing feelings, with a number of participants noting how this had affected them 

• The relaxation exercise 

• Learning new things 

• Colouring in the “feelings” (Understanding how we experience feelings Worksheet) 

• “The relevance” and “everything” about this session 

• Having Guilt and Shame explained 

In Session 5, participants most liked: 

• Meditation – the 3‐Minute Breathing Space exercise 

• Learning about anxiety, and the way in which we can deal with anxious thoughts 

• How we can change our thoughts and feelings 

• Tip Sheet 8 ‐ Fight or Flight Response 

Participants in Session 6 most liked: 

• The Values Card Sort activity 

• Understanding and getting to know our values 

• Learning about myself 

• Clear, helpful, loved this 

• Lying on the floor and doing the activity (3‐Minute Breathing Activity) 

In Session 7, participants most liked: 

• I was able to understand 

• Worksheets, discussion 

• Relapse prevention 

• Awareness that I’ve learnt a lot of skills in recovery 

• Support card and strategies idea 

Participants were also asked what they least liked about each session. Some issues related to factors 

outside the Treatment Protocol – lack of refreshments such as tea, coffee and biscuits, or not being 

able to smoke. (It should be noted that at Mirikai refreshments were provided from Session 2 

onwards). Other issues, such as the difficulty in talking about oneself, realising in the first session 

that the cravings were still there and the difficulty experienced in raising personal problems were 

also highlighted. Participants mentioning these concerns did not, however, feel the sessions should 

be changed. 

While two participants in Session 3 most liked The Raisin Exercise, two other participants stated this 

was the activity they least liked. One participant did not like the relaxation exercise at the 

commencement of Session 4, and three participants noted that some of the sessions were “too 

long”. Related to this was a further concern expressed by seven participants that there was a 

shortage of time, or that the sessions were too rushed. One participant in Session 5 (How to deal 

with anxious thoughts and feelings) stated the session was “too boring”. Twenty‐two of the 59 

participants at Mirikai (37.29%) and 29 of the 67 Cyrenian participants (43.28%) stated there was 

“nothing” that they did not like about the sessions or that it was “all good” or that they liked it. 

When asked about what changes, if any, should be made to the Treatment Protocol, ten responses 

related to the length of sessions (needing to be shortened), while five thought that more time 

should be given to the groups, even running some sessions as half‐day workshops. One participant 

thought Session 1 was too short and another from Cyrenian where the majority of participants had 



been in the program for some weeks, thought it needed to be provided earlier in the program. One 

participant thought the sessions needed to be more intellectually challenging and one response 

indicated that Session 5 needed to be more interactive. 

Twenty‐eight participants from Mirikai and 20 of the Cyrenian participants provided final comments. 

The majority of these were positive and related to facilitation of the sessions and the perceived 

benefits from taking part. One participant stated there was too much time between sessions 9at 

Cyrenian), another stated “keep it going” and three others thought more time should be devoted to 

the entire course or more time allocated within the program. The contribution of all facilitators was 

rated highly, with many thanking facilitators for the sessions. 

4.2. Facilitators’ response 

Groups at Mirikai were lead by two facilitators, who conducted all sessions. At Cyrenian the first six 

groups were led by one facilitator, and the final session led by another. All facilitators provided 

valuable feedback which has resulted in some changes in the way in which the Treatment Protocol is 

now presented in its final form. 

All facilitators agreed that the participants were able to understand the material in the Treatment 

Protocol, that Worksheets and Activities were helpful and Tip Sheets were informative. The 

homework was considered to be helpful, however problems in completing the homework were 

highlighted. At Mirikai, homework was processed as part of the following session, which in turn 

meant that the material associated with that session was not always covered in the time allowed. As 

a consequence, session times were extended and facilitators found themselves “in a constant bind 

between facilitating, processing and completing the material”. Facilitators noted, however, that this 

was not the major cause of the tension between content and process. In general facilitators thought 

that there was far too much material for each session – and that the amount material needed to be 

reduced or the program needed to be lengthened. 

In response to the question, What do you think the participants liked most about today’s session? 

facilitators noted the following: 

Session 1 

• Interactivity 

• Completion of The Decisional Balance Worksheet 

• Building motivation to change, The process of recovery (Step 9 in the Session outline) 

• Goal setting 

Session 2 

• Learning strategies to deal with cravings 

• The fact that strategies for changing drug use behaviour were clearly set out 

• The 3Ds, Introduction to Acceptance Commitment Therapy (ACT) 

• Urge surfing, recognising triggers 

Session 3 

• The homework task (Vitality vs. Suffering Diary) 

• The Raisin Exercise 

• Unhelpful thinking patterns 



Session 4 

• Relaxation exercise enabled participants to connect well to the rest of the session. 

(It was also noted that the relaxation exercise worked better with the Mirikai group than the 

previous week’s Mindfulness exercise – The Raisin Exercise) 

• Discussion around emotions and Worksheet 10: Understanding how we experience feelings 

Session 5 

• The fact that positive thinking/acting can change participants’ entire lives 

• Anxiety discussion, anxiety survey and managing stress 

Session 6 

• The Values Card Sort – it was noted that participants responded well to the cards and their 

meaning and purpose, and that this activity was done with enthusiasm and interest 

• Identifying values 

Session 7 

• Discussion 

In response to, What do you think the participants liked least? facilitators noted time factors – both 

the length of sessions and also timing of the group (e.g., not running the group in the evening after 

dinner or early on Monday morning following an eventful weekend when other matters need to be 

dealt with). This latter concern is an issue for timetabling, rather than a criticism of the Treatment 

Protocol, and something which needs to be considered by services when using the materials. 

Interestingly, while some participants found some activities and worksheets difficult, others found 

the same information useful and easy to work with. The Raisin Exercise, which had not been found 

to be useful with the younger Mirikai group, was one of the most liked activities experienced by the 

older Cyrenian group. 

In designing the sessions, the authors considered each session should be of approximately two hours 

duration, and that ideally the group should be given a brief refreshment break half way through the 

session. Facilitators varied in the way in which they presented materials, and where sessions 

involved working through and processing the information contained in all Tip Sheets, sessions 

became longer, raising concerns about concentration and focus. Undertaking and then processing 

the week’s homework at the commencement of sessions, also added to the overall length. These 

issues were highlighted in the final feedback on the Treatment Protocol. 

Facilitators generally agreed that the Treatment Protocol was easy to deliver, other than in relation 

to time pressures impacting on adequate coverage of all materials. However, some activities and 

Worksheets were found by some participants to be difficult and at times confusing. For example, 

the Decisional Balance was simplified at Cyrenian to a simple Pros and Cons about using. However, 

handling the information in this was does not allow the person to effectively weigh up the Pros and 

Cons from both perspectives. The idea of this activity is to see where the balance lies – do the Cons 

associated with using and the Pros for a different lifestyle tip the balance? 

Facilitators also agreed that the materials were pitched at the right level. This was interesting, given 

the fact that each of the groups differed in age and length of residency. The materials have been 

designed for clients in the earlier stages of treatment, and this was highlighted in the Facilitator’s 

response from Cyrenian, where the group had been in the TC for 45‐240 days with a mean of 113.35 

days. In comparison, the Mirikai group had been in treatment for an average of 55.38 days. 



Session 2 (specifically the Bridge Concept and the Decisional Balance Worksheet), Session 2 (amount 

of information), Session 3 (The Raisin Exercise) and Session 6 (Values) were noted as being 

somewhat difficult to deliver. This might be addressed by reducing the materials in the sessions or, 

as was suggested by one facilitator, dividing some of the sessions into two smaller sessions. 

Generally it was felt that materials needed to be retained, but that they could be delivered in a 

different way. One suggestion we have made is to utilise the metaphors and concepts, together 

with some of the other Tip Sheets in the program during the preceding or following weeks to 

reinforce the learning gained from the sessions. 

A number of changes were suggested, including fewer materials, which would therefore reduce the 

length of sessions. Some activities were found to be difficult for some participants (e.g., The Raisin 

Exercise) and one facilitator noted that bringing all materials for each session together (i.e., Tip 

Sheets and Worksheets contained within the session materials rather than in separate sections 

within the training manual) would be preferable. 

Facilitators noted the most helpful Worksheets were: 

• Lifestyle issues causing problems in my life (Session 1) 

• Decisional Balance (Session 1) 

• Understanding how we experience feelings (Session 4) 

• Feelings of Anger, Loss, Shame and Guilt (Session 4) 

• Pleasant Events Calendar (Session 4) 

• Personal Values Exercise (ranking of personal values – Session 5) 

• Coping Statements for Anxiety (Session 5) 

• Unhelpful thinking patterns (Session 5) 

• Anxious Automatic Thoughts Questionnaire (Session 5) 

• Values Bull’s Eye (Session 6) 

The most informative Tip Sheets were noted as: 

• Some facts about cravings (Session 2) 

• Managing your feelings in Recovery (Session 4) 

• Fight or Flight response (Session 5) 

The activities considered to be most helpful by facilitators were: 

• The relaxation exercises (but not The Raisin Exercise) 

• The Values Card Sort 

• Engaging discussions around topics of interest f9or clients – particularly ACT, emotional work 

and values 

• Anything that was ‘hands‐on’ – colouring emotions, card sort, relaxation was higly effective 

Facilitators provided the following thoughts on the package: 

• The Materials/ideas/activities were clearly well prepared and the total package is an 

excellent resource for any drug rehabilitation program (not just ATS users) but it would need 

to be delivered over some months and not in closed group as this presented problems each 

session 

• Tip Sheets ‐ some too academic 

• Treatment Protocol ‐ ideas and material very good, but too much for time allowed 

• Worksheets ‐ Good, clear and workable, but we had to hurry or leave some 

• The package contained too much for our clients and meant that we were in a constant bind 

between facilitating, process & completing the material. I believe that we need at least 

double the time to adequately allow clients to contemplate life changing decisions & actions 



• The material was all very good 

• Didn't use the clinical assessment. The package was generally good to use 

• The program itself was fairly long and could be extended a couple of weeks to allow sessions 

to be shorter and less intense 

When asked about the overall presentation of the materials, facilitators noted the Treatment 

Protocol was: 

• Clear, set out well, understandable, varied and helpful for any drug user (or program) 

• There was a suggestion that more role plays and reflection/discussion/share time would 

invite greater participation from the residents 

• Great resources for a presentation 

• The training package presented me with difficulties in that each unit was not a unit. Flipping 

from section to section for Tip Sheets and Worksheets was a problem when time is a factor. 

My preference would be to include Tip and Worksheets and protocol together 

• The standard of the material and its set out and format was excellent 

• Noted the materials were suited to the earlier stages of the treatment program (for which it 

has been designed) and that the Relapse Prevention material would be better handled later 

in the program. Both participants and facilitator thought Session 7 should be conducted in 

this way 

• Pretty good ‐ some of the models presented were a bit complex, so took time to explain 

5.0. Conclusion 

As a result of the first trial of the Treatment Protocol with Mirikai in Queensland and Cyrenian House 

in Western Australia, some changes have been made to the materials and the presentation. The 

prime concern expressed by participants and facilitators was that there were too many materials 

provided for each session – therefore sessions were lengthening out. This was impacted on further 

where homework tasks were not completed in the time between sessions and were therefore 

undertaken and processed at the commencement of each session. 

Therefore some of the materials have been changed, the wording of the Pavlov’s Dog worksheet 

(Module 2) has been changed considerably and has become a Tip Sheet and other activities (e.g., 

The Raisin Exercise in Module 3) are provided as suggested activities, but may be replaced by others 

(e.g., the Floating Leaves on a Moving Stream exercise could replace The Raisin Exercise). The 

purpose of The Raisin Exercise had been to reduce stress by slowing participants down and to bring 

their awareness into the present – it is a Mindfulness exercise which can be useful in helping people 

who have become cut off from their senses to be more in touch. However, its use must be a 

judgement call for the group facilitator. Some people found it difficult to approach the exercise 

mindfully and therefore were not able to get the value from the task. Others rated the exercise as 

one of the things they most liked about the module. 

The way in which Tip Sheets are used is also up to the group facilitator and the program. Different 

facilitators used them differently in the trial, some providing the Tip Sheets with little explanation, 

while others read through and processed the information with participants. The value to 

participants of discussing and processing the information was evident in the evaluations. However, 

another approach is to use the Tip Sheets independently of the session in a Concept Group or other 

forum during the time between groups to reinforce the learning. As an example, The Bridge Concept 

(Module 2) has been used in its original form by many TCs since the 1970s. 



The version here has been adapted as the original version was specific to the program (e.g., The Ley 

Community in the UK). Therefore the points of progress related to that program’s stages. For TCs 

that conduct concept groups, The Bridge Concept and other metaphors contained in the Treatment 

Protocol are useful additions to materials. In the context of the Treatment Protocol, The Bridge 

Concept, Some facts about Cravings, Drug Treatment Metaphor and other Tip Sheets could be used 

in this way. This would reinforce the materials from the module and could become the ‘homework 

task’. Therefore at the end of each module, suggestions have been provided as to how materials 

might be used in the time between sessions – hence The Bridge Concept, Pavlov’s Dog or the Drug 

Treatment Metaphor might be used in a concept group between Modules 1 and 2 and then 

discussed in Module 2. 

One suggestion coming from the evaluation was to present all the information pertaining to the 

module within the unit material – i.e., Tip Sheets and Worksheets included into the module’s 

materials, rather than in separate sections within the training manual. While this may make the 

presentation of the modules somewhat easier, the concern was that this would in fact work against 

a flexible use of materials – e.g., the flexible use Tip Sheets in the TC and as information sheets for 

staff, family members and others to help them better understand some of the issues which their 

family member might be experiencing. However, the order of sections has changed, so that Clinical 

Assessment is now Section 1, Tip Sheets (which may be used independently of the Treatment 

Modules) are in Section 2 and Sections 3 (Treatment Modules) and 4 (Worksheets) remain the same. 

At the commencement of each module outline, there is a list of materials needed for that module. 

Facilitators do need to read through this list, to prepare for the group – including photocopying the 

Tip Sheets and Worksheets necessary for the number of participants in the group, but it is hoped 

that the presentation of the manual in this current form will assist in this task. 

Finally, we are grateful to the participants and facilitators at Mirikai and Cyrenian House for trialling 

the Treatment Protocol and providing such valuable feedback. We are delighted that the greatest 

concern was that there was too much information contained in the modules – that is a whole lot 

easier to address than finding the materials had completely missed the mark! 

Therefore, if it seems appropriate to break the module into smaller sessions, the invitation to do so 

is there. Although we have termed the following materials a ‘Treatment Protocol’ TCs, other 

treatment agencies and facilitators are invited to use the materials flexibly in a way that best suits 

their own client needs. 

The Treatment Protocol will continue to be assessed and evaluated. We look forward to your 

continuing feedback.

ATS Literature Review, Consultations & Trial - Odyssey House

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