MODEL FOR THE TREATMENT OF SUBSTANCE DEPENDENT YOUTH IN RESIDENTIAL FACILITIES

TABLE OF CONTENTS

FOREWORD BY THE MINISTER ACKNOWLEDGEMENTS 1. INTRODUCTION 2. PRINCIPLES 2.1 Accountability 2.2 Appropriateness 2.3 Child Centered 2.4 Continuity of Care/Aftercare 2.5 Continuum of Care 2.6 Effective and efficient 2.7 Empowerment 2.8 Family-Centered 2.9 Family Preservation 2.10 Rights of Young People 2.11 Integration 2.12 Normalization 2.13 Participation 2.14 Permanency Planning 2.15 Restorative Justice 3. APPLICABLE LEGISLATION 4. MODEL FOR THE TREATMENT OF SUBSTANCE DEPENDENT YOUTH IN RESIDENTIAL FACILITIES 4.1 Description 4.2 Goals 5. ESSENTIAL ELEMENTS 6. STRATEGIES, PROCESSES AND METHODS 7. PREPARATION FOR IMPLEMENTATION 8. CONCLUSION 9. GLOSSARY

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FOREWORD Increasing levels of substance abuse amongst young people across all echelons of our society prompted the National Department of Social Development to develop an appropriate and effective response to this social issue. Research findings and increasing pressure on existing treatment programs confirm the above issue as well as the fact that young people are becoming dependent on substances at an earlier age than ever before. In a report on research carried out on trends in alcohol and other drug use in South Africa, Parry et al (2004) concluded that “the study points to the need for AOD (alcohol and other drug use) intervention programs that target young people and the need for continued monitoring of adolescent AOD use in the future”. A review of existing treatment programs led to a consultative workshop, attended by representatives from existing registered treatment centres and a range of role-players with expertise in child and youth care and substance abuse. This resulted in the formulation of a Best Practice Model, which reflects the core elements essential to a treatment program for young people under the age of 18, within the context of a child's rights culture. Furthermore and included in this Model, are unique interventions sourced from existing treatment programs, for possible adaptation in different settings. The unique nature of this Model facilitates its adaptation to a broad range of child and youth care residential settings, which includes secure care facilities, children's homes and places of safety specialized in-patient treatment centres.

DR ZST SKWEYIYA MINISTER OF SOCIAL DEVELOPMENT
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ACKNOWLEDGEMENTS The National Department of Social Development would like to thank the following for their invaluable contributions to the formulation of this document: The Working Task Team consisting of representatives from the National Department of Social Development, the KwaZuluNatal Provincial and Durban Regional Offices of the Department of Social Welfare and Population Development respectively, Durban Children's Home (Siyakhula), National Association of Child Care Workers and SANCA Durban Alcohol and Drug Centres. All those who participated in the consultative process in any way, by attending the workshop held in Durban on 15 April 2004 and/or making written representation. The respective Management Boards of Durban Children's Home (Siyakhula) and SANCA Durban Alcohol and Drug Centres for making available their respective Directors and staff to undertake the compilation of the Best Practice Model for the Residential Treatment of Young People Dependent on Chemical Substances, and to pilot this model. The young people at Durban Children's Home (Siyakhula) and SANCA Durban Alcohol and Drug Centres (Warman House) for their participation in the pilot project.

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1. INTRODUCTION The Department of Social Development observed an increase in young people reporting for in patient drug treatment. It is alarming that more and more patients with heroin addiction report for treatment, especially young people. This led to the Department of Social Development to engage in a project to develop a best practice treatment model for young people which after completion, would be replicated in all the provinces of South Africa. In view of the situation that is facing young people in the country, it is imperative for the Department of Social Development; in partnership with other stakeholders; to develop comprehensive youth programs that will address the problem of substance abuse among the youth, whilst not ignoring the other age categories. This model is based on the Minimum Norms and Standards for Inpatient Treatment Centers, Minimum Standards for Child and Youth Care, Prevention and Treatment of Drug Dependency Act 20 of 1992, Constitution of South Africa and the child care policies and legislation.

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PRINCIPLES

These principles provide the foundations of the Best Practice Model. 2.1 Accountability

Everyone who intervenes with young substance dependent persons and their families should be accountable for the delivery of an appropriate and quality service. 2.2 Appropriateness

All services to young substance dependent persons and their families should be the most appropriate for the individual, the family and the community. 2.3 Child Centered

Positive developmental experiences; support and capacity building should be ensured through regular assessment and evaluation of programs which strengthen the substance dependent person's development over time. 2.4 Continuity of Care/Aftercare

The changing social, emotional, physical, cognitive, spiritual and cultural needs of substance dependent persons and their family should be recognized and addressed throughout the intervention process. Links with continuing support and resources must be encouraged after disengagement from the system.

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Continuum of Care

Young substance dependent persons and their families should have access to a range of differentiated services on a continuum of care, ensuring access to the least restrictive and most empowering environment and/or program/s appropriate to their individual developmental and therapeutic needs. 2.6 Effective and efficient

All services rendered to substance dependent young persons and their families should be rendered in the most effective and efficient way possible. 2.7 Empowerment

The resourcefulness of each substance dependent young persons and their families should be promoted by providing opportunities to use and build their own capacity and support networks and to act on their own choices and sense of responsibility. 2.8 Family-Centred

Support and capacity building should be provided through regular assessment, planning and ongoing evaluation of programs which enhances the family's functioning over time. 2.9 Rights of Young People

The rights of young people as established in the UN Convention and SA Constitution shall be protected.

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Integration

Services to substance dependent young persons and their families should be holistic, inter-sectoral and delivered by a multi-disciplinary team. 2.11 Normalization

Young substance dependent persons and their families should be exposed to challenges, activities and opportunities at the social, emotional, cognitive, physical and cultural levels respectively which promotes participation, development, resilience and social functioning. 2.12 Participation

Young substance dependent persons and their families should be actively involved in all the stages of the intervention process. 2.13 Permanency Planning

Every young substance dependent person should be provided with the opportunity to build and maintain lifelong relationships within a family and/or community. 2.14 Restorative Justice

The approach to substance dependent young persons in trouble with the law should focus on restoring societal harmony and putting wrongs right rather than punishment. The young person be held accountable for his or her actions and where possible make amends to the victim.

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APPLICABLE LEGISLATION
Basic Condition of Employment Act Amended, 2002 (Act No.10 of 2002) Child Care Act as amended, 1983 (Act No. 74 of 1983) Child Justice Bill 2003 Correctional Service Amendment Act, 1992 (Act No.122 of 1992) Domestic Violence Act, (Act No. 116 of 1998) Drug Trafficking Act, 1992 (Act No.140 of 1992) Employment and Equity Act Heath Act, 1977 (Act No. 63 of 1977) Health Professional Act, 1974 (Act No. 56 of 1974) Labour Relations Act, (Act No.66 of 1995) Medicine and Related Substance Control Act Amended, 2002 (Act No. 59 of 2002) Mental Health Care Act, 2002 (Act No. 17 of 2002) Non Profit Organisations Act, 1997 (Act No. 71 of 1997) Nursing Act, 1978 (Act No. 50 of 1978) Occupancy Health and Safety Act, 1993 (Act No. 85 of 1993) Pharmacy Act, 1974 (Act No. 53 of 1974) Prevention and Treatment of Drug Dependency Act, 1992 (Act No. 20 of 1992) Probation Services Act, (Act No. 116 of 1991) Promotion Equality and Prevention of Unfair Discrimination Act, 2002 (Act No. 52 of 2002) Public Finance Management Act,1999 (Act No. 1 of 1999) S.A. Constitution Act, 1996 (Act No. 108 of 1996) S.A. School Act, (Act No. 84 of 1996) Social Work Act, 1978 (as amended) (Act No. 110 of 1978) The Criminal Procedure Act, 1977 (Act No. 51 of 1977, Section 296) Tobacco products Control Amended Act,1999 (Act No. 12 of 1999)

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MODEL FOR THE TREATMENT OF SUBSTANCE DEPENDENT YOUTH IN RESIDENTIAL FACILITIES Description

This best practice model promotes a holistic integrated approach to residential treatment that is designed to address and respond to the unique needs of young people suffering from substance abuse. Treatment is rendered within a therapeutic milieu, within a child's rights context, which ensures the safety of the young person, and recognizes the importance of developmental assessment. The model promotes a strong therapeutic approach within a child care setting, ensuring that each young person is responded to in terms of his/her individual needs. 4.2 Goals

4.2.1 To create a cost-effective therapeutic program which ensures that each young person receives a holistic response to his/her specific needs. This response is provided within a developmental context, which ensures respect for the young person's individuality. 4.2.2 To ensure that therapeutic programs offered respond to the treatment needs of young people, thereby ensuring that the young person experiences his/her rights. 4.2.3 To provide an opportunity for the replication of the Best Practice Model, thereby ensuring a uniform response to young people who are substance dependent, in line with child care policy for young people in residential settings, and the policy on minimum standards for residential programs for the treatment of substance dependence.

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ESSENTIAL ELEMENTS

5.1 The model promotes the developmental approach in responding to young people accessing treatment. Continuous assessment ensures that strengths and developmental areas are highlighted, with developmental challenges and other issues receiving a holistic response to the unique identified needs of the individual. 5.2 The medical model is applied in terms of describing the substance dependent behavior, and defining the specific areas requiring a medical response. Medical assessment and evaluation is an ongoing requirement. 5.3 The ecological perspective is incorporated in the model, with family/significant other involvement being recognized as being crucial to the young person's recovery. Family members/significant others are encouraged to participate in a meaningful manner throughout the therapeutic intervention process. 5.4 The model embodies outreach and networking, as the most relevant support systems needed by the young person are assessed during and after the treatment period. 5.5 While the therapeutic program is eclectic, it functions from the same philosophical approach drawing on a range of existing models including, but not restricted to, the medical model, systems theory, ecological approach, therapeutic community theory, Minnesota model, Circle of Courage model and the Adolescent Development Program Model. This results in a wide range of options being available, thereby ensuring that the unique needs of young people can be met.

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5.6 All personnel intervening with young people must be trained in terms of knowledge and interventions specific to addictive behaviour management and they must have a clear understanding of the development needs of young people. All personnel and young people must understand the rules pertinent to the treatment program, as well as the consequences of non-compliance with these rules. 5.7 Children's rights are interwoven through every aspect of the program, thus ensuring the protection of the rights of young people. Furthermore, young people are educated in terms of these rights and the responsibilities that accompany them. 5.8 A trained multi-disciplinary team is required to ensure that young people are assessed and treated holistically. This further ensures that a range of responses and expertise is available to assist, and give direction, to identified developmental areas. It is essential that trained child and youth care workers form part of this team, as their expertise in terms of life space work, behavior management and activity programs is vital for the development of young people. 5.9 Trained medical personnel need to be available to address and manage medical issues, which may arise as a result of the substance abuse. Other medical professionals such as psychiatrists need to be available to assist with the diagnosis and treatment of young people with a possible dual diagnosis status.

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5.10 Aftercare is a crucial element in the young person's recovery. This component needs to be purposefully designed and planned in a manner which creatively uses existing resources, or develops resources in areas that are underresourced. Aftercare must provide both the young person and the family with the necessary ongoing support on the young person's disengagement from the program. 6. STRATEGIES, PROCESSES AND METHODS

6.1 Pre-admission is a vital process necessary for identifying the need and motivation of each young person, preparing him/her for the therapeutic process, and assessing the support, which family/ significant others will bring to the treatment process. 6.2 Young people are assessed medically on the day of admission in order to determine the extent of their substance use/abuse and the physical effects thereof. The assessment also identifies the medical protocol, which is indicated. 6.3 Each young person must be developmentally assessed within three weeks of admission in order to establish an Individual Development Plan. Assessment is an ongoing process and regular reviews monitor the progress in terms of reaching set targets. 6.4 The therapeutic program ensures that all aspects required for the healthy functioning of the young person once he/she returns to the family and community, is taken into consideration during the treatment process. Key topics need to be covered within the therapeutic program. These include education on substance dependence, management of specific behaviors and emotions related to substance dependence, relapse prevention, aftercare, self- awareness and personal growth, health and hygiene, communication
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skills, spirituality, sexuality, HIV and Aids, education, diversity and other life skills. The length of the program should be between three and twelve months. 6.5 Ongoing training and supervision of all team members is essential in providing an accountable and integrated service. It further develops the skills and knowledge of the staff team and fosters team building and commitment 6.6 Volunteers provide meaningful contributions to the program. It is important to ensure that their involvement is carefully supervised within a structured volunteer program, that there is a clear purpose for their involvement and that they are empowered with training, support and direction. 6.7 The restorative approach is applied to conflict situations that may arise within the program. This ensures that harmony is restored between the victim and the perpetrator, and promotes the concept of peace. Skills attained by staff members through using this approach can be utilised should the program be used as a diversion option by the court. 6.8 An educational component is provided. This component takes into consideration the particular needs of individual young people whilst in treatment and involves networking with relevant school authorities and other creative responses for literacy. 6.9 The incorporation into the treatment program of AA, Alanon, NA and other community support systems is important as it ensures that young people are provided with concrete experience on how to access support when needed.

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6.10 A structured activity program providing sporting activities, music, crafts and art is important in terms of assisting young people to discover new strengths, to learn how to utilise their free time effectively and how to have fun. 6.11 Skills development is also part of the therapeutic program, where a young person is assessed and linked to a skills development initiative to empower him/herself. 7. PREPARATION FOR IMPLEMENTATION

7.1 All staff working in the program receive the relevant training which includes Substance Abuse training, Adolescent Development Program training, Developmental Assessment training, Behaviour Management training and Basic Child Care training. 7.2 All legislative requirements and relevant guidelines/policy related to minimum standards, need to be in place. Staff must be aware of these requirements, have received the required training and have the capacity to meet them. 7.3 Trainers need to be identified, trained and appointed in order to offer the relevant training and mentorship, thereby ensuring an effective service delivery. 7.4 Awareness programs and marketing strategies promoting the availability of the service, need to be developed and implemented. 7.5 It is essential that recognised established services practicing the Model fulfill a mentoring function in terms of support, input and ongoing training to organisations wanting to replicate the Model.
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7.6 Adequate funding is critical in order to ensure the successful implementation, replication and sustainability of programs for the residential treatment of young people dependent on substances. 8. CONCLUSION

The model will serve as a guide to promote uniformity in the management of substance abuse amongst the youth in residential facilities. The pilot phase was completed in March 2005 and the practice guideline was developed to guide service providers on how to implement the model.
GLOSSARY
Addictive Behaviour: - refers to: • A strong desire or sense of compulsion to engage in a particular behaviour (especially when the opportunity to engage in such behaviour is not available). • Impaired capacity to control the behaviour (notably in terms of controlling its onset, staying off, or controlling the level at which the behaviour occurs). • Discomfort or distress when the behaviour stops. • Persisting with the behaviour despite clear evidence that it is leading to problems. (Ref: Pols, Dr R, Farrin, Ms J A Sirenko, (1994) Handbook for Medical Practitioners & other Health Care Workers Australian Government Printing. Canberra Adolescent Development Program: refers to the strengthening of young people by focusing on existing strengths and providing opportunities for the development of new strengths. The developmental curriculum encourages new learning. The expression and articulation of feelings and emotions is encouraged and young people are provided with support and empathy during these times. 14

Aftercare: refers to follow-up care that offers ongoing support to maintain sobriety/abstinence, personal growth and assists with reintegration into the community/family. Awareness Programs: refers to structured programs which provide individuals and groups with the opportunity to obtain information from knowledgeable others in order to enhance personal understanding, build capacity with regards to life skills and make educated choices. Behaviour Management: refers to the managing of behaviours exhibited by individuals or groups of young people in a manner which is respectful and dignified, providing them with capacity and support, which enables them to learn inner control and effective social behaviour. Circle of Courage Model: refers to four pillars of self-esteem: belonging, mastery, independence and generosity. The four pillars (values) are related to and influence each other. When the needs in each of these areas are met a young person is able to experience a sense of well-being and wholeness. Developmental Approach: refers to a focus on strengths rather than pathology, to building competency rather than attempting to cure, and a strong belief (reflected in practice) in the potential within each young person and family regardless of the reason for referral. Developmental Assessment: refers to the process of identifying, understanding and responding appropriately to developmental tasks and needs, through the process of seeing the young person as a whole and taking his/her context into consideration. Disengagement: refers to the process of preparing young people for leaving the program. Particular attention must be given to the recognition of mixed feelings from the young person as well as the importance of a clear plan for integration back into family and community.

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Diversion: refers to the channeling of prima facie cases away from the criminal justice system on certain conditions. These conditions are usually the participation in particular programs and/or reparation where possible. Dual Diagnosis: refers to a concurrent mental health condition that exists alongside substance related disorders. The term “dual diagnosis” often applies here. Ecological perspective: refers to the practice of understanding and viewing each young person within the context of, and connected to, his/her family and community. Marketing Strategy: refers to the planned activities applied by the facility in creating awareness of the program/s offered to the target group and the community in general. Medical Model: refers to a model based on the premise that chemical dependence is a primary, progressive, chronic and relapsing disease. Minnesota Model: refers to a model which is based on the premise that persons who are chemically dependent can assist one another and has as working principles the assumptions that chemical dependence exists, is a disease and is a multi-phasic illness. Multi-disciplinary Team: refers to a therapeutic or multidisciplinary team of health and social development professional and accredited addiction counsellors (if members of the centre's staffing body) who provide treatment at the centre. See section 2.17 of the Minimum Norms and Standards for In-Patient Treatment Centres, for the minimum staff components of this team for type A and B facilities. Restorative Approach: refers to resolving conflict in a manner which focuses on healing and accountability rather than punishment, and which involves the participation of the community surrounding an incident, including the young person and his/her family, as well as the victim where appropriate.

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Sustainability: refers to efforts made by the facility to strengthen the program thereby ensuring its ongoing maintenance and hence the meeting of specific program needs. Systems Theory: refers to looking at young people in relation to the various systems within which they are or have been functioning. Every part of the system is connected to every other part and this inter-connectedness means that a change in one part will cause a change in some other part of the system, thus bringing about change in the total system. Therapeutic Intervention/program: refers to the clinical process by which the patients/clients are assisted in abstaining from their drug abuse/dependency and in participating in rehabilitation to achieve their optimal level of functioning. This process is based on best practice health care principles. Treatment should be holistic and, as far as possible, address all the patients'/clients' (and their families' and caregivers) needs, i.e. physical, psychological, social, vocational, spiritual, interpersonal and lifestyle needs. Therapeutic Milieu/Community: refers to a residential facility which provides the chemically dependent person with the opportunity to learn to lead a substance free life, within a safe, structured environment. Volunteer: refers to a person who offers their knowledge skills and/or time to areas of the program in a manner which supports the overall goal of the program. These services are provided free of charge and the volunteer is screened and given clear direction in terms of expectations by the service provider.

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Building a Caring Society. Together.

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