Rationale and Staff Evaluation of Using a “Therapeutic Milieu” for Substance Users Within a Tuberculosis Ward

Abstract

Approximately 30% of tuberculosis (TB) patients in Israel were treated, in part, in two dedicated hospital wards during the years 2003–2005. A portion of them manifested severe psychosocial conditions. An intervention based on the “Therapeutic Milieu” (TM) model was implemented in the larger ward and included a staff evaluation of this intervention. The concept of TM, based on psychosocial paradigms and behavioral medicine, is aimed at providing a supportive environment for patients. Weekly group patients' meetings and monthly group staff supervisions were performed during 15 months (2003–2005). Forty of the 196 (20%) TB patients, mainly “complex,” and 13 of 20 staff members (65%) attended regularly and discussed how to deal with substance abuse, personality disorders, and immigration-related crises. Out of 40 TB cases, 30 (75%) were also substance users. Ten staff members self-analyzed the impact of this intervention in terms of (1) having given adequate tools for the staff, (2) reducing physical violence, (3) increasing adherence to TB treatment, and (4) more efficient treatment for their substance use. No direct evaluation was done among the TB patients. According to staff members, this intervention had a positive overall impact. However, using Therapeutic Milieu in TB ward hospitalization, as a “window of opportunity,” remains the first step in a longer journey for rehabilitation. The study's limitations are noted.

Keywords:

• tuberculosis
• psychosocial
• Therapeutic Milieu
• substance abuse
• Israel
• dropout
• relapse
• compliance

Notes

The five major elements recommended by WHO are (1) political commitment; (2) adequate laboratory diagnostic facilities; (3) standardized short-course chemotherapy given under DOT supplies; (4) consistent drug supplies; and (5) permanent reporting system.

³ Treatment can be briefly and usefully defined as a planned, goal-directed change process, of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bound (by culture, place, time, and the like) and can be categorized into professional-based, tradition-based, mutual-help based (AA, NA, etc.), and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users—of whatever types—which aren't also used with nonsubstance users. In the West, with the relatively new ideology of “harm reduction” and the even newer quality of life (QOL) treatment-driven model, there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Editor's note.

⁴ The (Hebrew) questionnaire can be obtained by writing to the first author.

¹ The opinions expressed in this article are those of the authors and do not purport to represent the opinions of the agencies with which they are associated. Part of this paper was presented in abstract form at the Fourth Congress of the International Union Against Tuberculosis and Lung Disease, Europe Region, Riga, Latvia, June 2007. This evaluation was part of the external evaluation done by the Department of Tuberculosis and AIDS at the Israeli ministry of health.