Bridging Disciplinary Boundaries (January 11 - 14, 2007)

In this study, focus group and in-depth interviewing methods were used to analyze how clients and staff of a drug treatment clinic in St. Gallen, Switzerland, describe, assess, and conceptualize heroin-assisted treatment. Clinic based heroin-assisted treatment (HaT) is a relatively new treatment method in the addiction field. It has so far only been broadly implemented in Switzerland. HaT programs target a specific group of severely addicted drug users who failed in methadone maintenance treatment. These clients usually failed because methadone has a relatively weak psycho-active effect (“rush”). As a consequence, some methadone maintenance clients continue to misuse illicit street heroin, and this in turn means that they also continue to experience the consequences of a street user life style (health problems, decreased social functioning, and problems with law-enforcement). Beginning in 1994 the Swiss health authorities established HaT as an integral component of the Swiss drug treatment system. Although there are important differences, HaT clinics are roughly comparable to methadone maintenance programs. Aside from providing heroin, clinics offer medical, psychiatric, as well as psycho-social services such as individual and group counseling sessions and employment readiness programs. The provision of HaT follows tightly regulated procedures, and collaboration with in-house specialists (physicians, psychiatrists, and social workers) is a condition of ongoing treatment participation. Several experimental and observational studies attest to the overall effectiveness of HaT (improved mental health and social functioning, decrease in street drug use, fewer illegal activities, and high retention rates). However, HaT has so far only been studied as a ‘treatment package'. Consequently, there is relatively little evidence about the ‘black box' of HaT. The findings of this study provide a first step in addressing this knowledge gap. Focus group and in-depth interview methods were used to study how clients and staff of a HaT program in St. Gallen, Switzerland, describe, assess, and conceptualize HaT. Particular attention was paid to a) the overall assessment and conceptualization of HaT as a drug treatment approach (treatment philosophy); b) treatment planning (including planning of treatment termination); and c) the role of particular treatment components such as provision of heroin, medical, psychiatric, and psycho-social services. Findings suggest that clients and staff generally perceive HaT as an effective drug treatment method for severely addicted drug users. Most clients reported that after entering HaT they experienced a ‘stabilization' effect in terms of their health and social functioning. Most clients and staff conceptualized HaT as a first step toward abstinence rather than as a long-term treatment for drug addicts. Staff and client's assessment of some auxiliary treatment components differed somewhat. Clients were less sure that services like employment readiness programs increased the effectiveness of HaT. Implications for clinical practice include the importance of careful treatment planning, including the planning of further treatment in methadone or abstinence-oriented programs as well as the necessity to further clarify the efficiency of particular treatment components. The relevance of these findings for the American drug treatment system will be discussed.