In Belgium a large diversity of treatment possibilities exists for people with drug problems. Not only in regard to the types of treatment centres, but also regarding the specific methods of treatment that are used. Furthermore, due to the organisation of the Belgian state structure with its different policy levels (the federal level, the communities and regions), not all types of treatment centres fall under the same legislation or the same financial regulations. Treatment centres might fall under different policy levels, but also under different policy domains (e.g. public health, internal affairs). Moreover, often several authorities are involved at the same time and consequently the division of competencies between them is not always clear.
In first instance a number of treatment centres specialised in (illegal) substance abuse treatment have gradually entered into a so-called ‘revalidation agreement’ with the National Institute for Invalidity and Health Insurance and consequently fall under the authority of the federal policy level. These centres are often referred to as the ‘specialised substance abuse treatment centres with RIZIV/INAMI14 convention’. Most of these centres are exclusively oriented towards people with illegal drug problems. Some of them have added a clause in their agreement that allows them to take up a limited number of people with primary alcohol problems.
By the end of the year 2000, 28 centres (possibly with different units or treatment modules) were working within the framework of such a financial agreement with the RIZIV/INAMI. Within this group of treatment centres a distinction has to be made between four different types of treatment centres: long-term residential programmes (the
14 The “Rijksdienst voor Invaliditeit en Ziekteverzekering” (RIZIV) and “Institut National d’ Assurance Médicale
et Invalidité” (INAMI) are the respective Dutch and French terms for the National Institute for Invalidity and Health Insurance in Belgium.
therapeutic communities); the residential crisis intervention centres; the ambulatory centres and the medical–social reception centres. In 2000, 14 long-term residential treatment centres, 8 crisis intervention centres, 7 ambulatory centres and 8 medical– social reception centres had entered in an agreement with the RIZIV/INAMI (INAMI, 2001). This number of centres stayed stable until 1 April 2003, when a new medical-social reception centre entered in an agreement with the RIZIV/INAMI.
A second group of services where people with drug problems can turn to are the psychiatric hospitals and the psychiatric wards in general hospitals. These treatment centres are as such not exclusively oriented towards people with illegal drug problems; on the contrary, a variety of psychiatric problems are treated. On the other hand, due to the specific characteristics of their client population, it is possible that certain psychiatric hospitals or psychiatric wards in general hospitals have decided to create a specialized substance abuse unit. Naturally, all of these treatment centres follow the same general regulations as other hospitals and are therefore mostly subject to federal legislation. The policy level of the communities has however certain competencies on the matter (e.g. quality assurance).
A third group of treatment centres that plays a significant role in the treatment of substance abuse problems are the Centres for Mental Health Care (CHMC). As well as the psychiatric hospitals and the psychiatric wards in general hospitals, these centres treat a large number of psychological or psychiatric problems. Certain Centres for Mental Health Care have however developed a certain specialisation in the treatment of drug problems. According to the principles of the Belgian state structure, where the communities are responsible for certain attributed person–related matters, the Centre for Mental Health Care can be situated exclusively under the competences of this policy level. Due to historical and pragmatic reasons however, the responsibility for the CHMC in the French-speaking part of Belgium has been transferred to the Walloon Region instead of the French Community (COCOF for the Brussels Region).
Although these three groups of treatment centres can be considered to take up a large part of drug users starting treatment in Belgium, the group of other treatment facilities for persons with drug problems should not be ignored or underestimated. Other types of treatment or guidance than the ones mentioned above are: initiatives in the general health or social welfare sector, general practitioners, self-employed psychologists or psychiatrists, emergency wards in general hospitals, outreach work, non-subsidized initiatives, half way houses, sheltered living, temporary projects, self-help groups, etc. Certain types of treatment centres run parallel in the different parts of Belgium since they are subsidized at the federal level. Other services are organised or represented in a different manner. General practitioners for example tend to play a larger role in substitution treatment in Brussels and the French Community than in the Flemish part of Belgium (EMCDDA, 2002).
When describing this diversity of treatment possibilities, the focus was on the different treatment centres, but one should be aware of the recent evolutions concerning care circuits and the used concepts. When looking at different treatment possibilities in the context of a care circuit, we rather look at the different modules that can be offered than to the distinction between treatment centres.
A care circuit forms the complete offer of care of a network, for a certain target group in a certain region. Such a circuit consists of units of care that offer certain modules. These modules represent the necessary care routes for that specific target group and offer the guarantee of continuity in care and care adapted to the specific needs of the client
PART A New Developments and Trends
Belgian National Report on drugs 2004 61 (Nassen et al., 1999). In the French Community, instead of a care circuit, the concept of network has been introduced by a decree of the Walloon Region (details are given in 1.2.c).
In mental health care and youth assistance, as in the assistance for drug users, the organization of care by networks in the form of care circuits, becomes more and more of a frequent thought. Care adapted to the client, continuity of care, collaboration and more effective and efficient care are central concepts (Vanderplasschen et.al., 2001b). A specific intervention that is aimed at promoting coordinated and continuous care at individual level is case management.
In 2004 a dissertation concerning these last subjects was published. The dissertation “Implementation and evaluation of case management for substance abusers with complex and multiple problems” of Wouter Vanderplasschen focussed on the organisation of substance abuse treatment in a specific region (Ghent) and on an alternative approach to optimize the quality of treatment and service delivery for substance abusers. In particular the study aimed at:
- evaluating aspects of coordination and continuity of care in agencies that addressed this target population in this region;
- implementing and evaluating a model of case management for assisting substance abusers with multiple and complex problems;
- integrating this intervention in the network of available services (Vanderplasschen, 2004).
In November 2003, a research project, financed under the research programme “Supporting actions to the federal policy document on drugs”, started concerning “Case management in the substance abuse treatment- and criminal justice system”. The aim of this study is on one hand to come to a conceptualisation of case management, focusing on occasional differences between case managers operating within the criminal justice system and those connected to substance abuse treatment, and on the other hand to identify conditions for the implementation of case management within the criminal justice- and substance abuse treatment system. The results of this study will be available by the end of 2004.
In pursuit of the Federal Drug Policy Note, the Flemish steering group mental health care started in 2004 the project care coordination substance abuse (Overleg Vlaamse zorgcoördinatoren middelengebruik en de Vlaamse overlegplatforms GGZ 2004). Care coordinators have to facilitate consult with regard to a care circuit for people with substance related disorders. The available care offer and the extent of cooperation are different for each province, so a differentiated approach is necessary. To find some inspiration and to tune the care coordinators meet at a regular basis.
In the Walloon Region, in the area of Charleroi, a network of several institutions: (Diapason, Unisson, Trempoline and Coordination drogue), called “DUTC” was created (other networks exist in the Walloon Region). The aim of the DUTC is to create a work in network complementary to other existing networks in order to improve the work of assistance offered to the user (Trempoline 2003).