|Written by Alan Matthews|
|Thursday, 13 December 1990 00:00|
The Dutch Approach to Drug Treatment & Education 1
CARE AND CURE
a visit to the Jellinek Centre, Amsterdam
The Dutch approach to the management of drug problems can provide valuable lessons to others attempting to tackle similar situations. Here, we present two reports by visitors from Britain in search of some clues.
The Dutch approach to drug problems is much the same as their approach to driving in the centre of Amsterdam.
At first glance it appears chaotic, everyone does as they please. On closer inspection, however, the observer will begin to define a calm sense of purpose underpinning the apparent mayhem.
Confined as they are to the narrow crowded streets and bridges that criss-cross the city centre canals, motorists have to adopt a co-operative mode of driving. If the way ahead is blocked, you simply reverse and find an alternative route to your destination. Everybody understands this and, consequently, confrontations are rare and tempers remain even.
As the motorist is stuck with the general layout of the city centre, so the city fathers are stuck with the knowledge that drugs and their use have always, and will always, be a part of human behaviour. Just as it is impossible to re-build the city to accommodate cars, it is equally impossible (and naive) to think we can re-structure society and human desire.
In a way, this attitude prevails when tackling drug problems. Pragmatism and a sense of mutual co-operation is virtually a national trait of the Dutch. They have identified the social, legal and health problems related to the use of drugs in their society and have set about dealing with them in the most practical and realistic way available.
Of a general population of 650,000 in Amsterdam, it is estimated that there are approximately 6,500 opiate users (the majority of whom use a range of drugs and are therefore classed as 'poly-drug' users) and roughly 40,000 people who abuse alcohol. Of that 6,500, it is estimated that 30% inject, while the remainder smoke their drug. About one third of injectors are infected with HIV.
Amsterdam provides a comprehensive 'care & cure' system for dealing with problem drug users, whether that be for alcohol or illicit drugs. If you read Henk Jan Van Vliet's article in the first edition of this journal (Van Vliet, 1989) you will have gained some understanding of how Dutch society and attitudes have evolved.
Here, I would like to illustrate Henk Jan's writing by focussing on a practical example of how these attitudes influence the work of one aspect of service provision in Amsterdam - the Jellinek Centre.
The Jellinek is, in fact, not one centre but an umbrella organisation within which a number of approaches and disciplines work together to provide a wide range of educational and treatment options for both problematic drug and alcohol users. On the education side is the Drug Prevention Project, which deals specifically with designing and disseminating materials and providing training for workers.
The Director of the Drug Prevention Project, Jaap Jamin, acted as my guide to the Jellinek, arranging appointments and explaining how the organisation worked. From the outset, it must be understood that the Jellinek is one aspect of an "integrated, co-operative" system of service provision for problem drug users in Amsterdam. Realising that prevention strategies can only be effective if the co-operation of clients is sought and maintained, a number of 'safety-nets' are in position to ensure this contact is on-going.
Before reaching the Jellinek, therefore, problem drug users have a number of options on offer that deal more specifically with the care side of the equation. Initially, there are three levels of care that problem drug users can make use of, which have the general aim of reducing the damage done to both the individual and to society as a whole. These are:
Methadone Buses: which supply oral methadone to registered clients; exchange old syringes and needles for new; and supply condoms.
Family Doctors: who supply oral methadone to registered clients; give physical check-ups; and direct clients on to cure programmes.
Neighbourhood Centres: supplying oral methadone; urinalysis; syringe exchange; condoms; physical check-ups; psycho-social treatment; AIDS prevention; and referrals to cure programmes.
If a client, for whatever reason, decides or is advised to go for further treatment, they would normally be referred to the Consultancy Bureau for Alcohol and Drugs (CAD), which is pa of the Jellinek Centre. This is the first stage of involvement for the Jellinek, where the client's problem will be assessed and a treatment programme devised. This could entail the client being treated at the CAD or referred t either an in- or out-patient clinic.
One of the most enlightening aspects of my trip was the level of co-operation between different disciplines. The perfect example of this was my visit with the co-directors of the CAD, Bert Minjon and Roland Wolters. Bert handled the treatment side and Roland the probation. As Bert explained
"In Amsterdam we have a 'care and cure' philosophy. The CAD represents the cure side and consequently we only deal with those who are ready and willing to change their lifestyle."
However, this does not mean that failure to comply with or complete a treatment programme is the end of the line as clients can always return to one of the care options listed above until they feel ready to try again. This 'safety-net' means that contact is maintained with clients, minimising harm and monitoring progress.
The Jellinek, unlike many drug treatment systems, includes alcohol abuse within its brief. Even so, I was not too surprised to learn that for the estimated 40,000 alcohol abusers there are 96 beds available almost immediately, while for the 7,000 drug abusers there is a waiting list for 80 beds. This is an indication of how the two problems are viewed, by Western societies generally but even in this somewhat enlightened city. Referrals the alcohol services can come privately from a family doctor, or via the CAD.
One particularly interesting aspect of the work of the CAD is the involvement with the penal system. The Dutch prison service itself can provide many useful examples of dealing with offenders, the main focus of which is reform rather than punishment. On a visit to Bijlmer prison, one of two large remand centres in Amsterdam, I was initially struck by the overall design and layout of the facility. It looked, to me, just like one of the tower block housing estates I am familiar with on Merseyside, but in better condition!
Robert Chenevert, the co-ordinator of the Jellinek's prison project, and his team, work within the prison itself providing drug treatment for those that request it. The top ten floors of the six tower blocks that make up Bijlmer are split into five 'pavilions' (one pavilion being two floors) housing 24 inmates (12 cells per floor, one inmate per cell)
One of the pavilions was solely for those prisoners who wanted to stop using drugs and this was where the drug-free treatment took place. He briefly outlined the programme and aims as
Two to three week de-toxification period, using oral methadone, on arrival (this is standard in most Dutch prisons) .
Drug-free therapy, mainly group-work oriented but with some individual counselling.
Referral to rehabilitation centre.
The one prisoner per cell was an aspect that intrigued me, as this is not the case in England. Robert explained that it is a general policy that incarceration is viewed as a last resort Consequently, the prison population of Holland is between 4-5,000. However, these around 50% are in prison for drug related offences.
Drug treatment as an alternative to custody is an option that can be taken by clients at any stage during their progress through the legal system. On arrest, while awaiting sentence or while serving a term, clients can request treatment. This usually means a reduction in their sentence, but is in no way viewed as a soft option, either by the police, the courts or the clients themselves. Failure to comply with treatment or to complete the programme means a return to custody to finish their sentence.
I was particularly interested in finding out about the spread of HIV through needle-sharing or unprotected sexual contact in prisons and what was being done to combat this. But Robert with that Dutch air of disarming (almost naive) logic told me that this was not considered a problem due to the single cell system and constant supervision by prison staff. While accepting that this may cut down risk behaviour, I still felt that explicit anti-AIDS policies needed to be implemented, if only to reinforce the issue.
A recent study showed that among drug users and drug using prostitutes awareness of HIV prevention was relatively high. Female prostitutes reported frequent use of condoms for both vaginal and oro-genital contact (89% and 64% respectively). Amongst intravenous drug users, the majority of those surveyed (74%) exhibited an awareness of the dangers of needle sharing and a need for significant lifestyle changes regarding safer drug use. Although the prevalence of HIV infection in Amsterdam was increasing, it seems to be occurring at a slower rate than in other European cities (Hoek, J.A.R van den et al. 1988)
The CAD, working closely with the police, probation and the prisons project, get many referrals through the legal system. As noted above, they assess the client's problem and decide on a course of action. The two treatment components here consist of either Out-Patient: diagnostics; methadone reducing programmes; methadone maintenance; individual therapy; group therapy; family therapy; psychiatric therapy; AIDS prevention and condom supply; acupuncture; referral to in-patient treatment; and after-care.
In-Patient: clinical detoxification; clinical drug-free therapy; and after-care.
The treatment goal of both approaches is termination of the addiction problem but in a broad, almost holistic context.
There are three in-patient 'clinics' (or rehabilitation communities) sited outside Amsterdam which provide the final aspect of drug treatment. On arrival, for those not already drug-free, a one-week detoxification programme is provided using oral methadone.
Referrals to these centres can come from any of the sources cited above and it was interesting to note that 25% of their clients came directly from prison under special conditions as part of their sentence.
The centre I visited, at Parkweg Buiten, was situated in an old farmhouse in the rural flatlands of picture-postcard Holland. Roel Hermanides, the director, explained that this centre catered for the heavy, long-term poly-drug users who may have developed serious social and emotional problems during their drug using 'career'. The average age of residents was 30, but the oldest was 50. The programme here lasted 9 months while another centre at Parkweg Binnen, which catered for younger clients, had a five month programme.
Roel explained that the regime was a fairly strict, intensive programme clients from a dependent frame of mind to the gradual acceptance of more responsibility within the community and ultimately out in the rest of society. The focus was more on the circumstance of dependence rather than the drug per se. The cynic in me stirred. This sounds good in theory, but what was the experience in reality? Roel's frankness, like that of the majority of people I met, was refreshing. He readily admitted that approximately one third of new residents leave during the first month. But this is not seen as a failure as they still remain in the system by returning to one of the previous options until they are ready to try again. Contact with clients is, once more, maintained. During 1988, 300 clients went through the in-patient treatment of the three centres, 203 were new to the system and 217 completed the programme.
A heavy emphasis is put on after-care, beginning with a period of re-socialisation during their final three months at the centre. This entails finding work and housing back in society in preparation for their departure. Part of the after-care process demands that clients attend a weekly meeting for the first twelve months of residence back in society, which could also include individual and family therapy.
"Do you ever see former clients after they finish treatment?" I asked, thinking that strong relationships must be established between residents and staff. "Only very informally" Roel replied "and unintentionally. We feel that it is best if former clients move on and go forward with their lives. We don't accept former residents as potential staff members, as in the Synanon model for example."
Spending a few days looking at an organisation as diverse as the Jellinek left me feeling rather like one of the three blind men trying to describe an elephant by touch alone. One aspect cannot be viewed in isolation from the others, you have to stand back to consider the whole beast, both within its own context and that of its environment, to understand how it functions.
Using a hierarchy of liaison and consultation, the Jellinek appears to find common-ground and an administrative framework which allows workers to function efficiently and co-operatively between different disciplines to provide a comprehensive range of treatment options in a non-judgemental, non-competitive way.
To understand how this works in the broader, social context we need to look (once again) at the Dutch attitude and approach to life in general. In other countries civil war is being fought - a war on drugs and drug users. The Dutch have called a truce in this war, as they realise that the only casualties are their own people, caught in the crossfire of conflicting ideals and philosophies.
Amsterdam is neither a haven nor a paradise for those who want to use drugs. Drugs are illegal there, just as in many other countries. Amsterdam is, however, a place where drug problems are treated seriously and realistically, but in a calm, pragmatic manner. The Jellinek is but one component of that comprehensive, integrated problem prevention policy.
Hoek, J.A.R. van den, Haastrecht, K.J.A. van, Zadelhoff, A.W. van, Goudsmit, J., & Coutinho, R.A., 1988, Prevalence and risk factors of HIV infections among drug users and drug using prostitutes in Amsterdam. AIDS. 2.55-60
Vliet, H.J. van, Drug Policy as a Management Strategy, The International Journal on Drug Policy Vol 1 no 1 1989