Treatment of drug addicts: a six years' experiment
The treatment programme
The Youth Clinic
The Contact Centre
THE STABILIZING PERIOD
Østre Gasvaerk (the youth pension in Copenhagen)
The day school in Copenhagen
The trade or handicraft school in Copenhagen
The Sorø House
The Hesbjerg Castle
PLACING IN FOSTER-FAMILIES
THE "STUDENT"-PROGRAMME OR THE EX-ADDICT-PROGRAMME
The structure and organization of the treatment system
Author: Karen BERNTSEN
Pages: 9 to 24
Creation Date: 1976/01/01
Youth Clinic Copenhagen Denmark
In Denmark, as in other Western European countries, the problem concerning drug abuse and drug addiction among young people started in the middle of the sixties.
It took some time, however, before it was considered as a problem, and in the beginning it was hoped that the less it was brought up in the mass media, the less publicity and sensation around the drugs, the easier an increase in the use could be avoided.
But slowly the drug problem grew, and at the same time we saw other manifestations of frustations, dissatisfaction among the youth regarding the way of life in the modern welfare society. There were the students' revolt, the various movements such as the provo-movement, the flower-power movement, etc.
The politically active part of the young generation demonstrated, provoked the establishment; they would show the weakness of the welfare society, and they wanted to change it. They provoked by their attitude, their behaviour. Some of the means to rebel against the older generation, the parents, were a different kind of clothing and hair-cut (the long hair), smoking of marihuana, taking LSD, mescaline, etc.
But in the wake of these groups followed other youngsters, whose social and economic background was quite different. Young persons, who had great personal and social problems with which they were unable to cope. Often youngsters having been brought up in broken homes or in institutions, having been school drop-outs, having been isolated and without good relations with either adults or peer groups.
The new and old drugs: hashish, LSD, amphetamine, morphine and later morphine base or heroin were used by them not as a demonstration or rebellion but as a means of escape from reality. They found out that it was impossible for them to live up to the demands and expectations of the adult world, and they were soon involved in a life and in groups where the essential thing was drugs. These groups of drug abusers or drug addicts were not new groups, they were well-known groups of the so-called "social losers", some of them being mentally disturbed, some of them being maladjusted, delinquent youngsters. The new thing was that a new symptom, drug-taking, had appeared.
During the first years the actions taken concerning the treatment of the young drug addicts followed the traditional ways: the intake in psychiatric hospitals without special measures for this young group, isolation in prisons and institutions, probation and ambulant treatment, etc. But the results were poor. Nobody really knew what to do.
In the autumn of 1968 the Youth Clinic in Copenhagen put forward to the Department of Social Welfare and to the municipality of Copenhagen a proposal concerning a treatment experiment of young drug addicts. The Youth Clinic was established in 1960, in connexion with a research of juvenile delinquency granted by the Ford Foundation in U.S.A., and since 1965 it had functioned as a guidance centre for young people in the age groups 14-21. It was financed by the Department of Social Welfare but worked as an independent institution, administered by the Danish Federation of Mental Health, and under the responsibility of a board.
Since the drug problem appeared in Copenhagen, the Youth Clinic had tried to follow the development. For one-and-a-half years the two persons in charge of the Clinic, two psychologists, had been members of an informal group of psychiatrists, psychologists, lawyers and social workers who had discussed the problem and tried to gather information on the measures taken in other countries. One of the psychologists of the Youth Clinic has studied the treatment facilities in some states of U.S.A., in England, and in the Netherlands. This information together with the experiences from the work in the Youth Clinic with delinquent and associal youngsters and with young people with psychological and/or other social handicaps composed the background for the proposal of the treatment experiment.
It was emphasized that the experiment was based on treatment on a voluntary basis. It was stressed that the drug problem was regarded as a symptom, which often blurred other social and psychological problems. Public discussion about the drug problem had been too narrow and one-sided in so far as it ended up in the false belief that the problem could be solved by concentrating on the drugs without taking into consideration the problems behind the drug-taking. The proposal also stressed the importance of finding ways and means to motivate the young drug addict to give up the drugs, which contributed to destroy him socially, physically and psychologically. But this in itself was not thought to be sufficient, to be drug-free was only the first step in the resocialization process. Afterwards it was just as important to have patience and to give the client time and possibilities, to make him conscious of his own weaknesses and strength, to teach him to be responsible and independent, to make him so strong that he could really make his own choice for the future and work towards realistic goals.
The last step would be to get him out of the treatment programme and to get him accepted by the normal society, to get rid of the stigma as a drug addict. The proposal stressed the need for money, facilities and staff. And concerning the last item it was emphasized that the Youth Clinic would try to get more young people involved in the programme as staff members. The reason for this was a hypothesis concerning the importance of getting inspiration and ideas from young people, the importance of having young people acting as role models for the drug addicts, and the belief that the problem of authority and generation conflict would diminish.
It must be said that during the years we have had some unforeseen problems concerning authority and generation gap, not so much between staff and clients, but rather between young staff members and the professionally trained staff of the Youth Clinic in general and the two psychologists in charge of the programme in particular. The proposal was approved, and the treatment experiment started in the spring of 1969.
It was rather interesting that the approval of this untraditional treatment experiment based on the principle of voluntariness coincided with the parliament's approval of tightening up the maximum sentences for drug-crimes from two to six years. By this the political "hawks" got theirs, and the political "doves" got theirs.
It is now more than six years since the programme started, and it would be against the intention if there had been no changes since then. But the main principles are the same, for instance the treatment on a voluntary basis as opposed to compulsory. We are using methadone during short detoxification periods so that it is a drug-free programme, and we are against the methadone maintenance programme. We try to build up our programme as much as possible so that the programme is adjusted to the needs of the client in the different stages of his development instead of trying to adjust the client to a programme which only meets with the needs of the staff. (This is easier written than done.) We are trying more and more to involve the clients in their own and other drug addicts' cure, to give them as soon as possible a chance to quit their role as drug addicts, to give them responsibility, rights and obligations.
This results in a rather complicated system, which will be simplified here excluding some less important aspects.
The Clinic occupies a five-storied high building in a working class area in Copenhagen. It is the central place of the system. The group in charge of the programme has its offices here, and in the meeting room the meetings of the board, of the various sub-committees and the weekly delegate meeting take place. The book-keeping and finance departments are placed here. The staff placed at the Youth Clinic are all professionally trained persons: psychologists, social workers,psychiatric consultants and the secreterial staff. All files and records are kept here.
An important part of the treatment programme has been the idea of continuity of the treatment. This means that each client joining the programme is attached to one therapist (a psychologist or a social worker), who follows the client through. Each therapist is responsible for 20-25 clients, which - as will be explained later does not mean that the therapist needs to have daily contact with all his clients. When the client is in other facilities in the programme, the responsibility is given over to other staff members. But the therapist at the clinic must know where his client is, and how he is, and the client must know to whom he can turn when in need. There are 12-14 therapists, which means that at any time there will be 280-350 drug addicts in treatment.
The drug addict can apply directly at the Clinic or he/she can be referred to the clinic by the private practitioners, the prison system, the hospitals, the schools or by parents and relatives. Young persons other than drug addicts, too, can apply or be referred to the clinic, and during the last year the clientele seemed to change slowly, for instance youngsters with sexual problems, alcohol problems, etc.
The therapist takes the intake interview and together with the client decides what kind of offer within the programme will be best suited to him taking into account as well his drug-career and number of detoxification attempts which failed, as his actual social, psychological and somatic situation, etc.
This article concentrates on the treatment programme planned for the vast majority of drug addicts who are registered at the Youth Clinic, but first a short description of the average client. He is between 21 and 23 years old, the length of the drug-career from 4-7 years, he has tried all kinds of drugs, hashish, LSD, amphetamine, barbiturates and opiates, but the preferred and most commonly used drug is morphine base which is taken by injections several times a day. He has been in conflict with the law for violation of the narcotic law and often of the criminal law also. He knows the prison system and the psychiatric hospitals from inside. He has no work, poor education, lives in a slum area, associates only with other drug addicts, his family has given up. His physical state is poor from bad nutrition, abscesses, etc. His social state is bad, even if he receives economic help in the form of social security (250 DK a week). This money is hardly through to buy his illegal drug for one day. Therefore, he must raise money through various kinds of criminality. His motivation for getting rid of his drug habits is weak, he is ambivalent, tired of his way of life but at the same time scared and frightened and without great hope for the future, and he has very little power of resistance against adversities.
These few characteristics are mentioned to give an impression of some of the problems involved.
There are two entrances to the treatment programme. One is the Youth Clinic, the other one is the Contact Centre. One of the differences between these two places is that the Contact Centre has a more direct street-level function, whereas at the Youth Clinic the client will often come by appointment with the therapist, and he is not supposed to wait or stay a longer time.
The Contact Centre is at present located in an old building near the harbour. It is open during day-time and often during the evening, too. You can walk in from the street and stay as long as you want. You can get food, take a bath, wash your clothes, play ping-pong, watch TV, and, most important, get acquainted with the staff and see the doctor, who comes every day. As a newcomer you can be anonymous until you decide to join the treatment programme, then you must give your name, etc.
The staff consists of a few professionally trained persons, a psychologist, a social worker, a physician and two secretaries. The remaining staff are 9-12 young people, some professionally trained, some students of medicine, psychology, etc., and some without special social training. The latter group are in shorter periods working at the Contact Centre to gather up a group of drug addicts who are at least slightly motivated to get rid of the drugs. It is hard to evaluate as to how strongly the client is motivated; a simple and realistic way to judge the motivation is to make appointments for attending group sessions at the Contact Centre, and if the client comes to these meetings, it is enough.
There are very few rules at the Contact Centre, you are not allowed to deal in drugs or to steal, and it is recommended not to use the centre for taking injections.
At the centre, plans for the detoxification tours are made, two of the young staff members combine a group of 6-8 junkies, who accept the conditions, and then the preparation period starts. It lasts 1-2 weeks. During this time the group meets regularly to get to know each other, the social workers or the psychologist, who is now responsible for the clients getting in touch with the social security department so that the client can have economic help and clothes; a medical examination and a blood test are made; contact with relatives (if there are any) is established as well as contact with other authorities, for instance the police or the court. And then, at a fixed date, the detoxification starts.
Although the drugs are considered as a symptom only, the first real step in the treatment and resocialization process is to stop the clients from taking drugs and, of course, this can be done in different ways: in hospital settings, in prisons, or ambulantly. It can be done by medication of different durations or by "cold turkey". The way we have done it during the last 4-5 years is in principle the following:
After a group of 6-8 drug-addicts have gone through the preparation period at the Contact Centre, the group with two staff members leave the city and drive to a rented house in the country. At that time the detoxification by methadone starts. The detoxification lasts only 10-12 days, the methadone is given orally in a solution (no tablet - no injections), and normally it is given twice a day, starting with 2 X 25 mg, cut down to 5 mg per day. If necessary, supportive medicine and sleeping pills are given, but it is aimed to keep them at a minimum.
The group consisting of the 6-8 clients and 2 young staff members live together in this country house for 3-4 weeks. It is important to mention that it is tried to avoid a feeling of institutionalizing and to make the house and the life here as "normal" as possible. Although, in the beginning, the staff are responsible for the medicine and the money, the functioning of the household is the responsibility of the whole group. Nobody comes from outside to clean, to shop, to cook, that is the group's responsibility. They must try to work together, they must agree on how to spend the money, what to do in leisure time activity, etc. They ministry to help and support each other. It is important to activate the clients and to teach them to take responsibility, to make decisions. Once a week the relaxation therapist will visit the group, and they will also be visited by an expert in group techniques, who will help to solve conflicts between the group members. If possible, they will get in touch with the neighbours because it is important to start communicating with ordinary people.
It has been asked why we use the 10 days' methadone detoxification, why not use the "cold turkey" method? Some of the reasons are that the methadone calms down the fear of the drug addict, that it does no harm, and that it makes it possible for the two, non-medically trained staff members to live with the 6 drug addicts because the symptoms of abstinence are less than by the "cold turkey". Why do we prefer the life in the country? Why don't we stay in the big city where the clients belong and to where they will return? Because our experiences have shown that it is too hard for drug addicts to stay so near the drug scene, the temptations are too great, and it is harder to keep the group together in the city. But detoxification in itself is only the beginning of the resocialization process. Almost none of our drug addicts will be able to return to the city after 3-4 weeks and to cope with their problems there.
In general, four to five out of six drug addicts will stay to the end of the detoxification tour. One or two will leave before, most often when the methadone has been finished. The group, of course, will try to keep them-at least that is what is said, but as the stay is voluntary, anyone may leave when he wants. But they cannot expect to come back to the group just like that because that is a group decision. If they leave and start taking drugs again they must wait for another tour.
But the fact that it is rare that a group of six clients complete the detoxification tour could give thought to the hypothesis of the need for "scapegoats". In order to feel better yourself, you must have somebody who is in your opinion not as good as yourself. When one or two are thrown out of the group or are leaving, the rest of the group is strengthened.
Later on I will describe a new model in which ex-addicts are used in the detoxification tours as assistants to, or substitutes for, the staff members.
After 3-4 weeks in the country, when the clients have been drug-free for about 2 weeks, a change is needed. The group is now rather small, the clients are restless, the staff members having been on 24 hours' duty for the whole period are exhausted and must counterbalance overtime.
Plans are made for the next step, which can be called the stabilizing period.
Usually 3-4 detoxification tours are going on at the same time. What to do next is discussed with each client. It is important that he knows the different facilities within the programme and other offers which are available.
In some cases it is relevant to postpone the decision by making a special programme for a shorter time: 2-3 weeks. This is called the stabilizing period. Here we do not have a fixed programme, it is established according to the time of the year, the interest and fantasy of the staff members and the clients involved. It is planned during the detoxification period, and usually it can be carried out only if the clients put aside some pocket money for it. This is done for pedagogical reasons.
The programme may consist of a two weeks' skiing tour to Norway in wintertime, a camping tour in Denmark, a canoe tour on the Swedish lakes in summertime, etc. These are in one way holiday trips, but at the same time they may be of great importance because the clients get away from the drugs environment, they get new challenges, they feel they are stronger than they believed, and they get new experiences.
But where to go next?
That again depends not only on the decision of the client but also on whether or not there is room for him in the facility he wants to join, and if he is accepted there.
At present, the treatment system has at its disposal in the city of Copenhagen a youth pension, a day school, and a handicraft school, and outside the city a house near a provincial town, and in the country a bigger house with land. At these places special programmes are run for ex-addicts. If the client does not want to go to any of these places, it is possible for him to join a foster-family, and if he does not want that either, he may go back to Copenhagen and continue the contact or treatment on an out-patient basis.
In the following paragraphs, the Danish names of the different facilities will be used.
This pension accommodates 10-12 clients, and the staff consists of 4 persons who are working on equal terms.
At this place it is expected that the client has stopped taking opiates, etc. He is expected either to work or to be in training or in an educational situation, either inside or outside the treatment system. There are special rules for the first month the clients are staying there, for instance they must spend their leisure time either in the house or together with older inhabitants or with the group. They must agree to being home two evenings a week for therapy sessions or house meetings. It is tried to let the house function as a small collectivity and to let the clients take over as much responsibility and power of decision as possible. In the case of a client going back to drugs, instead of being thrown out, he is offered support, a "crutch", either some other client or a staff member, which he prefers, who will stay close to him most of the time, bring him to and from work, etc.
As many drug addicts has been school drop-outs and had very ambivalent feelings about further education, at the same time wanting to improve their knowledge and being sure that it would be impossible in ordinary school settings because of their previous bad experiences there and their gaps in knowledge, we established our own school.
At this school 3 teachers are employed, and the average number of pupils is 12. The pupils are taught on an individual basis because some of them need to learn elementary reading, writing and arithmetic, and others who want to join high school or university level are taught mathematics, languages, etc. Emphasis is put on teaching civics and the organisation or structure of society.
When the pupils leave the day school and are admitted to high school or other higher educational institutions, they may continually come to the day school for additional lessons.
Having established the day school we felt a lack of a similar possibility for training of clients who were more interested in and suited for manual work. As a lot of drug addicts had in their lives very few and bad experiences in normal work situations, there was also a need for them to be trained in time keeping and in working at normal working hours. It was necessary to procure a sort of protected work situation where they could be adapted to these things before trying to get normal jobs.
The trade or handicraft school was then created, 3 artisans (a painter, a carpenter, and a plumber) as well as a craftsman (educated at the Academy of Art) were engaged, and some workshops were established in the building of the youth pension. Between 12 and 15 drug-free clients are working there.
The trade school has contact with various public and private institutions, kindergartens, small private schools, institutions for refugees, etc., and gets jobs consisting of shining up, repairing, making furniture, new playgrounds and the like. The institutions pay for the materials used, the treatment system pays the salary of the artisans, and by special arrangement the social security pays the clients additional money for the work they do. The trade unions have agreed that special arrangements like the above mentioned are excluded from the normal contracts.
The pupils of the trade school also work for the treatment system in so far as they may sew curtains or make beds and smaller furniture, repair and paint the rented detoxification houses when needed. But it is preferred that the majority of jobs are outside the treatment system because this gives the clients a better opportunity to meet people under normal conditions and to get used to normal working situations.
The trade school secures a protected working milieu in the way that the clients are not thrown out if they are late, leave early or are unable to work for 40 hours a week. But they get additional money only for the number of hours they work per week. For the time being the greatest problem is, of course, that even the clients who are indurated for and capable of working outside in society have very few chances of getting a job because of the tremendously great number of unemployed.
The Youth Clinic has another facility for clients who have succeeded in their detoxification. It is situated 60 kilometres from Copenhagen near a provincial town of average size. There is accommodation for 12 clients, the staff consists of 4 persons. The rules here concerning drugs are the same as those at the youth pension in Copenhagen, no drugs are allowed.
The advantage of this place is that the big city with its temptations is at a further distance, the disadvantage is that the clients cannot use the day school or the trade school in Copenhagen. That means that the clients must either attend training or education courses in the neighbouring towns or they must be occupied at the house. There are possibilities for growing vegetables and fruits, and there is a small workshop for ceramics. Besides, a recycling project has been started recently; this implies that the clients involved will go around the neighbourhood collecting things which have been discarded, they will offer to clear out attics, etc. Then they will repair, paint, mend, clean and sell the things in a sort of jumble or flea market. If an idea like this had been mentioned 5 years ago, I suppose it would have been rejected both by staff and clients as a filthy, unworthy job, but now it is "in". There is no time-limit for the stay at the Soro House, it is up to the individual client to know when he himself feels able to manage outside the institution and to know what to do when living in a realistic way.
This is another, rather big place situated on the island of Funen 160 kilo-metres from Copenhagen. It takes 3 hours to get there, the ferry boat alone takes 1 hour.
It is an old, badly kept castle with a small forest and land. It is beautifully situated with nice surroundings, but rather far from the nearest town (20 kilometres).
Twenty to 25 clients can stay there at a time, and the staff consists of 6-7 persons. It has been rather difficult for the staff to run the place in an adequate way because of the number of clients. There have been problems with drugs, with alcohol, and with the unwillingness of the clients to work and co-operate. Three months ago a new group of staff members started with a rather new plan, trying to form a small collectivity. They have split the castle up into 4 family-units living together. They have formed family, work, cultural and financial departments with members from the clientele and the staff. And they have formed a parliament for making rules and laws.
They have now finished making the necessary repairs, painting and improvements inside the buildings and are starting their plans for occupation. They plan to have workshops, a recycling project, a farming project with cattle etc. as well as a "kitchen workshop".
Their goal is to become self-supporting, to form a co-operative system. On account of the unemployment in society they intend to establish different kinds of workshops outside the premises where the clients who move out may come to work and earn their money.
Whether they will succeed in their plans, it is too early to say. The philosophy here, as in other facilities, is that the clients must get involved and engaged, must learn to make decisions, to take responsibility, to live together with other people, to be socialized.
Some of the detoxificated clients are not interested in, or are not thought fit for, one of the above mentioned facilities run directly by the Youth Clinic. These persons are then offered the opportunity of being placed in a foster-family for short or long periods.
The Youth Clinic has at all times contact with about 30 families scattered all over the country. Some of them are middle-aged stable families with grown-up children not living at home, others are younger couples with or without small children who have moved out into the country to live in a less bourgeois, more bohemian way. Some are living in collectivities of which a few consist of ex-addicts formerly treated in the system, who have also moved away from the big city. It is important to match the right foster-family with the right client, and this can be rather difficult. The majority of the foster-families has only one client at a time, but some are interested in receiving two clients or a couple. One exception is a couple with four children living at a big farm; he is an American film-man, she a Danish teacher. They have made special arrangements so that they can manage 6 to 8 clients at a time.
The foster-families get paid by the social security office in Copenhagen.
Two staff members from the Youth Clinic are attached especially to the foster-family programme.
It is important that the client and the foster-family get acquainted before accepting each other. Therefore the client will visit the home a few days before deciding whether to move in with the family.
Nevertheless, it is our experience that a number of clients leave the house or are thrown out within the first week.If the client stays beyond this period, he will often stay on for 6 to 9 months.
For a long time we have been discussing how it might be possible to speed up the resocialization process, and how important it would be to find a method of helping the clients to change their roles from addicts/ ex-addicts to a less stigmatized, more acceptable, and more normal role. We have also been discussing some of the problems concerning the role of being a client in a treatment system and the connexion between the therapist or the staff member and the client. We have got the feeling that both the client and the therapist have a tendency to try to cling to their roles because, in this way, they satisfy their own needs. The client wants help, and the therapist gives it. Therefore the client may improve but not be "cured", the therapist wants to help, so he needs the client, improved but not "cured". Accordingly we started the "student" programme which has in fact many similiarities with an American ex-addict programme, but for the reasons mentioned we did not want to use the name "ex-addict". The slogan here is: by helping others you will help yourself. By getting a new role giving you a lift of status you will see more clearly your own strength (and weaknesses also), when you are trusted and get responsibility, you will trust yourself more and will be able to live up to the responsibility expected.
In order to make the client fit for this role a student course is held. This is a 3-4 months' programme which is offered to drug-free clients, who may not be involved in a normal training or educational situation or who may not be in a normal work situation.
Each course is attended by 8 students (drug-free clients), lead by two staff members (at the moment 1 psychologist and 1 teacher). The course is divided into three stages:
The group live together during the first month. The first week is used for getting to know each other, dividing the jobs in the household, deciding who are to be responsible for the money, the car, etc. Here the students with a driver's licence are allowed to drive cars belonging to the system. The staff are acting as consultants to the students but are not taking initiatives. It is planned and agreed only beforehand that week-days are divided into compulsory working-hours (from 9 to 12 a.m. and from 2 to 5 p.m.), during which time meetings are held, preparations for assignments are made, and reports written. The group finds out what kind of assignment they prefer or what kind of task to fulfill during the next 1 to 2 weeks. One example: Get contact with a school, a youth club, a home for old-aged people in the neighbourhood and tell them about and discuss with them the drug problems. Another example: Find out what kind of youth problems there are in a provincial town in the neighbourhood and what kind of facilities are available for youth. When they have decided on the task, they must find out whom to contact, what to ask for, how to ask. Then they must carry out the task, discuss it and write reports about it. All of this seems rather difficult for most of them, not being used to communicating with so-called normal people, they are faced with rather hard confrontations but they grow with them, they achieve more self-esteem, they start changing their roles.
After the introduction period the real challenge starts. The job now is to participate in a detoxification tour with new drug addicts. As mentioned earlier, the normal detoxification tours consist of 2 staff members and 6 drug-addicts. Here it is different, there are only 1 staff member and 2 students going out with 6 drug-addicts. For a short preparation period (1 week) 4 staff members are with the 8 students, they discuss the problems coming up during the detoxification tours, (the students have their own experiences). They use role playing, various games, and 4 groups are composed. It is deliberate that there is only one staff member at this programme. If there were two, they would keep together, and the two students would be in a marginal position between staff and clients. Now the staff member must lean on and trust the students. The second period lasts 4-5 weeks, and the important period is the detoxification tour where the students work on an equal footing with the staff member. The two people in charge of the student-programme act as consultants to the tours, especially trying to solve conflicts and problems between the students and the staff member. The students are paid for their job during these 4-5 weeks, but they do not get the same salary as the staff.
In the third period the group of 8 students (if they are still 8, because usually 1 or 2 will leave during the first or the second period) come back and for the next month live with the two persons in charge of the programme. They will write reports on the detoxification tours, they will discuss and find out where they succeeded, where they failed and they will find out where to go from there.
The three student programmes carried through up till now have shown how important it is for the students to make realistic plans. We have seen that most of the students could accomplish the job, but also that some of them were too self-confident wanting to manage on their own but they relapsed into drugs and had a hard time before coming back and admitting their failure. They had got a status, and it was hard for them to lose it. For these reasons we have planned other student programmes. Besides that, it is recommended that the students should participate in two or more detoxification tours. One plan is to use the students in the search for new drug addicts needing treatment. Another is to make a public relation group preparing material, going out into schools and youth clubs giving information about drugs, speaking on the radio, etc.
There are other plans only one of which, however, will be mentioned here, namely the aim at involving the students in an "appeal committee". In as big and complicated a treatment system as this with so many people, staff and clients, scattered all over the country it is unavoidable that there are complaints of various kinds. We want to establish an appeal committee consisting of some students, some staff members and one or both of the psychologists in charge of the Clinic, where clients as well as staff members may come and have complaints dealt with.
Once or twice a year a minisociety is held. A minisociety is a two weeks' programme, in which it is tried to get people of different age-groups, from different social classes, with different educational backgrounds, with special social/psychological problems or with different symptoms of problems or so-called normal individuals, to live together.
The size of the minisociety differs from 40 to 60 people. Some of them are clients (drug-free) from the Youth Clinic, others are staff members and therapists. Some of them are students in social work or psychology. There are children and, if possible, a group of old-aged persons. Further we try to get groups with physical handicaps, for instance, blind or deaf persons, and a group of unemployed or a group of alcoholics in treatment, etc.
The minisociety takes place in one of the holiday camps where the members of the society are put in houses each holding 6 persons, the family group. The staff consist of 3 to 5 persons who are in charge of the society for the first three days and after that only act as an action-research group.
The goal is to let people experience how to make the family-group function and how to make the minisociety as such function. What kind of structure and organization is wanted, how to avoid a chaotic situation, etc. Important also is the fact that the only role of the members is to be a member of the minisociety, the clients are not clients who can get help from their therapists, the therapists are not therapists who are supposed to help the clients. The problems are the problems of the society and must be solved there.
Furthermore, it is essential to see if different groups with different problems can help each other, can find other and more relevant ways to solve their problems by communicating with each other and with individuals from other groups.
It is difficult to distinguish between treatment and after-care just as it is often impossible to distinguish between pre-treatment and treatment. But to give a few examples concerning after-care it can be mentioned that in a case where the client lives by himself or with his parents or with his own family, and he is in a training educational situation or has work, the contact with the therapist at the Youth Clinic is kept as long as it makes the client feel safe.
This contact may be rather loose, every second or third month, but according to whether the problems are smaller or bigger, the contacts may become more or less frequent. On account of this practice it is quite difficult to give an exact date for the end of the treatment.
Another example of after-care can be illustrated by mentioning the clients, often couples or groups of 3 to 4, who decide to leave the city and settle down in the country or in small provincial towns. They lack, however, the money for the deposit and the rent. Here we are able to help them financially by giving them a loan. A contract is made for the instalments, and support is given by visiting them in their new houses until they are able to manage on their own.
When the experiment of treating drug addicts started in 1969, the Youth Clinic consisted of a smaller group of professional people and a secretarial staff, in all 16 persons. They knew each other well, had the same attitude, were able to discuss on equal level and to work together.
But very quickly the system expanded, the staff grew and were scattered all over the country. In 1975 there were between 80 and 90 staff members and there were 13 or 14 different facilities in Copenhagen and the rest of the country. This has, of course, given rise to many problems, and the administration has become more complicated.
The task of the persons in charge is first of all to try to keep the whole system together as a unity, to get the different sub-divisions to work together because they are dependent on each other in the way the clients are treated. It is the task of the persons in charge to see that every sub-division functions well, to give inspirations and ideas to new experiments, to appoint and to discharge staff members.
But at the same time it is important that the sub-divisions have a certain amount of autonomy. However, it is a rather hard question which degree of autonomy combined with what amount of responsibility is optimal, especially in this kind of work. Throughout the years, especially from 1971-1973 there have been rather big problems and struggles between certain groups of very politically active young staff members and the two persons in charge as well as conflicts between the professionally and the non-professionally trained staff. But these problems were not exceptions to our system because, as far as I know, the same kind of trouble and conflicts have taken place in the same kind of work in many other countries. As mentioned before, the system is now organized in such a way that the two psychologists in charge are responsible because they are appointed leaders. The system is kept together first of all by a weekly meeting, a delegate meeting, attended by the two leaders and two representatives from each sub-division. These two representatives may be two staff members, 1 staff member and 1 client or 2 clients.
At these meetings questions about financial problems, new initiatives, new plans, are discussed. A report is given about the actual situation in the different sub-divisions, and special positive and negative events during the last week are brought up. The aim is to give information and to get the staff and the clients involved and engaged not only in their own part of the system but in the treatment system as a whole. The two leaders will inform about their work within and outside the system, for instance as members of various drug-committees, or about their meetings with municipal or State authorities and about their contact with mass media. For the information of the staff a report of the meeting is written and distributed to all staff members.
Once a week there are therapy meetings where the psychologists in charge, one or two psychiatrists and the therapists discuss different treatment methods and individual clients. These meetings are often used,as brain-storms for special, perhaps rather non-traditional ways, of helping the most complicated clients.
The majority of new staff members, professionally and non-professionally trained, have none or very little experience with drug addicts. Therefore, courses of about a week's duration are held for groups of new staff members in which they learn about drugs, about social and mental disorder in general, about drug addicts in particular. They will learn about the treatment programme, about our attitude and methods. The course is held at our training centre where they live together. Besides, the new staff members may use one or two weeks for moving around in the different sub-divisions to observe in practice what is going on and to get acquainted with other staff members.
If there are special problems in one of the sub-divisions, the staff with or without clients may ask for a seminar for 2 or 3 days at the training centre to solve their problems. Seminars may be held with representatives from the different sub-divisions if the problems concern the co-operation of two or more sub-divisions.
If a new facility is going to open up, or if a new project is being planned, the people engaged in this and the psychologists in charge are going to the training centre for a 2 to 5 days' meeting. Often 3 or 4 persons from outside with special knowledge of and interest in the subject are invited as consultants. They may be Danish or from abroad, but because of language difficulties Scandinavians are preferred.
Before trying falteringly to give a few answers to the very touchy question of the outcome, the results of the treatment, some facts about the clientele and the staff must be given. As mentioned before the staff consist of about 80 persons.
There are two psychologists in charge, 3 psychiatrists and 1 physician working as consultants on a part-time basis. The therapist group consists of 6 psychologists and 8 social workers whose case-load is 20 to 25 clients each. There is a secretarial group of 10 persons, a group of book-keepers and cashier of 4 and a telephone operator. Three teachers are employed at the day school. Four artisans at the trade or handicraft school.
Finally, there is the big group of about 40 persons, some are professionally trained and some not. They are placed in the different facilities in or outside Copenhagen, about half of them being attached to the detoxification tours. There are at any time between 280 and 350 clients in the programme. Some are on their way in, some on their way out. The number of clients placed or engaged in our own facilities differs but on average it is between 90 to 100 clients who are staying at the three drug-free facilities, are in the student programme, on detoxification programmes in foster-families, attend day school or trade-handicraft school. Between 100 and 125 clients are in after-care, drug-free, living privately, working or in training. The rest, about 100 to 125, are clients among which the majority are on drugs and at the moment not in real treatment. Some of them are new clients waiting for a detoxification tour, some are old clients who have tried 2 to 5 times, perhaps more, to get drug-free and who want to try again. Maybe they will get a chance, maybe other measures will be tried, or perhaps they will be given up (for the time being). Some of this group are hospitalized, others are in jail or prison.
The average age of the clients is now 22 to 23 years, and there are now very few below 18 years. Four years ago the average age was 16 to 18 years - our present clientele consisting to a certain degree only of the same persons as in 1971. This trend that we have so few very young drug addicts must be seen as a positive sign in the development, as it is the general opinion in the country as a whole that the drug problem among young people is stagnating and perhaps diminishing because the new generation as such is not interested in opiates, etc. The new "old" problem is expected to be alcohol. Marihuana and hashish are not seen as a problem.
The distribution between the sexes has been the same throughout the years, one third being female, two thirds being male. About 500 clients go through the system each year, and about 1,500 drug addicts have been registered by us during the 6 years we have been in operation. The death rate is, as found in many other researches, much higher than it ought to be taking the age-group into consideration. Fifty-three have died (3.5 per cent). Only 2 of these died, however, while they were placed in one of our own institutions.
Turning now to the touchy point of results. First of all: it can be discussed what is meant by result, what is a good result, what is a bad result?
Is it enough that the client is drug-free when he leaves the programme? Is it acceptable if he then turns to alcohol and becomes an alcoholic, because at least then he does not break the law to satisfy his need for stimulants?
Is it enough if he is kept out of prisons or hospitals and instead is given an invalid pension because socially, psychologically and physiologically he is not able to get work and support himself, but at the same time periodically takes drugs without being involved in crime?
When does one assess the results of the work? Six months, 1 year or 3 years after discharge?
One can continue with questions like these concerning the outcome. One thing should be mentioned in this connexion, namely: it is a general trend that the politicians, the authorities, and the public are demanding better and quicker results from the new and untraditional treatment systems than from the old, traditional, well-known systems in the hospitals and the prisons. At this point it is not taken into consideration, whether the new systems are economically cheaper - which they are - whether they are more humane, etc.
One gets the feeling that the general opinion is that if these new systems do not live up to somebody's expectation, then they will be closed and society will continues to use the traditional institutions, the results of which they seldom know but from which they do not expect very much.
A scientific research has been made by the Research Institute of the Danish Federation of Mental Health concerning the programme of the Youth Clinic. The person in charge of this was professor Dr. Ph. Eggert Petersen. He and his group of research workers followed the programme during a three-year period 1969-1972. They studied the development of the programme, followed and analysed the problems and conflicts, studied the files and records of the clients, and the treatment procedure and the outcome. After an observation period of at least 16 months after discharge they made a follow-up study. The research was divided into an extensive investigation comprising 481 persons and an intensive investigation with interviews of a smaller group of 88 persons. There are great similiarities between the data from these two groups. Between 46 to 48 per cent have got no criminal sanctions, 70 per cent have not been placed in mental hospitals or in other drug-treatment institutions, and between 33 to 36 per cent have none of these criteria. Fifty-two per cent have work or are in an educational situation. Sixty per cent are drug-free, and 76 per cent have adequate living quarters.
Eggert Petersen concludes: "Based on the findings one must repudiate the idea that narcotic addiction cannot be "cured". On the contrary, the research shows that in reality the treatment system can and does treat narcotic addicts, a respectable number of whom is giving up narcotics upon completion of treatment as a result of, among other things, the treatment itself".
Thirty years ago the treatment of individuals with social/psychological problems was completely concentrated on the individual himself, as if he were living in a vacuum. Then the importance of interpersonal relationships was seen clearly and the group treatment, the conjoint family treatment started. But more and more the social conditions, the whole society was seen as playing an important role in the life of the single individual.
We have tried as much as possible to get away from the traditional institutionalization with its stigmatizing, its making the individuals irresponsible, passive and dependent, and its distance between inmates, patients, prisoners and staff.
We want to make our clients active, responsible, and independent. We try to diminish the gap between staff and client, to make the client self-confident, to give him a realistic attitude towards his own strength and weakness. We are trying to imitate the normal social learning process because that is what has often failed partly because of the rather hard conditions in which they were brought up. We try to give them time, to be patient, because you cannot heal damages, which have started 20 years ago, in 2 or 3 months. We try to put demands on our clients but these demands must be adapted to the developmental stage of each individual.
Do we succeed? Now and then yes, most often I think we succeed in something, bringing the clients a little step further in a positive direction, and now and then we do not succeed at all. I do not believe that a treatment programme or system can be imitated or transferred from one country to another, from one culture to another. But I believe that it is important to be informed of the things going on in other countries. Perhaps there is a chance to get some kind of inspiration from what one sees, hears or reads, to get some new ideas and fantasies which may be useful for one's work in the future.