Some reflections on the present situation of drug abuse among young people
Compulsory versus voluntary treatment
Death rate among young drug-dependent persons
The young drug-dependent woman and her child
Author: K. BERNTSEN
Pages: 15 to 22
Creation Date: 1981/01/01
Interest in drug abuse has recently increased in Denmark and other Scandinavian countries, in particular with regard to certain aspects of the problem. This paper reviews the questions of voluntary versus compulsory treatment, the high death rate among young drug-dependent persons and the problems of the young drug-dependent woman and her child. Although it is difficult to predict future developments in drug abuse, the paper concludes that ways and means must be found to provide children and young people with a more meaningful life. This will mean tackling the social, economic and psychological situation of those at risk of becoming drug-dependent.
This article deals mainly with the situation in Denmark and other Scandinavian countries. Although the situation with regard to drug use in these countries differs in some ways, it has many points of similarity.
It is now more than a decade since the Scandinavian and most of the other European countries started to become seriously concerned about drug abuse among young people and tried to do something about it. At that time, at least in Denmark, the mass media showed a great interest in drug-related problems.
There followed years when the subject was nearly forgotten. Other problems came into focus: the world situation in general and the problem of refugees, increasing unemployment, inflation etc.
However, interest in drug abuse has recently increased. In the Scandinavian countries for example, the question of voluntary versus compulsory treatment has been taken, while the high death rate among young drugs-dependent persons has also been of serious concern.
Special attention has also been paid to the problems of children born to drug-dependent women.
These are some of the problems which are addressed in this paper.
In Denmark the official policy has been and still does favour voluntary treatment. At the end of the 1960s there was much public discussion among professionals and politicians regarding compulsory or voluntary treatment. The subject was later dropped, and the treatment programmes which were established, first in Copenhagen, and later in the larger towns, were all based on the principle of voluntarism.
During the past year, however, not only in Denmark but also in other Scandinavian countries, the discussion about compulsory treatment has been revived.
As far as I can see, the main reasons for this are partly the reports on a Swedish experiment called "Hassela", which is based on compulsion, and partly inadequate knowledge of the results of existing treatment programmes [1, 2]. The Hassela Collective is an institution which belongs to the municipality of Stockholm. Each year it takes in 12 young drug-dependent persons, 6 of each sex, from a hospital department, the Maria Polyclinic.
Child-care law in Sweden is applicable until the child is 20 years of age. Young people must not be more than 20 years of age at admission. They are chosen from among heroin abusers who are involved in crimes, some of whom join the programme voluntarily. Others are sent, and if they abscond they can be brought back by the police; it is this point, the compulsory placing, on which the debate has focused.
The book Hassela, Frangen til Frihed (Compulsion for freedom) states that Hassela wants to "release youth from the compulsion which lies in drug-dependence, drinking, prostitution etc."
The Hassela teaching does not build on therapy in the traditional sense but on education, training, rehabilitation, and building up a consciousness of responsibility and independence. It is a programme which is intended for children from the class of unskilled labour.
It is important to emphasize that Hassela is not an isolated institution with locked doors. It has an open-door policy with a warm milieu and is set in the countryside. There is work to be done, physical training during the day, and in the evenings debates, political education, dancing lessons and various other cultural activities. The programme starts with a week's mountain climbing under hard physical conditions. After one year the group moves to another collective connected to a folk high-school.
The success rate of this rehabilitation programme is said to be over 75 per cent, but it is difficult to discover what this figure is based upon.
The Hassela experiment has inspired a similar kind of institution in Norway, the Tyrili Collective. This has, however, met with opposition from a large group of professionals who are in favour of voluntary treatment, and it has recently resulted in the establishment of a Hassela Collective based on voluntarism [ 3] .
There is now a proposal in Sweden to create a new law [ 4] , based on the Hassela experiences, under which it would also be possible to use compulsory treatment for drug-dependent adults. In some cases compulsory treatment will last for two months, in other cases the treatment may be prolonged by a further two months.
At present there is serious debate in the Scandinavian countries on this proposal in particular, and on compulsory treatment in general. Some professional groups are in favour whereas others are against the idea.
It is dangerous to make generalizations about the model of compulsory treatment. The Hassela has been used for quite young people under the law of child care. But how will the older generation of drug-dependent persons react? The Hassela programme is designed for a three-year period of education and training. The proposed Swedish law talks about two, perhaps four months of compulsory treatment.
The Hassela programme was established and is run by an experienced, charismatic personality. The founder, his family and staff share the same ideas. Is it possible to find many other such persons, for whom the compulsory part is only a small ingredient of the whole programme? And if not, compulsion will become the main ingredient, and if four months prove to be insufficient, what will be done then?
The other reason for the discussion about compulsory measures is perhaps a lack of knowledge about the results of voluntary drug-free programmes. At the beginning of the 1970s there were some follow-up studies in Denmark, which covered the period 1968 - 1973 [5 - 8]. They showed that one third of drug-dependent persons were drug-free after a three-year observation period.
Recently, the first part of a follow-up study was published, entitled Unge Narkomane 7 år Efter (Young drug-dependent persons seven years after) by Soren Haastrup and others [ 9] .
The study covers 300 youngsters, 200 of whom were registered in 1973 in the drug-free programme of the Municipality of Copenhagen, and 100 in a special treatment programme in a psychiatric hospital (Nordvang) in one of Copenhagen's suburbs. At the time of admission they were all dependent on opiates, the average age was 21 years, and they had started using drugs when they were approximately 17 years of age. Two thirds of them were men, the other one third were women.
The follow-up study took place in 1980 and consisted of personal·interviews and information from various official sources.
The results were as follows:
It is not easy to evaluate the results as so much depends on the persons who make the evaluation. The total of 38 per cent (classes I and II) is only slightly more than one third better, one third the same, and one third in a worse condition, the normal situation which has been found in many follow-up studies concerning treatment results [ 10] .
One interesting point is that, on one hand, the majority of those in this category have moved away from the city and have settled in the country. On the other hand, those in a worse situation have moved from the suburbs to the centre of Copenhagen.
It is, nevertheless, important to collect follow-up results in order to prove that it is possible to help young persons out of their drug-dependence by voluntary treatment methods.
The high death rate among young drug-dependent persons is a problem of great concern.
In all follow-up studies the number of deaths reported is extremely high, and in the Danish study it was found that 47 persons (16 per cent) had died during the seven-year period. In a normal population of the same age group one would expect to find that two or three persons had died. The preliminary report mentions no cause of death, but from other research it is known that an overdose of unknown or mixed drugs is often the cause [11, 12].
When persons who have become drug-free during their stay in hospital, prison or in a drug-free treatment programme return to the city they run an increased risk of death if they take a dose of drugs similar to their previous levels. It is important to provide information on this risk.
There are a certain number of suicides, proved by farewell letters, but there are also cases where it is difficult to ascertain if the death was accidental or suicidal.
More deaths are noted in periods when there is a scarcity of morphine and heroin on the black market, because drug-dependent persons take whatever they can get without knowing what it is. Another problem is that drug-dependent persons who have been on drugs for years become self-destructive; they are apathetic, they do not care if they are alive or not because their lives are not worth anything to them; they do not consciously commit suicide, it just happens. When one has been working with drug-dependent persons for many years, one often wonders why some, who are still alive, have not died long ago, and conversely, why some persons die, when you thought they were getting on rather well.
It would be interesting to conduct research into the particular characteristics of those who die. This research might help to identify suicidal tendencies and also help to prevent or reduce the high death rate among young drug-dependent people.
In countries where the drug problem has existed for 10 years ormore, a new aspect has been highlighted during the last four to five years. That is the risk of pregnancy and the birth of children to drug-dependent mothers [ 13] . Previously it was taken for granted that drug-dependent women seldom became pregnant, but more and more of these women recently have had children.
The first problem is that drug-dependent women are frequently unable or disinterested in regularly using contraceptive methods.
The second problem is that when pregnancy occurs it is often only discovered in the fourth or fifth month, too late for a legal abortion. This is due to irregular menstruation and sometimes to shorter menstruation periods.
A third problem occurs even if the pregnancy is proved earlier and a legal abortion is possible. The woman may refuse an abortion because she believes that the birth of a child will bring about a change in her situation and cause her to cease drug abuse. It is, of course, possible that this might happen in some cases, but generally speaking it is unrealistic.
It is very difficult to persuade the pregnant drug-dependent woman to undergo regular obstetric treatment. She is often living in bad housing conditions, her partner is also drug-dependent, she does not get the right food, she earns her money by prostitution, and she injects whatever drugs she can get.
The birth is often premature, the child is underweight and is born with abstinence symptoms which must be treated immediately.
The result is that in most cases the child is taken to be cared for away from the mother, for weeks perhaps, and because the two are separated the natural tie between the mother and the newborn child is not established.
The vicious circle really starts here. The mother is released from the clinic without her child; in most cases she will return to the situation she was in before. The doctors and nurses expect her to behave responsibly, to visit the clinic regularly, and to care for the child. She is scared, she feels guilty perhaps about the newborn child and the state in which the child was born. She takes up drugs again, and she fails to live up to the expectations of the clinic.
Sometimes some other persons, social workers etc., help her to obtain a new flat and clothes, furniture, money, and at last she takes the baby home. But what happens now? These children are often more difficult than normal children, they cry more, they sleep less, they are irritable, they have stomach troubles. All this is hard to cope with, especially for a woman with personal and social problems and without a stable partner to support her.
Follow-up studies of these children show that they are often shunted around, from hospital to institution, from grandparents to mother, and back again. Our experience shows that these children are very restless, they seek a lot of superficial contacts, they reject deeper relationships, and they show signs of a strong deprivation syndrome.
What can be done? The best course would be to prevent pregnancy before the drug-dependent woman is drug-free and is able to live a stable life. This does not seem possible at the moment. One must therefore change the strategy for handling the problem and try a different approach.
In most places, one thing ought to be done, that is to co-ordinate the work of all the people involved during the pregnancy, at birth, during the neonatal period, with child-care, with the socio-economic situation, with the housing problem etc.
It is suggested that an experiment should be conducted where the pregnant woman is offered a place to live for at least four months before the birth and perhaps one to two years after the child is born. The place would accommodate five or six other pregnant women or young mothers; it should have sufficient, but not too many staff, and have one person especially responsible for each mother and child. An effort should be made to avoid the long separation between mother and child after birth; this disturbs the possibility of emotional contact between them.
Many programmes are quite strict in their rules about drug usage or the non-appearance of the mother for a few days. It would, of course, be disastrous if the child was left alone. But if the child were cared for by the same staff person during the stay, one could afford to be more lenient with the mother and to give her time to adjust and to learn her responsibilities.
Experiments of this kind have been carried out in the United States with good results [ 14] .
It is hard to forecast what the future holds; the social and economic situation has changed in so many ways during the last decade. In many Western countries the drug problem began to develop during the years when there was little unemployment and no economic crisis, so it must be due to other psychological causes.
This situation has now changed completely, and if we want to do something to stop the growth of the problem of drugs and alcohol, we must find ways and means of giving our children and young people a more meaningful life and hope for the future.
It is harder and harder to get a job, and to understand the need for training and education. More and more young people give up thinking that society needs them. There always will be a group of children who, because of their social background and their abilities, will struggle to get good marks, will compete and will get good jobs. But the danger is that the other group, those who live under harder conditions, who are not stimulated enough either at home or at school, will increase. For many of them the easiest way out, perhaps, will be to start on a drug or an alcoholic career.
Therefore, it is not enough to establish treatment centres etc., to spend time discussing compulsory versus voluntary treatment. As has often been said before, if we don't tackle the social, economic and psychological situation of those at risk in our society, we will not be able to cope with the drug problem.
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