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Addiction, Treatment
Written by Bart Majoor   
Monday, 12 April 1993 00:00

The development of the dutch drug treatment approach

  • paper presented at the 1993 Drug Policy Foundation Conference, Washington D.C. by Bart Majoor, clinical psychologist and Head of the Department of Methodology and Training of the Netherlands Institute on Alcohol and Drugs (NIAD), Utrecht, The Netherlands.
At the beginning of the seventies the emergence of a hard drugproblem, fuelled by the replacement of opium by heroin in 1972 (courtesy CIA involvement in the Golden Triangle) demanded a new approach to the treatment of addicts. The traditional system of MCA's and their related clinics applied the even traditional medical-psychiatric approach of alcoholics on drugaddicts:  addicts are ill and can be treated for their illness by a doctor or a psychiatrist.

If this is done, it soon becomes clear that the single medical-psychiatric approach to drugtreatment doesn't work. In those years the use of drugs was still a protest against the establishment. Young people found each other in a subculture where the use of drugs was an important ritual to show that you were part of the group.

Due to the Opiumlaw the use of drugs could become such an important characteristic of the protest against the establishment. Drugs were forbidden. To do something that is forbidden is within a youthculture an important way to say 'no'. Like in a family with adolescents: they have to fight their parents norms and values in order to be able to develop their own system of norms and values.

So, the Opiumlaw criminalised these young drugusers, while the traditional approach to treatment of (alcohol)addicts put their problems into a medical frame of reference.

The treatment out of the medical model is directed towards total abstinence of the drug. Very few drugaddicts appeared to be able to do so. Characteristic were frequent - often short - periods of abstinence (f.i. in jail) to bring down their level of tolerance and restore physically in general. After such a short period of abstinence most of them (80-90%) relapsed into the use of drugs again.

The criminalisation of druguse causes complications in the treatment of drugaddicts too. One could say that care and cure for drugaddicts was and still is very polluted by the fact that heroin, cocain, etc. is illegal. There is a lot of societal uproar because of the criminal acts involved in obtaining these illegal drugs (car radios, prostitution, etc.). Buying the drugs from illegal dealers causes lots of annoyance on the streets in certain town areas. Ofcourse they are arrested frequently for these illegal practices and are send to jail or they have to pay fines.

This 'illegality' is a choice of society, f.i. western societies who should know the lessons of 'drooglegging' from recent history. In terms of care and cure of drugaddicts - being in daily contact with those people - this illegal context is always present. It penetrates in every aspect of the clients' life, so it appears in every session between helper and client. It creates a depressed, often negative atmosphere.., ánd perspective!

The criminalisation of druguse sets on a proces of deterioration on the individual level. Deterioration describes a proces of pollution, declining and social upheaval of a person who is dependent on an illegal drug in the actual social context. Like in any situation of survival, the social interests become less important than the individual interests. The process of deterioration in drugaddicts is characterised by 8 features:

  • 1- dependency or addiction
  • 2- polydruguse
  • 3- progressive deterioration of general physical health
  • 4- poverty
  • 5- junkybehavior
  • 6- drugrelated criminality
  • 7- dependency on drugscene (subculture)
  • 8- social isolation
Deterioration is mainly caused by social factors, although physical and psychic factors play a role in this proces. A drugaddict becomes part of a negative spiral of deterioration because his/her environment reacts in such a way (by stigmatising and criminalising) that expulsion takes place. The drugaddict will then isolate him/herself more and more and withdraw in a subculture or scene with very different norms and values.

It soon became clear that this context for treatment of drugaddicts caused all kind of difficulties. The traditional medical-psychiatric approach to the individual client didn't work for a majority of drugaddicts who came for help. Although at the end of the sixties the existing MCA's renamed themselves more and more 'bureau's for consultation on alcohol and drugs (CAD), as an expression of their willingness to apply their competence on alcohol as well on drugs, they weren't prepared for the very different demands of drugaddicts.

Although they all said that they wanted to 'kick off', it soon became clear that they came for something else. They didn't want to stop their habbit, they wanted a temporary shelter from the 'hit-and-run'-life outside. They often were exhausted from living their lives in the drugscene. Because the 'treatment-system' was still very much trained on 'aiming at living an abstinent life', our clients - who were soon called junkies - developed a very inventive set of behaviors to get what théy wanted.

And so a new syndrome was born: the 'junky-syndrome' that describes the lying, cheating and steeling of drugaddicts... The games addicts play.., did anyone ever ask why they play these games? The junky-syndrome compares their behavior with that of people in german concentrationcamps. Behavior that is totally directed at one goal: obtaining the drug that is crucial to their lives. Any person they meet is seen in that light, everyone is an instrument to reach that goal whether it is a dealer, an old lady with a fat purse or a worker at the drugclinic. That's why burnout among drugworkers should get a lot of attention in terms of supporting them. Only by continuous maintenance of a worker the process of burnout can turn into one of 'burn-through'.

With those clients the 'cure'-way of thinking that helpers held, had to be replaced by a more unconditional 'care'-way of thinking. Not only out of charitative motives but especially out of pragmatic considerations.



It had been within the framework of general youthhelp that this care-approach had come into development.

*Hier het verhaal van de oprichting van het Amsterdamse JAC in 1967.

This approach - the socalled 'alternative assistance' - was inspired by the work of mainly american sociologists on deviant behavior and subcultures. This led to an alternative approach to helping people in which social rehabilitation of the client was the important goal of treatment.

*hier het verhaal van de selfhelp in the underground (drugteams, Release).

After Amsterdam many JAC's followed in the country, adressing much attention to drugtakers. While the JAC's had this important 'alternative' influence on the treatment of drugaddicts, in their daily practice the specific implications for this alternative approach to drugaddicts were too demanding for these organisations.

The development of an alternative approach for drugaddicts in an ambulatory setting starts in Amsterdam in the early seventies. On the waves of the flower power/hippy subculture young people start to come to Amsterdam. In youthcentres like Paradiso and the Melkweg the liberal dutch approach to the drugproblem was operationalised. The youngsters slept in a big park in the centre of Amsterdam (the Vondelpark). Thousands of young people were experimenting with cannabis, LSD, speed and somewhat later opiates. It became clear to the local government that something had to be done to reduce the risks of those experiments. The Vondelpark-project started with a little staff of experienced workers who tried to contact the young people sleeping there. They provided information on subjects that mattered to the youngsters and helped them when they were in trouble. The experiments with drugs asked for a lot of attention. When the use of heroin spreaded quickly among those experimenters it became clear that more was needed.

A categorial care-approach was developed in the seventies by individuals and organisations who were concerned about the drugproblem. Together with individual policymakers they played with alternative care-models for drugaddicts. It was a time of experimenting and the government provided a lot of money for those experiments because the drugproblem became more and more an important political issue.

*Hier HUK, Princenhof etc.

R'dam - learning form A'dam mistakes - methadone bus

So community based reinsertion of drugaddicts became in the beginning of the seventies already a substantive part of the drugpolicy in the Netherlands. The central goal of the government with this policy is harmreduction: which means to reduce the risks of drugtaking for the addict himself, his direct environment and for society as a whole. These risks are not restricted to the properties of the drug involved, but are also dependent on the reasons why they are used, the nature of the social group in which they are used and the circumstances in which the use of drugs takes place.

Based on these premises a pragmatic approach to the drugproblem in the Netherlands was developed in the past two decades. This means that the government tries to find an effective balance between the three main policy instruments in this field, i.e. law enforcement, health care and social rehabilitation.

One way to describe the developments from that point on, is to pay attention to what happened in the clinical and ambulatory settings. Especially in the seventies and eighties these fields were quite apart in their methodological translations of the alternative model. It is only in the nineties that the integration of their development and a tuning into each other is taking place (costs of total addiction-assistance in Holland in 1992 was 264 million guilders or 130 million USdollars; residential/ambulatory, alcohol/drugs/gambling ánd prevention-programs; we have about 22.000 harddrugaddicts on a population of 15 million people).

AMBULATORY SETTING

  • care and cure
Within the ambulatory setting two main stream models of working with drugaddicts developed over the years. First there were the treatment programs for the cure of addicts who were already physically clean. Beside this there were far more programs for the management or care of addicts who were still on drugs. These programs were directed at harmreduction and social rehabilitation of the clients.

Out of the humanistic psychology of Maslow the so-called 'acceptation-model' was developed. This model states that the basic needs from Maslows hierarchy of needs had to be provided by these programs (= Harm Reduction) in order to create a base for further growth of the client (= Social Rehab). Their physiological needs and the need for safety are firstly satisfied by programs that provide methadone in a maintenance-dosage. First medical aid is provided and the clients are regularly screened on illnesses like hepatitis and tuberculoses. Clients can also get free meals, take a shower, wash their cloths, etc. The clients are helped with the management of their money and with finding a house. For clients who want more than just stopping the deterioration-proces, there are projects where they can learn to learn and work.

  • medical-societal care/the methadone-issue
The hypothesis that methadone maintenance programs would create a base for further change by giving a client the opportunity to become less dependent on the drug didn't work as expected. Most clients use their daily dosage of methadone as a cheap or easy starter. Because of the methadone they won't get sick in terms of abstinence symptoms. But methadone doesn't give them the kick they crave for so they continue to use heroin, cocain, alcohol, sleepers and tranquilizers in order to satisfy this need.

What methadone did do however was providing a very important means of contacting the hidden population of drugaddicts. Especially out of a health care perspective it is important that 80-90% of the drugaddicts in the Netherlands is seen by the workers on a regular base.

Regarding methadone one can conclude that after 20 years of working with it on a large scale it doesn't offer much more than a very effective means of contact with the drugaddicts. Therapeutically it doesn't provide the changes in a clients life that were expected when we started methadone-programs. Since a few years the professional dialogue on the use of methadone in care programs is re-opened. Although some 30% of the clients who get methadone is doing well and live a socially integrated life, with most of the clients one sees the development of gradually becoming a plant. They vegetate/become totally dependent on the care programs and they continue to use all kind of drugs. Since the clients who were only addicted to opiates hardly exist any more, this is another reason to doubt the effects of providing methadone. Beside this it is also very expensive for the government to provide thousands of addicts with methadone on a daily base while there is hardly any perspective that their number will decrease.

One of the reactions now is to push programs that demand more of the client in terms of change. More pressure and compulsatory measures are taken in order to stop a client from becoming totally dependent on the care system. The Americam methadone programs who appear to be more succesfull place more demands on the clients. Payments by the social security system are only made when a client lives up to the demands of the program. The rationale of this approach is simple: don't give money to a heroin addict - a junky! - without compulsatory (read 'life-threathening') conditions, otherwise it is like throwing the money into a black hole...

In terms of management and care we may have a point here, but I wonder whether it does something on the level of cure. Anyway, the 'acceptation'-model has been driven to the extreme in the Netherlands and we seem to be at a turning point now. The repressive approach in the care and cure of drugaddicts is now more and more wellcomed as the answer to the lack of results of the field in general. Another important factor in this proces is that the country is economically in a time of recession. There are less funds, so there is a call for efficiency that enhances a harder methodological approach.

To me it just seems another war on drugs, now on the level of assistance... And a war on drugs is a loosing war as we all know by now.

EPD's

Already at the end of the seventies it became clear that especially in the big city-drugscenes of Amsterdam and Rotterdam 5 to 10% of the addicts were the so called 'Extremely Problematic Drugaddicts or EPD's'.  Here the combination of severe and longterm polydruguse, severe psychopathology and deterioration to the worst degree as defined before, creates a very difficult group of clients. Their individual lives are crazy, dehumanized, dangerous nightmares caused by a personal physical and psychological substratum and - again - the social context of illegality.

Soon it was decided that in order to let the programs for 'normal' addicts do their work, this group needed to be taken care of in socalled 'trashcan'-programs. These programs are very hard to enter for a client but are very unconditional in their approach once you are in. Harmreduction in the most basic sense of the word is the philosophy of these programs. Protection of society, of other care- and cure-programs and protection of the clients against themselves are the important aims of these programs.



  • field- and streetcornerwork
Another task of the ambulatory field that developed out of the alternative approach in youthcare is field- and streetcornerwork. In the traditional medical-psychiatric model the helper is the expert who waits behind his/her desk for the client with whome they have made an appointment. The client comes in time, tells a story and gets a recipe - sometimes for pills, mostly in words of advice - to reduce or solve his problems. With drugaddicts it was clear that this way of meeting them didn't work. They simply didn't show up..!

Methadone was the only reason why they came at all. So field- and streetcornerwork was developed to contact the clients in their own environment with the aim of harmreduction and social rehabilitation. Especially in the work with specific groups of drugusers out of different cultural backgrounds (i.e. Surinam, Antillian, Maroccan and Turkish clients) fieldwork has proven to be a succesfull way of working.

The problem with this way of working is that few people seem to be able to work in this way. Fieldwork asks of the worker a specific set of characteristics that in their combination are hard to find in people. The job asks a synthesis between a calling, a specific expertise and a style of living of the worker.

In the dutch care-system for drugaddicts those fieldworkers were for a long time the scouts of the newly developing approach to drugaddicts. Only now in the nineties gradually a more active culture of out-reaching assistance is spreading in the drugfield.

  • social rehabilitation
As we saw already, the acceptation-model became widely spread in the ambulatory drugfield. Accept that a client is addicted and start to work from there on with him/her. Treatment - used here in a broad sense, i.e. care- ánd cure-interventions -  should not only be aimed at the (abstinence of) the substance involved. The social situation of the client and the strong and weak sides of his/her personality should also be taken into account. If one agrees with this view on the problem, it is an impossible demand to simply ask (or force) an addict to stop using drugs or alcohol. Even when he would succeed stopping and would turn his back on the drugscene, the ex-addict will find himself in a 'no man's land'. The often described phenomenon after kicking off physically is the psychosocial 'empty hole' in which they find themselves: no friends or family, no work, no education, no identity.., just a sucking, black heritage from their junky-past. So, no perspective which often causes relapse into addiction.

This is an important reason why social rehabilitation has become an integral part of the work with drugaddicts. Not only as a point of attention in the aftercare when treatment is ended but rather as a starting point for treatment. The philosophy here is that when it is possible to reduce and stabilize the risks of being an addict and in addition to create a real social perspective for the individual in the first place, the conditions for succesfull treatment will be much better. This pragmatic approach will result in a higher effectiveness of treatmentprograms and will also render more efficiency in terms of costs.

Social rehabilitation is an approach that involves a lot of different methodologies that are highly interconnected. This makes it hard to describe but there are a number of key-characteristics of rehabilitation that can be mentioned.

1- high accessibility of careprograms

To start with rehabilitation of a person one needs to be in contact with the client ('pacing' in the broader sense of the concept). As we have seen the demand of total abstinence is impossible to live up to for most addicts. If total abstinence is a prerequisite for treatment the majority of clients would not be reached in a voluntary setting. This would result in further deterioration which will cause more harm to the person involved, his/her environment and to society as a whole. So, it is important to reach as much clients as possible for some form of care or cure.

If cure is not (yet) possible, then care is an important aim. I talked about these palliative forms of treatment in the paragraph on medical-societal care. These 'low tresholdprograms' in the Netherlands make that we reach about 80-90% of the population of drugaddicts.

When in the midst of the eighties HIV-infection and AIDS suddenly became an important aspect of the work with drugaddicts the high accessiblity of the careprograms made it a lot easier to reach the clients to inform them about safe use and safe sex. The infrastructure was already there to start needle exchange programs on a large scale. The relationship with the clientgroup was there to start an effective prevention-campaign which is still operationalized in a creative way (f.i. basic box). This results in a relatively low rate of HIV-infection among i.v. drugusers (welk %?).

In general, beside the widespread existence of low-threshold-programs in Holland, one of the important reasons why we have (together with Ireland) the lowest rate of 133 drugaddicts per 100.000 inhabitants (Europe: 261) and the lowest rate of drugdeaths in Europe (1991: 42; f.i. Frankfurt: 1000), is that our social security system is still very benevolent.., but we are working on it..!



1


2- high flexibility of treatmentprograms

The treatment of drugaddicts is a fairly complex task which is still rather new to professional workers. What we call drugaddicts is in fact a very heterogenic group of clients that share only the symptom of dependency on a substance. The underlying psychopathology and/or their social problems are often very different.

Beside this, the introduction of new illegal drugs, polydruguse, AIDS, children of drugaddicted parents, different cultural backgrounds, etc. are a few factors that are making the drugproblem more and more complicated. In terms of treatment this means that small teams of professional workers from different disciplines are needed to be able to provide the flexibility in responding to a specific client's need in this dynamic field of work.

3- community-rooted treatment programs

Rehabilitation or community based reinsertion also means that treatmentprograms should be rooted in a recognisable area of the local community.  In bigger cities every neighbourhood has its own features that will partly determine the prevalence of a drugproblem there. Small projects with workers who know the streets, the people and the specific problems there will make it easier to contact drugusers and addicts who live there (pacing!) and help them integrate into the community again. Rehabilitation means as little distance as possible between treatment and life itself.

4- empowering the healthy parts of a client

This is probably the most significant characteristic of rehabilitation. As helpers we generally tend to focus on what is 'sick' in a client, f.i. being addicted to a substance. This attitude towards a client has its deep roots into the traditional medical/psychiatric approach to treatment. In rehabilitation we accept - at least for the time being - that there are sick or failing parts in a client and focus for treatment on the potential or healthy parts of a client. In this way we can start to restore the clients social perspective and empower the client to take on more responsibility for his/her life. The helper isn't the expert anymore, but the guide who supports the client in finding his way out of the negative spiral of deterioration.

This approach can be operationalised by rehab-projects that focus coherently on the different life-areas, f.i. management of finances/debts, living in a house, education, working, free time spending, cooking, judicial affairs, relationships, social skills, etc.

In experimenting with this 'less-expert, more-guiding' approach to the clients, there was a dogmatism to the other extreme. While the traditional approach consisted of counseling and psychotherapy most of the time, a worker in these social rehab-programs was instructed not to talk with a client about his/her psychological problems. Again, only in the nineties, an integration of both approaches is clearly taking place.

5- Rehab-programs as part of a network

As stated before, rehab should be an integral part of a multi-functional treatmentsystem including ambulatory and residential facilities for cure, care and social reinsertion of drugaddicts. This is what we call the vertical tuning in between the different facilities within the field of drugtreatment.

Beside this a horizontal tuning in is necessary between rehab-projects and general institutions who are available to every citizen. In this way we minimalize stigmatising effects and normalize the social position of the drugaddict.

Casemanagement is a rather new and promising concept in this respect. In general it means that based on the possibilities of a certain client a casemanager looks for the best way to provide the needed guidance and support. In the case of drugaddicts the needed assistance is often complex. Some answers can be found in the specific drugtreatment programs, other assistance can better be found in general institutions. The casemanager coordinates the different interventions which are interlinked but can have very different aims, like enhancing social skills, stabilising durguse, restoring social contacts or family ties, preparing for school or a job, running a household, etc. A casemanager is the director of the particular cocktail of care- and cure-interventions that a certain client needs. The client should be enabled to write the script for his/her specific story of needs.

AMBULATORY CURE-PROGRAMS

As these care-programs for harmreduction and social rehab were developed on a large scale in the Netherlands during the eighties, the more cure-directed, psychotherapeutic ambulatory treatmentprograms were also developed. These developments in the ambulatory cure-programs for drugaddicts took place separately from the experiments within the care-programs.

As I said before, it is only at the beginning of the nineties that a wave of integration and synthesis is coming over the drugfield. In fact, it is only in the nineties that one can actually speak of the drugfield as a 'field'. In the ambulatory field this means that the two main ambulatory streams really start to tune into each other and use each other.

The CAD's - who weren't prepared for the care-needs of drugaddicts - used their existing infrastructure to experiment with all kinds of cure-programs for drugaddicts aimed at total abstinence of the drug.

  • registration and diagnosis
To be able to develop a reliable treatment-plan with a client one needs a lot of data on his or her background, actual psychosocial situation, sort of drugs used, frequency and way they are used, etc. Only recently fairly professional systems of registration and diagnosis are being applied in the treatment of drugaddicts.

The actual call for more quality in this field in Holland is in fact a call for more effectiveness in the treatment of drugaddicts. This call for quality is often translated into complicated quantitative systems for registration and diagnosis, while these data are just tools for quality in the treatment of the client. The quality is in the meeting with a client, in the ability to be near him or her in order to build the trust that is needed to be effective with professionally applied interventions.

  • head-heart dilemma
This is what I call the heart-head dilemma in working with people, especially with drugaddicts. One could say that in the care-field the workers were to identified in their heart in being solidary with the client, fighting together for a better social perspective and in the end taking away the 'response-ability' of the client.

In the ambulatory cure-field one sees in general during the eighties a contrary survivalpattern in that the workers were more identified in their heads while developing treatmentstrategies for drugaddicts. This meant that there was a lot of professional distance in their approach to the clients which made it very hard for the client to meet the worker and built a working relationship. Sitting behind their desk they were to busy trying out some sort of method without being able to listen to the needs of these strange clients. Two worlds apart, so that a 'head'-approach is saver; it protects you against loosing your head.

The integration of both fields of care and cure in the nineties shows that head ánd heart are needed to be an effective worker with people.

The head-heart survival patterns also show one thing very clearly: nobody knew how to help a drugaddict and the care- and cure-field needed their separate development during the eighties in order to find some sort of identity, so that they can finally be interlinked in the nineties.

  • Detoxification
Beside developing methods for registration and diagnosis, the CAD's also experimented with methods for detoxification what was (at least in the beginning of the eighties) a prerequisite to psychotherapeutic treatment.

Detoxification is done in a clinical or ambulatory setting sometimes with the help of acupuncture or a gradually lowered dosage of methadone. Urine-checks are done on a frequent base so that it is clear that the client is not using (other) drugs any more. During detoxification one starts already with cleaning up the mess in the clients social life and preparing for psychtherapy in the stage after detoxification.

  • Psychotherapeutic methods
It is interesting to see how the search for effective cure-methods for drugaddicts resulted in trendy waves of popularity of certain therapeutic approaches. Behavioristic technics like motivational counseling, relapse-prevention and selfregulation were very popular. Suddenly set aside for the familytherapy-approach or large scale experiments with groupdynamics. More psychodynamic approaches out of an analytical or Rogerian framework were tested. Rational Emotive Therapy, Gestalt- and Psychomotor skills, Bio-energetics, acupuncture, hypnosis, yoga, etc. were applied in fast changing trends. These trends showed more of the professional uncertainty of the worker than what the client atually needed. On the other hand the fact that all those tools were experimented with means that they are available now and can be applied if needed in the therapeutic work with a client.

All the experimenting in Holland with care- and cure-programs has provided us now with a network of very differentiated treatment-forms. As we saw, drugaddiction is also on the personal level a multifactored problem so that a wide range therapeutic skills need to be available.

  • Probation-tasks
As we have seen, the CAD's have probation-tasks regarding alcohol- and drugaddicts who are caught by the police. Especially for drugaddicts this is quite a field of activities. The aim is to inform a client about possibilities for assistance he may want to obtain.

As the fact became clearer that drugaddicts were regular inhabitants of prisons several drugtreatment programs in penitentiaries were started. The approach of these programs is based on the therapeutic community, is group-oriented and has explicit treatment goals.

Another development in this field is that more and more prisons start drugfree counseling units which are focussed on initiating and preparing for treatment after detention rather than on treatment.

Prisons are probably the clearest place to see the clash of the two approaches to drugaddiction: punishment combined with help and assistance. Does it work? Will the 'junky' play this game too? Yes, they will untill they decide for theír reason that it is enough, that they want to quit any gasme... The repressive regime in prisons makes it very hard to realise this and be pragmatic. F.i. regarding the HIV/AIDS-danger, needle-exchange and availability of condoms in dutch prisons is still no subject of discussion; they don't want to talk about it while they know it is happening right before their eyes.

It is a moral conflict allright, but to withdraw then to the level of a big bird that hides its head in the sand when the situation is too complex or dangerous, seems to me an unworthy strategy to the human specy...

In general, one can observe this well known bird in the policy regarding prisons and drugaddiction: 60% of our prisonners is a drugaddict. We have 8000 prison-cels in Holland of which only 240 (= 3%) are reserved for drugfree detention..

RESIDENTIAL CURE-PROGRAMS

As I explained, the ambulatory care and cure approaches developed in the seventies and eighties along separated lines and it is only in the nineties that there is a development towards big scale regional institutions for care and cure of addicts in which the different tasks of care and cure are more tuned into each other. Although - and this should be kept in mind constantly - the pollution in the treatment of drugaddicts by the illegal status of the drugs they use, is only becoming more severe.

Regarding the residential treatment of drugaddicts one sees in fact the same isolated development as within the ambulatory field. Also here, the nineties seem to be the moment for further vertical integration within the field of drugtreatment in that ambulatory and residential treatment are tuning in more and more now.

The first impulse to start residential treatmentprograms for drugaddicts was the simple fact that ambulatory treatmentprograms - if total abstinence was the goal - didn't succeed. Some clients appeared to be able to get rid of their addiction for a relatively short time and relapsed into their habbit again.

In 1969 the first residential drugclinic was opened in Amsterdam. One of the important goals for treatment was finding the right individual dosage of methadone for opiate-dependent clients. Further treatment was of an individual and medical orientation like in the traditional ambulatory programs for alcoholics. The drugaddicts in general continued to use other drugs beside their methadone.

In 1970 Rotterdam starts the second drugclinic called the Essenlaan. Methadone was provided and the clients kept on using other drugs while staying in the clinic. Although the staff had put a premium on staying clean - one bottle of jenever if the client didn't touch drugs for one week (!) - this approach didn't seem to work. Maybe because the clients who didn't succeed in staying clean, would still get this premium, one liter of genuine dutch hard liquor..

In 1972 the Emiliehoeve started on the grounds of a big psychiatric hospital near The Hague (Bloemendaal). The staff learned quickly that offering few structure to drugaddicts didn't work and would end up in chaos. The democratic principles of the Maxwell Jones-model as it was applied in psychiatric clinics, was left and they chose to work with the very structured approach of therapeutic communities in the USA like Daytop and Phoenix House.

By stating clear boundaries in respect to clients behavior, by starting encountergroups and by adopting the drugfree treatmentapproach, the Emiliehoeve proved within few years that more than 50% of the residents were able to live a drugfree life after treatment and to stay that way. These results need to be critically looked at, especially as the selection of clients that actually finished the entire program of 2 ½ years was severe. Only one out of 5 clients who went into the program, really finished it succesfully. And only 50% of these clients succeeded on the long run.

Still the relatively positive results of the Emiliehoeve become known and the other clinics change their approach into the drugfree hierarchically structured therapeutic community model. New drugfree clinics are started allover the country.

But there is also a lot of criticism on the drugfree clinics. Especially the hierarchical structure and the high treshold were criticised while certain methods (shaving of the hair of a client who had run away and was relapsed in addictive behavior) created a concentrationcamp-image that lots of clients must have put off an intake.

By the end of the seventies and in the eighties a real mosaic of residential drugclinics appeared in Holland. Some of them clearly based their approach on religious (De Hoop, Vensterhuis) or philosophical grounds (ARTA). Centres for day-treatment are started and at several places residential settings for detoxification and crisisintervention are set up.

After years of splendid isolation in which the clinics developed their methods, there is an outward movement now within the clinical field. They seek cooperation with the ambulatory field, start up programs for social rehabilitation already during residential treatment and parents and partners are more integrated into treatment.

The length of the residential period is becoming less and the approach is more individual although groupdynamics are still an important level to work on within the community. There are also long waitinglists for residential treatment, but because of cutting down of funds and the general policy to replace residential treatment for ambulatory programs (substitution) one can expect that the traditional drugfree clinics will not get more capacity.

Recent developments show that the call for compulsatory treatment in stead of doing time in prison is giving a new impulse to residential treatment (treatment in penitentiaries; IMC).

PREVENTION

Last but not least, prevention is an important task of the institutions that work in the drugfield. Here we talk about primary prevention-programs aimed at f.i. schools, industries or horeca. Frequently used methods in this field are consultative or educative information by campaigns, folders and helplines.

Since the AIDS-epidemic came into our awareness, the preventive orientation towards addiction-care is even more actual.

(Safe house campaign!)

The professional development of prevention activites in Holland shows that the separation of primary prevention from secundary and tertiary prevention is not effective at all.

INNOVATIONS

General innovations:

  • policy decentralisation to local community level
  • qualitypolicy regarding institutions in the drugfield
  • more preventive orientation
  • horizontal linking (psychiatry, police/justice, first line, labourmarket and education)
  • more compulsatory treatment
  • substitution (less residential, more ambulatory treatment)
  • international exchange and policies
Specific innovations:

1- Prevention

  • educationprograms of children at schools
  • education of professionals
  • national campaigns (AVP - mass media)
  • preventionprograms for industries
  • helplines
  • riskgroups (streetkids, houseparties, etc.)
  • coffeeshops
  • AIDS (network NIAD, prisons, peer group, ethnic groups)

2- Ethnic groups

  • Mediteran groups
  • Surinam/Antillian
  • Molukkers
  • Refugees and asielzoekers

3- Specific targets

  • gamblingproblems
  • complex addiction problems/EPD's (NRV-advice!)
  • female clients and children
  • care innovation
  • self help (organisations)
  • Amsterdam, October 1993
  • Bart Majoor.

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