Drug Abuse

The Dutch Approach to Drug Treatment & Education 2

Drugs & AIDS Prevention & Education

Work With Young People in The Netherlands

by Julian Cohen

The main aim of my visit was to examine the Dutch approach to this subject and see what lessons could be learned for improving such work in Britain, especially around harm minimisation philosophy and practice. I visited a wide range of agencies which specialise in work with young people, as well as a number of mainstream drug treatment agencies, who work mainly with adult opiate users, to provide general background information against which the situation for young people could be better understood.

• Dutch Policy And Practice Towards Drugs.

Dutch policy and practice towards drug use is mistakenly seen by many people from other countries as extremely liberal and laissez-faire - a haven for drug users.

It is much more accurate to describe their approach as being pragmatic, realistic and practical and one that avoids over-dramatisation or moralisation. Faced with increasing drug use in the late 1960's and early 1970's, and related law and order problems, the Dutch have developed a strategy based on containment of the problem in the sense of attempting to limit the negative effects of drug use on individual users and wider society. Rather than believing that drug use can be stamped out, the Dutch have developed a policy of harm minimisation and damage limitation. This is often described as normalisation - an attempt to avoid stigmatising, marginalising or isolating drug users. The policy aims at integrating drug users into society and places the burden of social responsibility on them for all citizens.

This policy, which is accepted across the political spectrum of the Netherlands has a number of key aspects:

1. A distinction is made between 'hard' and 'soft' drugs. For example, cannabis use has been decriminalised and is available from a number of outlets as part of the strategy to separate the market, and availability, for 'hard' and 'soft' drugs.

1. The police and criminal justice system are deployed against organised, large scale trafficking, rather than individual users.
2. A comprehensive support and treatment system has been developed with the input of a high level of resources.
3. Services are diverse and accessible, maximising contact with problematic drug users.
4. A degree of participation and consultation with service consumers (drug users) is encouraged, with the assistance of government grants.

Whilst the actual practice varies from area to area, dependent on the specific nature of drug problems and political decisions made at Municipal level, this general picture holds true throughout the country. This has much to do with the high level of political debate and decision making at National Government level concerning drugs.

The Dutch have much to be proud of concerning the success of this approach. However, this is not to say that such an approach is problem-free. Difficulties are being encountered with regard to AIDS education, especially the encouragement of safe sexual practices and use of condoms. This would appear to be a problem common to both British and Dutch drug workers, as discussing issues of sexuality with their clients is, for some, a new and difficult aspect. Lack of social rehabilitation programmes and high unemployment are seen as barriers to the more effective workings of the system. Also, the division between 'hard' and 'soft' drugs is seen by some as relatively arbitrary, such that they would wish to extend the decriminalisation policy to other illegal drugs.

Increasing drug problems amongst ethnic minority groups (Moroccans, Moluccans, Surinams and Turks) are posing new problems and issues which have yet to be successfully tackled.

These include tension between young people and adults and the fact that most agencies are seen as white oriented, i.e. most drug workers are white. In some ways the Dutch are facing a crisis of direction with their strategy- the situation was described to me as one of 'standstill'. They are in danger of becoming victims of their own previous innovation and success. Certainly services are becoming increasingly professionalised, with better qualified and trained staff and more efficient administration and recording systems but, whilst this is being welcomed by many, it is also causing concern in its possible effect of distancing workers from clients and meaning less flexibility.

Dutch practice is, as is the case in Britain, primarily focussed on what they term as the 'hard' end of the drugs problem, namely long-term opiate use.

Having said that, alcohol is often seen as the main drug problem facing the young, particularly males, but there is a growing awareness of the problem among young women. Solvent use, a sporadic problem in some parts of Britain, is virtually unknown in the Netherlands. In fact, Dutch workers and young people were amazed at the level (and numbers of deaths) of solvent use in Britain. They all agreed that, with cannabis and alcohol being more freely available to young people in the Netherlands, there was little need to resort to solvents.

The picture given of the degree of use and resulting problems of cannabis varied amongst people I spoke to. The decriminalisation policy has often been supported on the basis of decreased use and lack of problems in recent years.

However, some youth workers I met did not share this view. They pointed to increased, sometimes excessive use amongst some groups of young people, resulting in problems of inactivity, insecurity, paranoia and lack of motivation. Again in contrast to Britain, there was little evidence of LSD or amphetamine use amongst young people However, cocaine was seen as a growing problem, but there was little concern over crack and the avoidance of a panic reaction over this substance was refreshing.

Other aspects of problematic drug use, especially those falling short of full scale dependence, are not easily tackled. This is of particular relevance to the situation for young people who may be using substances other than opiates, may not be dependent as such and do not see themselves as 'addicts'. Such young people are not easily catered for within the mainstream Dutch system, making early interyention work difficult. The Dutch have made some inroads in this area, as will be described later, but work with young people who experience drug problems is seen by many of the workers I met as an area that needs urgent development.

I was also concerned to learn about patterns of sexual activity amongst young people in considering AIDS. The Netherlands has a very low rate of teenage pregnancies (one of the lowest in the world) and abortion is freely available. However, the abortion rate among young women is also quite low. Contraceptive advice and information is more freely available than in Britain and young women are well informed, but concern was expressed that there had been few changes in sexual behaviour amongst the young when it came to condom use. In particular, workers I met saw young males as a crucial group to influence and said that despite explicit media campaigns condom use was still relatively taboo.

• The Organisational Structure Of Prevention Work With Young People.

Direct contact with young people concerning drugs and AIDS takes place through a range of institutions, projects and settings. These include schools, generic youth facilities, media campaigns at national and local level, drug facilities specialising in work with young people street corner/outreach work of a gene or specialist drug nature, residential homes and coffee shops and bars wher young people congregate.

Mainstream drug services are generally co-ordinated via a network of local Consultation Bureaux (CAD's) and Municipal Health departments In contrast to Britain, prevention and treatment services are integrated, in that the same organisation employs specialists in both fields. There also tends to be greater contact and co-operation between prevention and treatment workers than in Britain. Whilst treatment services in both countries have workers who specialise in prevention in the areas of HIV/AIDS and the promotion of safer drug use and safer sex, in Britain prevention work with the young, particulary through schools and the youth service, takes place via a relatively separate organisational structure: Drug Education Co-ordinator employed by Local Education Authorities. These workers are often experienced school teachers with little experience of, or contact with, the drugs field. Dutch prevention workers, however, are more integrated into drugs services and probably have a better knowledge and understanding of the drugs field, but may lack inside knowledge of the school system in particular. Ideally a balance is needed, the lesson for British Drug Education Co-ordinators being that they should ensure that they work closely with their local drugs services.

In addition, prevention work in the Netherlands is initiated at national level by the National Institute for Alcohol and Drugs (NIAD) in Utrecht. NIAD is a large organisation of 45 staff and was formed from an amalgamation of a number of alcohol and drug agencies. It has three main sections: research, training and prevention/education. The former two sections focus mainly on the drug treatment field. Research is mainly into epidemiology and the effectiveness of treatment services, although they are moving towards more evaluation of media campaigns and educational projects.

The prevention/education department has been involved in a range of activities including:

• 1) Production of a range of materials, especially leaflets and booklets.
• 2) A large scale primary schools project focussing on alcohol and tobacco.
• 3) A pilot of a new secondary schools curriculum project.
• 4) Involvement in the national alcohol campaign.

The role of NIAD has been complicated in recent years by political differences and turnover of staff, a situation that is still being worked through.

In addition, organisations such as Rutgersstichting specialise in initiating work around HIV/AIDS with young people. They play a similar role to the Family Planning Association in Britain and, as well as providing contraception and advice, have projects which produce educational materials for young people and train teachers and youth workers to handle issues of sex education and HIV/AIDS.

• Prevention Initiatives With Young People
• Primary Schools.

The main primary school programme has been developed at a national level by NIAD and is widely used. It is operated on the basis of using unemployed teachers who receive training about use of the materials and then do the work with classes of 11-12 year olds with the teacher usually in attendance. The focus is on alcohol and tobacco and includes information provision, smoking dummies, a range of activities (including a home survey) and some parental involvement. The orientation is on primary prevention (don't smoke or drink) and the programme has been evaluated by the University of Utrecht. It was shown that anti-smoking and anti-drinking messages were reinforced for the first year after the programme had been delivered, but this tended to fade in the long term. The programme is ongoing, with many classroom teachers now having taken over the delivery of tht materials. In addition, a number of cities run their own programmes, sometimes adapting the NIAD materials, with involvement of police and current drug users.

The evaluation of the NIAD programme also raised important issues which were picked up by a number of prevention workers I met and are corroborated by my experience in Britain. In their development of ideas about drugs, young people would appear often to begin with an anti-drugs stance that can be reinforced for a short period at primary school age. This is often short lived as they reach secondary school age and many begin to experiment with substances. It would also appear that young people sometimes hold on to 'anti-drugs' views but fail to connect these views with their own developing drug use. This suggests that, in both countries, longitudinal studies of young people's attitudes and patterns of drug use would be useful and that it is questionable whether narrow, primary prevention programmes at primary school age will have any useful effect in the long term (Schaps et al, 1981; Sheppard et al, 1985; Clements et al, 1988; Bagnall & Plant, 1987)

• Secondary Schools

I met with a number of specialist prevention workers who spent much of their time working with secondary schools. Their work included running training courses for teachers, in-school support with curriculum development and pastoral issues and the production and dissemination of resource materials. This has much in common with the work of Drug Education Co-ordinators in Britain, but differs in that it tends to be wholly focussed on drugs education rather than broader aspects of health education and classroom methodology. In the main, these workers felt that they put a lot of effort into schools without always seeing successful results. They felt that secondary schools did not always respond positively for a number of reasons, including:

• 1) Drug education was seen as a small part of the curriculum and was not that important.
• 2) Many schools felt that if they did much with regard to drugs education, local people and parents would assume they have a drug problem and the school would get a bad name.
• 3) Teachers saw their main role as knowledge transmission and were often very didactic in their approach.
• 4) Teachers have a lot on their plates and this is added to by unemployment amongst teachers, low pay and low motivation.

It was also interesting that some of the schools I visited avoided looking at illicit substances with their students - the reasons given were lack of teacher confidence and concern about what parents and local community might think. However, it is clear that most secondary schools will include something on legal substances in their curriculum as well as on cannabis. The approach of the schools I visited could be said to be somewhere between primary and secondary prevention - a message of "it is best not to do it, but if you do ....".

Special mention should also be made of the counselling system operating in some schools. As well as mentors, some schools have a system of specialist teacher/counsellors - trained counsellors

who have a number of hours off timetable to do the work. Of the schools I visited, one stood out in this respect. Six such counsellors formed a team and their names were widely known by students who could approach them. What was particularly interesting about this was that students were assured of confidentiality in all but life and death situations. This meant that a high level of trust had been established and students felt confident about the use of the service. The families were never automatically informed, although counsellors often encouraged young people to talk to their parents. This system obviously covered a wide ran issues and concerns but also dealt with drug related issues.

The Director saw it as being crucial not to over-react to young people's drug use. When asked about the effectiveness of the school's approach, he pointed two factors. Firstly, drug use was openly discussed rather than being an issue of confrontation and that in itself was a forward. Secondly, sex education and HIV/AIDS issues were treated with similar candour and, he added, the number of pregnancies and abortions the school had fallen markedly in the last few years.

Media Campaigns

Dutch prevention experts are aware of the limited and sometimes unintended outcome of large scale, national media campaigns (Buisman, 1988). The Dutch are much more explicit and rely less on subliminal images in their campaigns than the British, especially with regard to HIV/AIDS. They try to steer clear of shock/horror, deterrent approaches which have been common in Britain. The focus is more on positive images and behaviour, rather than an over-emphasis on negative aspects. To this end, humour is often utilised to engage people's attention. Lastly, national campaigns; sometimes linked to follow up activitities on a local basis, a strategy that is currently being planned for the forthcoming alcohol campaign with schools. Prevention workers in Britain have long been aware that, to have an impact, these principles should be followed, but have been relatively unsuccessful in influencing government action.

Residential Homes

It has been increasingly recognised in the Netherlands (and Britain) that there is disproportionate drug use and related problems amongst young people in residential homes. The Dutch are, however, beginning to tackle the issue in a more co-ordinated basis than are their British counterparts. This was originally started through local prevention projects and then taken up nationally by NIAD. I was particularly impressed by the work being done in Amsterdam by the Drug Education Project of the Jellinek Centre who employ a specialist worker to concentrate on this area. The work includes visits to homes, training staff to increase their confidence in dealing with residents' drug problems, developing policy and creating a dialogue with youn people to enable informal drugs education to occur.

Despite variations in regime and attitudes between different establishments, this project appears to have been successful in meeting these aims. In many cases this has resulted in harm minimisation policy being adopted by many homes, especially where cigarettes, alcohol and cannabis were concerned.

Street/Outreach Work

The Dutch have also been pioneers of street/outreach work around many issues, including drugs. This is seen as particularly important in reaching those drug users who do not, and are unlikely to, use mainstream drug services. Some projects are specialising in work with groups of young people who are regarded as being particularly at risk and unlikely to find mainstream drug service' relevant to their needs.

In Britain outreach work aimed specifically at drug users is in the very early stages of development. We do have outreach/detached youth workers, but their role is usually generic and they come under general youth provision. This means that the workers may have had little experience of, or training in, the drugs field. In my area of Britain (Tameside, Manchester), we have begun developing training and support for such workers, but it would clearly be a useful innovation if such workers were also attached to drugs projects. Outreach work provides a means of contacting and supporting young people who may be particularly at risk concerning drugs and AIDS. The difficulty of initiating such work in Britain is that drug use is much more underground than in the Netherlands, with fewer facilities where such young people may openly congregate.

• Specialist Services For Young Problem Drug Users

It was previously noted that many mainstream Dutch drugs services may not be appropriate for the needs of some young people. In recognition of this the Dutch have begun to explore special provision for this group. In Hilversum the 'De Halte' project works with 16-25 year olds who are referred by street workers.

The young people tend to be heavy users of alcohol, cocaine and cannabis. They are sometimes homeless and often have been idle for long periods. The project takes in 1ffi12 young people at a time, for periods of 3-6 months and involves the in a range of physical activities based l manual skills. The focus is not therapeutically on their drug use but ( involvement and development of skills Individual counselling is available, but the aim is to provide activities and help arrange follow-up work on a paid or voluntary basis.

The work is based, to some extent the 'alternative highs' theory of controlling drug use. The project has s to be evaluated and, despite some clear success with individuals, has faced a number of problems. This has include motivating young people to become involved in the first place and the issue whether it is a good idea to have young drug users all together in one group (l other side of this argument being whether generic agencies are prepared to help them). This project bears some similarities to the philosophy of the Artskills project in Merseyside, England and would be a useful model to explore further in Britain (Corina, 1987).

Also of interest is the Hadon project in Rotterdam. This is a community-bas initiative with shop-front premises which, deals with a range of drugs and AIDS issues. It includes a needle exchange l the workers also find themselves tackle generic issues facing drug users, such homelessness, finance and welfare problems. the project has also developed work with young people in the local community, including support for your drug users, parents' meetings and work with local schools. In some ways this is similar philosophy to the Community Drug Team set-up in Britain, but differ in the degree of work with young people and its high profile in the local community.

Generic Youth Facilities

Unfortunately, I was unable to visit many generic youth projects to see what work they were doing around drugs and AIDS

There is a network of youth clubs supported by the government and voluntary bodies, but I only visited one in Hilversum. 'De Tagrijn' is a large project in the centre of Hilversum with eight full-time workers (youth workers and social workers) and many volunteers, catering for the 16-30 age group. It offers a wide range of activities, including concerts, film shows, drama, sports, video making, a printshop, women's activities, computing, discos, music workshops etc. There is a bar open all day selling alcohol, soft drinks, tea, coffee and food. In addition, cannabis is sold on the premises, with 50% of the dealers' profits being ploughed back into the project. Even though alcohol and cannabis are allowed on the premises, 'hard' drugs, such as heroin and cocaine, are forbidden.

Many drug users, of both hard and soft drugs, use the facilities. De Tagrijn provides a meeting place for young people, involves them in a range of recreational and educational activities and provides counselling and support. (It even includes showers and washing machine facilities). Its attitude towards drug use means that it attracts a lot of young people who are heavy users and can provide them with support. This is in contrast to the British approach, where young drug users are often isolated and turned away by, or would not consider going to, youth clubs. De Tagrijn is thus another example of the Netherlands policy of maximising contact with users.

Whilst I was very impressed by this facility, it was not without its problems. The 'no hard drugs' rule meant that my first contact was at the entrance to the project with a group of users who had just been refused entry for breaking this rule. In addition, whilst the openness of alcohol and cannabis use has probably helped in establishing sensible norms for use and a safe environment in which to use, it has led to a small group of young people spending much of their lives idle, stoned out of their heads and not being involved in activities. In recognition of this the staff were thinking of curtailing the availability of alcohol and cannabis during the day. The local authorities, however, were not so keen - presumably because they prefer such activities to take place in a controlled, supervised environment.

• The Coffee Shops

The Netherlands is famous for its network of coffee shops which sell cannabis, particularly in the larger cities.

There are some very large ones combined with bars, such as the Bulldog in Amsterdam, but most are smaller and low key. They provide a facility for young people (and adults) to purchase a full range of cannabis products and consume them in a relaxed environment with music, soft drinks, games machines and board games. They provide a controlled environment in which sensible norms can be established for the use of cannabis.

In addition, they clearly avoid the use of other 'harder' drugs for fear of being closed down. Young people and staff I spoke to in coffee shops were very condemnatory about the use of heroin and cocaine and some displayed posters warning about cocaine use. Although, as previously mentioned, there can be problems involving excessive cannabis use, I was impressed by the positive role coffee shops can play for young people in encouraging less damaging patterns of drug use and providing a welcoming and relaxed facility.

• Services For The Children Of Drug Users

The Dutch are beginning to look more closely at the situation for the children o drug users. This is of particular importance as it is clear, all over the world, that one of the main drug problems for young people is the impact of adult drug use, particularly in the family setting. Despite the fact that the number of children of drug-using parent taken into care in the Netherlands is still high, this is not to say, as some people mistakenly believe, that all drug users are bad parents. However, it is an issue that has caused a lot of problems for drug agencies and social services departments in Britain and needs to be carefully considered.

A national committee is currently looking at this issue in the Netherlands, but it was stressed to me that removing children from drug-using parents was very much seen as a last resort. One of the more developed systems operates in Rotterdam where the 'Odyssee' project has a specialist childcare worker. All users who come into contact with the project who are parents, are automatically referred to this worker. A register of children of addicted parents is kept in Rotterdam, but this is separate from the Judicial Authorities. The specialist worker meets with the parents and discusses the welfare of the children and if other agencies are involved with the family, the work may not go much further and will be left to them. If not, the situation for the children is regularly monitored by the specialist worker and, where necessary, parental advice and support will be offered as well as referral to other agencies. If the situation deteriorates the Child Council will be informed.

In addition to these developments, a number of workers I talked to were concerned that more facilities should be developed directly for the support of children of drug- using parents. In particular, some were looking into the possibility of providing support based on the ALATEEN model used by A.A. in both countries. Whilst I am not an advocate of the AA approach I think we do need to look at support strategies for such children.

Conclusions

With regard to the development of drugs and AIDS control policies in Britain, I feel we could learn a lot from the Dutch. For example, their policy of decriminalising cannabis is one that we should seriously consider, especially in view of the widespread availability and use of cannabis and the high incidence of solvent use in Britain (Parker et al, 1986 Newcombe & O'Hare, 1987; Swabi et al, 1988; Cohen, forthcoming). Their policy of normalisation and harm minimisation has been relatively successful in controlling problematic drug use and containing the spread of AIDS. It has also resulted in an openness that maximises contact with users and provides many opportunities for successful intervention work, particularly with young people.

In Britain, our Drug Education Co-ordinators should work more closely with local Drug Agencies and consider initiatives with young people outside the school system. Similarly, drug agencies should consider ways they can develop work around issues concerning young people. It is also clear that in both countries research urgently needs to be conducted into:

• a) The development of young people's attitudes towards drug use in the transition from primary to secondary school age.
• b) The effectiveness of drugs education (especially in schools) with regard to prevention.
• c) The impact of media campaigns.

Much of the practice in drug education in British schools is to be commended, compared with that in the Netherlands. However, we should also give serious consideration to developing harm minimisation philosophy and practice in our education system, rather than relying on primary prevention. We should also develop our pastoral/counselling systems and explore the possibility of specialist teacher/counsellors operating a system based on trust and confidentiality.

Media campaigns and educational materials should be more explicit, relevant to young people, use humour and be positive in style. Where possible, they should be targeted at specific groups and include follow-up activities.

In addition, we should be giving particular attention to:

• a) The development of drug use and drug problems amongst young people from ethnic minorities.
• b) Young people and staff in residential homes.
• c) The development of outreach work targeted at young people who may be particularly at risk.
• d) The development of specialist facilities and initiatives for young problem drug users.
• e) Services for the children of drug users.

Generic youth service facilities should examine their role in supporting and working with young drug users. In particular, meeting places and safe environments where young drug users are made welcome should be encouraged.

Finally, Dutch and British prevention workers who specialise in work with the young should have more contact. Whilst treatment workers and researchers from the two countries have been meeting and exchanging ideas, this has not happened, to any great degree, amongst prevention workers. It is proposed that a small prevention workshop, involving specialists from the two countries, is run in Britain in 1990. Many of my Dutch counterparts were very interested in this proposal which I am already following up with my British colleagues.

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Julian Cohen is the Co-ordinator for Drugs education of the Tameside Local Education authority, Greater Manchester, England. This study was made under the European Community Pompidou Fellowschip Scheme