Pressure in drug treatment/addiction care
Saskia Jünger & Ronald A. Knibbe
The issue ‘Use of pressure in drug treatment’ is examined within the framework of a more extensive study concerning the medical-social care for methadone clients in the Dutch and German borderland (Euregio Maas-Rijn and Euregio Rijn-Maas Noord). The emphasis of this study is on a comparison of the Netherlands and Germany. In this context the opinions and attitudes of Dutch and German professionals and methadone clients regarding the use of pressure and directivity in drug treatment are examined.
The background of this comprises the differences between the Netherlands and Germany in the history of their drug policy and addiction care. Internationally, the Netherlands is known for their liberal drug policy. They have been pioneers in the field of low-threshold addiction care and harm reduction. Germany is rather known for its repressive drug policy and high-threshold drug treatment. However, since the early 80’s low-threshold care for drug users has been increasingly implemented in Germany. Nevertheless, there are still differences in drug policy between the Netherlands and Germany. The hypothesis is that developments in the Dutch and German drug policy do have an impact on the attitudes of professionals and methadone clients with regard to the use of pressure, rules and directivity in drug treatment.
Subjects and method 45 professionals (21 Dutch and 24 German professionals) and 50 methadone clients (25 Dutch and 25 German methadone clients) were interviewed.
The interviews consisted of 5-point scales and open questions concerning the benefits of pressure and directivity to the success of drug treatment.
Between Dutch and German methadone clients unanimity is found with regard to their opinions concerning the benefit of pressure and directivity to the successes of drug treatment. On average, methadone clients gave a score of about 2.8/2.9 (on a 5-point scale) on items concerning this issue, which means that, according to the clients, pressure should not be increased, nor should pressure be diminished. Dutch professionals set a higher value on pressure and directivity than German professionals. More than German professionals they consider pressure to be of benefit to drug treatment (Dutch prof. score 3.2 on a 5-point-scale, German prof. 2.7; p = .001). More Dutch than German professionals regard professional intervention as necessary for a successful rehabilitation of drug users; finally, Dutch professionals are more sceptical of the client’s own judgement of his situation and needs. Conversely, German professionals, more strongly than Dutch professionals, trust the judgement of the client himself regarding his situation or needs; moreover, more German than Dutch professionals report that ‘to take a drug user seriously’ in this context means letting him be free to move and - above all - that no pressure should be used, whereas more Dutch than Germans report that they take a drug user seriously by, above all, being directive.
Finally, with regard to all results one trend is striking: The opinions and attitudes of Dutch professionals and methadone clients differ more strongly than those of German professionals and methadone clients. Dutch professionals set a higher value on the use of pressure and directivity than Dutch methadone clients; the opinions of German professionals and methadone clients are similar by and large.
The results can be interpreted keeping in mind the history of the Dutch and German drug policies. The differences between the Dutch and the German drug policies are often reduced to the terms ‘liberal’ and ‘repressive’. The meaning of these terms can be summarised as
follows. In the Netherlands, for many years now, the main object of addiction care has been harm reduction. The emphasis is on large-scale and low-threshold care for drug users. A so-called integral drug policy is managed, characterised by a close co-operation between government, the judicial authorities, police and addiction care organisations. In Germany, the emphasis of drug treatment in the past was on long-term therapies in order to reach total abstinence of drugs. In the early 80’s a sort of counter-movement advocated the acceptance of large-scale low-threshold care. As a consequence, a certain polarisation can now be observed between government, the judicial authorities and police on the one hand, and defenders of an accepting drug policy (frequently professionals involved in drug treatment programmes) on the other hand. These circumstances probably explain the finding that German professionals are more sceptical of the benefit of pressure and directivity to the success of drug treatment than Dutch professionals. As a consequence of the repressive drug policy and the criminal prosecution of drug users, professionals in Germany - more than in the Netherlands - perceived the need to take the role of the clients’ ‘advocate’. They plead for the drug users’ autonomy as a compensation for the patronising attitude of the legislators. This can also explain the greater convergence found between the responses of German professionals and methadone clients than between those of Dutch professionals and methadone clients.