JOURNAL ISSUE 5
2002/2003

 

Ksenija Butorac
Snježana Šalamon
Centara Prevenciju Ovisnosti
Grada Zagreba

 

 

INTRODUCTION

According to data given by the Department for Public Health, the Public Attorney’s Office and the Ministry of Internal Affairs, the drug abuse problem in the Republic of Croatia is constantly rising.

There are about 20,000 registered drug users of marijuana, hashish, ecstasy, other amphetamines and also heroin and cocaine. Most consumers (about two-thirds) are below the age of 21. It was noticed that juveniles are often used for street sales because they have a privileged treatment in law procedure. In that way the main drug dealers could never be reached because they have no physical contact with drugs and cannot be processed. In 1999 the Department for Public Health registered 2,600 addicts who received proper medical treatment in medical centres or hospitals, which is 30 percent higher than the previous year.

According to data given by the Public Attorney’s Office, the number of adults reported for drug-related crimes increased by 700 percent from 1993 to 1998. The number of reported juveniles increased by 35 percent in 1996.

Research among pupils in the last grades of elementary schools (N?sample =12,000) and all four grades in high schools (N=11,300) showed that the older the students are, the higher the number of first time users of any kind of drugs. For example, in the last grade of elementary school (age 14), 16 percent of pupils have experimented with drugs and in the last grade of high school (age 18) 53 percent have used drugs.

Comparing the present situation in Croatia with the one in western European countries, the drug abuse problem has almost the same percentage but the percentage of opiate addicts is higher (3.7 of 1,000 inhabitants; Croatia has about 4.5 million inhabitants).

The European research (ESPAD, 1998) about drug use among the young population in the first grade of high school indicates that the number of illegal drug users increased by 60 percent from 1994 (ESPAD, 1995).

The enormous increase of drug abuse is determined above all by the change of the Criminal Law of the Republic of Croatia from 1997. That law incriminates all drug possession, no matter the quantity or kind of drugs. Before then, drug possession was treated as a felony. This kind of incrimination resulted with growth of that kind of criminal. On the other side, in the time from 1991 to 1997, the period of transition resulted in a high number of new drug consumers.

In 1996, the National Strategy for combating drug abuse was created. It consisted of long-term goals of fighting against drug abuse and explained the roles of mostly governmental institutions with special reference to the roles of schools, treatment programs and the rehabilitation of abusers. A government committee for diminishing drug abuse was founded as an expert counselling body with representatives from several departments. In practice, this committee has mostly an administrative role. The state office for drug abuse prevention and outpatient treatment was founded in an inadequate space with lack of personnel. Including all adequate departments in diminishing drug abuse with a clear mission was suggested by the National Strategy. A general evaluation shows that they did not develop programs that would be achievable on local levels. The exception is the office for internal affairs which, in its last term, according to personal and technical potentials, took a pro-active approach but on a dominantly repressive level.

The Ministry of Health (with hospital and outpatient treatment) still prefers a psychiatric-pharmacological approach (especially the use of methadone). Because of the non- existent criteria for the legal distribution of methadone there is an abuse of its availability; it can be obtained on the illegal drug market as well as heroin. This department had the mission to form a rehabilitation centre for serious abusers and a network of centres for prevention and the treatment of drug users, but this was not done.

The Ministry of Education gave instructions to all elementary and high schools for making prevention programs but the Ministry itself did not make any kind of strategy. So, schools had to take the initiative. It means that teachers, who are not educated for that kind of work, have to make and apply certain strategy according to the concrete situation in their classrooms.

The Ministry of social welfare also had some tasks: developing counselling program for schools, forming outreach programs and encouraging the foundation of civil communes. But nothing has been done so far, not even on a declarative level.

We are also concerned about the status of some communes that are rapidly being founded but whose foundations and work are not legally regulated. They are mostly built up on religious approaches and also on working therapy with drug-free approaches with no verified programs or experts involved. About ten communes of that kind exist at the moment and they are working with approximately 500 addicts.

Twenty-two regional centres for prevention and outside hospital treatment have been planned but only 11 centres have been founded. Most of them are located in the coastal area, which indicates the concentration of the problem in that part of the country. These centres have been founded recently but no multidisciplinary team has been formed yet so they cannot deal with the wide spectrum of problems. For example, they do not develop outreach activities with local schools, prisons or family doctors.

 

CENTRE FOR PREVENTION AND OUTPATIENT TREATMENT FOR DRUG USERS

The Zagreb Centre for drug prevention was founded as part of the National Strategy at the beginning of 1998. Territorially, it covers Zagreb and all the surrounding area inhabited by one-third of the Croatian population. Because of the urban way of life, drug addiction problems are even more outlined. But only seven employees work in the centre: a psychiatrist, a psychologist, two social workers, two social pedagogues and a criminologist. The Centre is trying to equally develop primary, secondary and tertiary prevention.

Primary prevention covers organizing counselling, lectures for teachers and parent workshops for the youth outside the Centre. The activities of the Centre are directed to the general public with occasional actions (contests, celebration of the international day for fighting against drug abuse), the public appearance of professionals from the Center in mass media and the printing of educational materials.

Secondary prevention is based on counselling and psychotherapy work which includes:
• counselling work that includes information and education for clients and their parents
• motivating specific categories of users for hospital treatment and connecting them with two existing departments for hospital treatment of addiction, both in Zagreb
• motivating users for connecting with social services, the Employment Office and similar institutions
• treatment for young people and their families who come to the Centre on their own or because of a teacher’s or social worker’s request
• organizing “taking off” treatment for those who were referred to it coersively by the District Attorney as the alternative measure to a criminal proceeding

These activities are processed by Counselling Unit as one part of the Centre. It is half-way between those who need help and classical institutions that treat their addictions and it can be very useful because drug users are not motivated for expert help because of fear of “heavy psychology” and “labelling”. The Counselling Unit has been recognised as a “softer”, more approachable institution by a great number of consumers and because of that it attracts youngsters who would otherwise be left to the street and dealers. The arguments for these facts are evidently a younger age and a minor degree of the clients with individual and social deviations who are in treatment in hospitals. Most of them are adolescents who are only experimenting or temporarily taking psychoactive drugs and are still without drastic signs of physical and psychic decline. That opens a big possibility of positive influence and solving the problem before it becomes a clinical case.

We can stress some general features of the counselling treatment:
• the treatment includes acute adjustments of problems which do not have the character of psychic illness but they disturb a quality of a client’s life
• the treatment does not affect the client’s personality structures, or interfere with the permanent patterns of adjustment
• operating primarily with conscious psychic subjects and available adjustment capacities of the client
• therapists realize the influences on the client through emotional support, education, persuasion, confrontation, interpretation, etc.
• mostly it lasts shortly; a few weeks to a few months.

The form and substance of counselling work determines the nature of the problem and the age of clients (usually adolescents). A minimal formal framework is recommended:
• abstinence of the client from drug use during the treatment (it includes regular urine control). Abstinence is giving him or her a chance to compare two different models of adjustment (with a drug or without it).
• the therapist insures discretion to the client during and after the treatment
• the therapist must have the elementary technical conditions for work and also enough time. Usually therapy sessions take place once a week and last 45-50 minutes
• it is desirable that the therapist has practical education (training) in some of the counselling work techniques, as well as having general knowledge of psychopathology, especially in the drug addiction field.

In consideration of the subject matter, the main work of counselling treatment should be the understanding of the whole drug abuse context with a goal of defining an adjustment characteristic of drug abuse, as well as finding the affirmative (health form of adjustment). If a therapist ignores the emotional benefit gained from taking drugs and only relies on arguments of damage, the desired results would not be given. He or she should always keep in mind that an adolescent does not think about long term consequences of his or her acts and as a temporary consumer he or she does not often experience the dramatic consequences of taking drugs.

Tertiary prevention has been thought as help for cured addicts in their social re-integration but that point is not functioning yet because of some practical reasons.

Descriptive facts

 

About 1,000 clients come to the Counselling Unit during any given year. Half of them are younger than 19 years, one-quarter is between age 20 and 23 (table 1). Fifty-seven percent of the clients and their parents come willingly. In 48 percent of the cases the initiators of the treatment are parents which tells us about their importance in early detection of the problem and intervention. According to this the Centre has intensified informing and animation of parents to recognize a problem in the early stage of their child’s drug abuse (Gossop & Grant, 1990). For example, mothers come twice as often as fathers (at the beginning without their children) to motivate their children to come to counselling. Parents are also motivated to take part in the treatment together with their children.
About 30 percent of young clients have been directed by Social Services and the District Attorney because of arrests for drug possesions (table 2). The clients of the Counselling Unit are mainly males (80 percent), and youngsters sent by the District Attorney and by Social Services are males in 90 percent of cases (table 3). According to the age, 95 percent of clients are not married and mostly live with primary family which is formally completed in 72 percent of the cases. Fifteen percent of clients come from divorced marriages (table 4). About 80 percent of clients are persons in high school or who have finished high school (table 5). Only 15 percent of clients have committed misdemeanors (table 6).
Regarding the kind of drug used it is necessary to point out that most cases concern users who are taking different kind of drugs at the same time, which has been confirmed by other research in Croatia (Butorac & Mikšaj-Todorovic, 1997). The users of cannabis (77 percent), ecstasy (25 percent) and opiates (21 percent) mainly come to the Counselling Unit but LSD (eight percent), amphetamines (six percent) and cocaine (four percent) users also come in (table 7).
Thirty-four percent of initial contacts refer to drug addicts (persons with serious dysfunctions), and that indicates the frequency of drug abuse, while the others are experimental and temporary users.

Work in the Conselling Unit

In the Republic of Croatia the outpatient treatment of drug users who do not practise methadone substitution therapy is a small one. However, the Counselling Unit for drug addiction problems in the Centre is the only institution in Zagreb which carries out the treatment of drug addicts without any medication. According to the experience of the Centre emoloyees, they make some principles which have been affirmed in their professional work:
1. The treatment should be easily available and without waiting
2. During the treatment it should not be forgotten that drugs are not the only problems of the client. It is very important to recognise and treat early other psychological disorders or illnesses.
3. Different kinds of treatments are combined: consulting, psychotherapy, family therapy and if it is necessary, classical psychiatric treatment.
4. The period of duration depends on the degree of the difficulties of client’s problems; the experience of Counselling Unit confirms the results of the NIDA about the optimum duration of treatment, which is about three months (Principles of Drug Addiction, A Research Based Guide). Counselling (individual or group) is one of the most important components of drug addiction treatment.
5. It is not necessary for the subject to volunteer; the motivation for the treatment of a drug habit is very often forced by the District Attorney, sanctions from the family or employers, etc.
6. Laboratory control of possible drug taking during the treatment is necessary.

 

CONCLUSION

In the present working conditions of the Counselling Unit it is almost impossible to establish the success rate of the counselling treatment because there is no control system of post-treatment life. So it is very important that counselling work uses scientific and verified procedures and methods. A partial evaluation of treatment efficiency can be obtained following the indirect parametres such as:
• changes in behaviour, attitudes, and beliefs during the treatment (the conditions are usually registered at the beginning and end of the treatment)
• registered relapses
• unsystematic “back information” from clients and society

If a client abstains during the treatment and he manages to function adequately in all important aspects of adjustments, it is justified to expect a positive post-treatment result. It is good to have in mind that the success of the treatment is not only the therapist’s credit without regard to the outcome. Finally, part of the temporary drug users stop taking drugs without any professional help.
According to the serious situation of drug problems in the Republic of Croatia we can conclude that the major part of the problems can be efficiently solved if we include a great number of the population that is affected by this problem. This means implementing an early detection and intervention system in schools, sport clubs, correctional institutions, prisons, etc. This problem can be solved only with a wide network of centres for prevention and treatment of drug users and they should work in accordance with the described model of this Centre.
Unfortunately, not even local communities are not made aware of this problem in the way of founding such institutions. Above this, the solutions that are connected with the control of methadone substitution programs are deficient, as well as the status of communes and a complete lack of programs which provide for the comeback of drug addicts to the positive social life.

 

SUPPLEMENT

Here follows the presentation how the Conselling Unit works with an example from our practise:
Marko, age 17, comes to the Counselling Unit followed by his mother who found some marijuana in the flat. After having a row Marko admitted that the drug is his own and agreed to come to the Counselling Unit. Marko keeps silent and his mother states facts. He is her only child. Marko attends high school and there have been some changes in his behaviour for some time, such as doing bad at school, absence from school and long absences from home. The parents do not have any authority as they have not had adequate contact for some time and Marko avoids any try to get closer to them. Both parents attributed the changes in Marko's behaviour to his adolescence, assuming them to be temporary. The mother is visibly upset; she cries and any communication is difficult due to her emotional state. She is taken to the waiting room to calm down.
During this time we talk to Marko. He shows resistance to the therapist and is angry with his mother because she treats him as a “junkie”. He gives his own version of the event, minimalizing the problem.
During a shorter talk, where criticizing and moralizing is avoided, the initial resistance disappears and Marko is ready to talk and face all dimensions of the problem. He realizes and admits the difficultes he has. After that talk we all arranged a new meeting and explained the principles of the counselling treatment. In the course of the treatment the therapist directed the conversation to the possibilities of doing better at school and of “getting goal points” in his present environment. Marko realized the risky situations and talked about them openly. The therapist at the same time tried to gain confidence. The therapist implied the messages of his readiness to be Marko's support in his positive changes such as solving his daily problem situations (how to structure his leisure time, how to regain his parents' confidence and how to communicate without rows and insults).
The treatment included the parents as well and tried to achieve mutual arrangements and a high-quality communication. We made an atmosphere that prompts the client to find strength for self-help and motivation for the realization of the given goals. During nine individual and family sessions we realized positive changes in the area of mutual respect.
Marko is doing better at school now. He goes in for Thailand boxing and has a successful emotional relationship with a girl from his class. For the whole duration of the treatment he strictly observed the abstinence agreement. His parents have a successful mutual communication between themselves and with “adult” Marko as well.

TABLES

Table 1. The age structure of drug users

Age	Number of Drug Users	Percent
Under 16	86	8.1
16-19	566	53.1
20-23	270	25.3
24-27	71	6.7
28-31	28	2.6
32-35	16	1.5
Above 35	27	2.5
Unknown	2	0.2
TOTAL	1,066	100.0

Table 2. Distribution of first contacts in regard to the contact person

First contact initiator	Number of Contacts	Percent
Drug User (Alone)	97	9.1
Parents	511	47.9
Other Family Members	65	6.0
Teachers	30	2.9
D.A./S.S.	317	29.8
Others	45	4.3
Unknown	2	0.2
Unknown	2	0.2
TOTAL	1,066	100.0

 

Table 3. Drug users’ sexes at the Counselling Unit

	Referred from D.A/S.S	Other	Total
Sex	Number Percent	Number Percent	Number Percent
Female	29 9.4	182 24.0	211 19.8
Male	280 90.6	575 76.0	855 80.2
Total	309 100.0	757 100.0	1066 100.0

Table 4. Completeness of the drug user’s primary family

User's primary family	Number of Drug Users	Percent
Formally Complete	766	71.9
Divorced Parent, user lives with mother	143	13.4
Divorced Parent, user lives with father	24	2.3
Not living with parent	4	0.4
One parent deceased	85	7.9
Both parents deceased	3	0.3
Other	24	2.3
Unknown	17	1.6
TOTAL	1,066	100.0

 

Table 5. Employment status

Employment Status	Number of Users	Percent
Pupil	495	46.4
University Student	154	14.4
Employed	129	12.1
Unemployed/Casual Work	276	25.9
Retired	5	0.5
Unknown	7	0.7
TOTAL	1,066	100.0

Table 6. Drug users’ previous repressive treatment

Times treated by police/D.A	Number of Users	Percent
Never	910	85.4
Once	113	10.6
Many Times	37	3.5
Unknown	6	0.6
TOTAL	1,066	100.0

Table 7. Types of drugs used*

Drug Type	Number of Users	Percent
Opiates	209	21
Cannabinoids	767	77
Ecstasy	254	25
Speed	55	6
LSD	82	8
Cocaine	39	4

* the total value in the column exceeds 100 since drug users who took more than one type of drug are represented in more than one column

 

LITERATURE:

Bebic,M. (1995). Preventivni programi ovisnosti, u: Zajednicki protiv ovisnosti. Ministarstvo
rada i socijalne skrbi, Pula, 7-14.

Butorac, K. & Lj. Mikšaj-Todorovic. Ovisnicki kriminalitet u RH, Hrvatski ljetopis za
kazneno pravo i praksu, 3, 2, 429-448.

Gossop, M. & M. Grant. (1990). Preventing and controlling drug abuse. World Health
Organization. Geneva.

Izvješce Državnog odvjetništva, 1999. Zagreb.

Izvješce Državnog zavoda za javno zdravstvo, 1999. Zagreb.

Izvješce Ministarstva unutarnjih poslova, 1999. Zagreb.

Materijal Ministarstva prosvjete, 1999. Zagreb.

Sakoman, S. (1999). Zlouporaba droga, strategija suzbijanja s posebnim osvrtom na
studentsku populaciju. Anali Studentskog centra u Zagrebu,1,119-140.

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