Counselling and Prison Based Addiction Treatment Gerard Moore, Muriel Redmond, Rita Glover, Chris Stevenson, Pamela Gallagher, Evelyn Gordon, Rick Lines, Linda O Driscoll, and Dermot Wallace Dublin City University April 2007 Contents Forward 3 Acknowledgements 5 Abbreviations 6 Executive Summary 7 Introduction and Methodology 26 Substance Abuse 33 Treatment Approaches 56 Health Care in Prisons 87 Presentation of Findings 100 Conclusion and Recommendations 131 Epilogue 148 Appendices 149 References 155 Foreword The Bedford Row Family Project is pleased to present this Research Report on Counselling and Prison Based Addiction Treatment. The Research grew out of the collaborative efforts of the Irish Prison Service, the H.S.E. (Mid-Western Region) and the Project. In 2005 these partners began an important dialogue about how best to integrate a counselling service into the broader context of addiction treatment within Limerick Prison. Out of this dialogue came a decision to initiate a research study that would invite the perspectives of a number of different groups on the matter – namely, prisoners, senior prison management, prison officers, healthcare staff and the family members of prisoners. Drug use, abuse and dependence within prison are all intimately bound up with the multifaceted character of the hardship, suffering and tragedy that befall many of the families participating in our Project. Hence, what happens or doesn’t happen within this context of prison-based addiction treatment is of great concern to us. Following the putting of the research out to tender in late 2005, Bedford Row were fortunate to engage a very experienced research team from Dublin City University (DCU) to carry out the proposed research. We were also fortunate to have continuous support and assistance for the research from all levels of prison staff and management. This on-the-ground assistance ensured that a range of people – prisoners, prison staff and management, healthcare staff, family members – contributed to the research process and to the shape of the findings emerging from it. I want to thank Gerard Moore and his DCU research team for the very comprehensive research report provided. The report treats the research question concerning the place of counselling within prison-based addiction treatment within the broad context it deserves. The account provided is both disturbing and hopeful at one and the same time. It is disturbing in the picture it presents of the depth and gravity of the drug problem within Limerick Prison and of the sense of despair this can and has generated within the prison community as a whole. It is hopeful in that its findings point to a range of very concrete steps that need to be taken if any model of counselling offered within prison-based addiction treatment is to have a chance of proving effective. The Bedford Row Family Project is convinced of the importance of Limerick Prison as a site for drug treatment interventions of different kinds. We are equally convinced that investment made there can prove fruitful and worthwhile in time for the region as a whole. We hope this Research Report will mark one further step in the commitment to ongoing evaluation both of the challenges set by drugs within prison life and of the approaches adopted to address these challenges. It was with great sadness that Bedford Row Family Project learned of the death of Mr. Pat Laffan, Governor of Limerick Prison, just as the research was being completed towards the end of 2006. We dedicate this Research report to his memory. In so doing we want to join ourselves in to his breadth of vision which sought an improved quality of life for all who work and live within Limerick Prison for whatever period of time. Jim Sheehan Chairperson Board of Directors Bedford Row Family Project  Acknowledgements The authors wish to acknowledge The support and assistance of the staff of the Bedford Row Project in the commissioning, support and conducting of this research. Information on the Bedford Row Project is available at www.bedford row The participation and contribution of prisoners and their families in both focus groups and interviews The participation and support from the Prison Officers and Staff in Limerick Prison which enabled data collection The contributions and participation of Voluntary and Statutory Health and Social Care Providers Finally the authors wish to acknowledge two special people who unfortunately are no longer with us but who were key contributors to this report born from lived experience of the day to day life in Limerick Prison. Governor Pat Laffan who’s support and commitment to improving the day to day lived experience of the men and women confined in Limerick Prison was central in the commissioning and development of this report. Mr. Dermot Wallace, a former prisoner and member of the project steering committee who will be remembered with affection by his family and friends. Abbreviations C.S.C: Correctional Service of Canada CBT: Cognitive Behavioural Therapy DOHC: Department of Health and Children DTCB: The Drug Treatment Centre Board EMCDDA: The European Monitoring Centre for Drugs and Drug Addiction EU: European Union FM: Family Member FP: Female Prisoner H.R: Harm Reduction HCS: Health Care Staff HIV/AIDS: Acquired immune deficiency syndrome HSE: Health Service Executive IDU’s: Injecting Drug Users IPRT: Irish Penal Reform Trust IPS: Irish Prison Service MI: Motivational Interviewing MMT: Methadone Maintenance Treatment MP: Male Prisoner MQI: Merchants Quay Ireland NACD: National Advisory Committee on Drugs PO: Prison Officer POA: The Prison Officers Association SESP: Social/Educational Staff Provider SPS: Senior Prison Staff SPS: The Scottish Prison Service WHO: World Health Organisation Executive Summary In 2006, the Bedford Row Family Project commissioned a team of researchers from the School of Nursing in Dublin City University (DCU) to compile a report on Counselling and Prison Based Addiction Treatment for Limerick Prison. The need for this research evolved through a collaborative process engaging the Irish Prison Service (IPS), the Health Service Employers (HSE Mid-Western Region) and the Bedford Row Family Project. The purpose of the research was to explore current and possible addiction treatment options for inmates in Limerick prison. This executive summary presents the main finding and recommendations of the commissioned work. Data for the study was collected through a literature review, a self report form, interviews and focus groups. A total of 15 focus groups with, prisoners, their families, prison officers, health, education, social and welfare staff drawn from the statutory and voluntary services were conducted. Additional data was collected by interview from health care personnel who were unavailable to attend focus groups Substance abuse and addictive behaviour are universal phenomena and together constitute a major public health problem. There is a growing trend in the consumption of recreational, prescribed and illicit psychoactive substances, and an increase in the health problems and crime associated with drug use. There is extensive scope for health and social gain among problem drug users. Within the prison population, research has shown that a significant proportion of individuals have a history of illicit drug use. Health care in prison is an area of increasing international concern. The Prison Health Care Services endorse the equivalence of health care between the community and the prison population. Drug use can cause a range of problems among regular consumers making people vulnerable to particular diseases or illnesses. While problematic drug use occurs in many communities irrespective of gender, class, race or nationality some individuals may be more vulnerable to becoming addicted than others, particularly those who live in communities that are socially and economically marginalised. Current conceptualisation of drug taking behavior, in reference to all psychoactive substances, suggests three categories under which use can be defined: Drug use: simply refers to the taking of drugs Drug abuse: refers to any harmful use Dependence: refers to substance dependence as a defined medical diagnosis. Substance Abuse and Prisons There is a correlation between imprisonment and problematic drug use. A series of studies has shown that drug use in prison is now commonplace and that many inmates come into custody with severe drug use problems. At least half of the European Union’s 356,000 prison population has a history of drug use. The harmful effects of drug use and especially high-risk behaviors, which occur in prisons, are well documented. Research into drug use in prisons has found that imprisonment impacts on an individual’s pattern of drug use. Drug use in prison is usually carried out in a hurried secret fashion with little regard for safety and many drug users inject in prison, some for the first time. Assistance to prison based drug users varies across EU countries. In most European countries treatment plans are provided for every prisoner for the duration of their prison sentence. Abstinence oriented treatment for prisoners is provided predominantly in special facilities such as drug-free wings and therapeutic communities. Abstinence orientated treatment is the dominant approach in existing prison based interventions. The ‘twelve steps’ concept is the most common approach. Substitution and harm reduction treatment have now become part of the normal range of services available in prisons. Provision of methadone treatment varies considerably between countries. The availability of drug-free units and drug-free wings also vary across different EU countries. Irish Prison policy aims at a total drug free environment in all prisons. The literature indicates that on entering prison drug use decreased. Reasons cited for the decrease in drug use following imprisonment included; Lack of availability of drugs, Attempting to stay off drugs, Not being able to afford drugs, Concerns about being punished. Heroin use has become a ‘cultural’ aspect of prison life enabling prisoners to be part of a group in prison; both for protection and to ensure a more consistent supply of drugs. However the choices that drug users in the community have to minimise the risks entailed by their drug use, through accessing counselling, needle exchange programmes and information on safer injection are removed from those in prison. Addiction Treatment Approaches The traditional approach, the abstinence based model is centred on the addict giving up the substance. The harm reduction model takes a more pragmatic perspective on addiction and aims to enable the addict to reduce or control their consumption thereby decreasing the harms associated with substance abuse. There are three steps common to both models that need to be negotiated, detoxification, recovery and relapse prevention. Five Stage Model of Change The five stage model of change is a useful tool in assessing a substance user’s current relationship with their drug of choice, their readiness to engage in treatment, and it provides a template for the service provider to assist the substance user in engaging in an appropriate treatment process. 1. Pre-contemplation stage – individuals do not believe they have a problem and therefore are resistant to change. The role of treatment should be to help the person become aware of the possible and real harms they are inflicting on themselves through their substance misuse. 2. Contemplation – this is an ambivalent stage in which the individual is aware of the cost of their substance abuse but these are still outweighed by perceived benefits to continued use. The treatment task involves helping the individual understand their misperceptions. 3. Preparation – during this stage there is recognition of the need for change and small steps may be made towards it. Treatment approaches should include enabling the person to develop a realistic plan for changing their behaviour and encouraging them to move away from being ambivalent in relation to addiction. 4. Action – this is an active stage of change where new behaviours are acquired. Interventions need to be supportive in that they enable the individual to hold onto their rationale for change and that they actively provide the person with the tools they need to take action. 5. Maintenance – this stage relates to the individual developing a sustainable lifestyle. Much supportive work in relation to relapse prevention is required. The Abstinence model Abstinence is normally understood as refraining from the consumption of the addictive substance and related behavior. For abstinence to be successful the substance user must also learn to restore a balance to their lifestyle through non compulsive engagement in other behaviors and / or substances this is both a physical and cognitive process in which the substance user’s adjust to being free from the direct influence of their addiction. Abstinence efforts in prisons aim to treat and prevent any illicit drug use. Normally they include a mixture of illicit drug use prevention measures and treatment options. The Harm Reduction Model Harm reduction aims at reducing the risks to the users physical and mental health and also aims to address issues of danger to others caused by the addictive person’s behaviors. Harm reduction programmes typically include a range of interventions, which, on a continuum, commences with communication with drug users and the general public and moves to the prescription of drug substitution treatment. The provision of counselling services is a central factor enabling the drug user to make informed choices about continued drug use. Harm-reduction efforts in prisons aim to prevent or reduce the negative effects associated with drug use and imprisonment. Initiatives such as needle-exchange programmes are viewed by many to be effective and viable for controlling the spread of HIV, and are not seen to obstruct safety or effectiveness of drug-use prevention polices. The prison systems that have achieved the most success in preventing the spread of HIV have promoted harm reduction and treatment strategies together-making bleach, condoms, methadone maintenance, needle exchange, and other drug treatment available. Common Characteristics of successful treatment programmes. Experienced qualified professional staff Flexible arrangements for inpatient and outpatient appointments Assessment and treatment for medical impact of substance abuse, may be provided by an off site agency Engagement of concerned persons in the treatment process, e.g. partners, family members, friends or employers A broad team of heath professionals which may include, Outreach Workers, Nurses, Doctors, Social Workers, Educators, Psychologists, Pharmacists and Psychotherapists Flexible approaches to treatment including individual, couple and group options Encouragement and access to engage in peer support and 12 step fellowships Quick and easy access to relapse prevention and aftercare support groups Commitment to research, training and development Counselling and Psychotherapy Approaches to Counselling and Psychotherapy have grown and developed through a number of phases during the past 120 years. The efficacy and effectiveness of counselling and psychotherapy has been subject to much debate since the 1950’s. Therapeutic drug free programmes involving individual counselling and group work are beginning to show impressive levels of impact on participants drug use and offending behaviour. Research on psychotherapy interventions has established that; treatment by a health professional usually works long term therapy produces more improvement than short term therapy There is no difference between psychotherapy alone and psychotherapy and medication for any disorder No specific modality of psychotherapy does any better than any other for any problem. Psychoanalysis, Cognitive-Behavioural Therapy, Humanistic, Systemic and Integrative Approaches have all been shown to be effective in the treatment of substance abuse disorders. Needle Exchange Programmes in Prisons Needle exchange programmes are part of the services provided by the HSE and others such as The Merchants Quay project to IDU’s in the community. These services are not available in Irish Prisons. Methadone Treatment Programmes Treatment options for active drug users include methadone maintenance (heroin substitute) and detoxification/drug free treatment. Higher dosages of methadone are associated with better outcome in terms of opiate use. Clients treated with inadequate doses of methadone commonly supplement their dose with illicit opiates. Methadone can be prescribed under a strict protocol as a maintenance, (potentially lifelong programme), for opiate users. Dosage Threshold Potential recipients Rationale Low Regular low dosage for pre contemplative to contemplative stage – administered under supervision with harm reduction input aimed at engaging the user in regular treatment Some tolerance of continued use Medium Regular prescription administered under prescription with harm reduction interventions aimed at enabling the user to stabilise and regularise their day to day life and improve their general health status Some tolerance of occasional slips High Regular dosage for committed abstainers from illicit substances – administered under supervision – social and psychological supports available on individualised bases. This may include self administration. No tolerance of continued use Challenges in Providing Health Care in Prisons Prisons are not, primarily, concerned with the health of the prison population and the need for security and discipline can cut across the needs of individuals for treatment. Additionally there is a difficulty in providing health care in prison in terms of different government departments being involved. Currently the Department of Justice, Equality and Law reform is responsible for running the prisons in conjunction with the Irish Prison Services. The co-ordination of drug treatment services in Irish Prisons is relatively recent and has taken place as a response to identification of the needs of prisoners. Initial reaction to the growing awareness of a persistent problem with drug using prisoners commenced with detoxification and counselling services in 1996. In 1999, a draft action plan was agreed between the Department of Justice, Equality and Law Reform and the Eastern Health Board to deal with substance abuse and drug treatment in the prison system. This plan included the development of drug free areas, introducing disinfectant tablets as a harm reduction measure, and methadone treatment and in other prisons to those who were already receiving methadone in the community. Since 1996, some progress has been made on these planned reforms. Since 2000, methadone maintenance is available in Mountjoy Prison, and other prisons, to those prisoners who were already on a methadone programme prior to incarceration. However, there are still limitations in the provision of methadone treatment in the prison as in the community. Methadone maintenance can be initiated in prison if clinically indicated and a community place can be secured. The prioritisation criteria used in the community also apply in the prison setting. The limiting factors in service provision are two fold; Availability of community places Human resource allocation at prison level. Not withstanding these factors the IPS have treated with methadone 1576 individuals in the year 2006 , 162 of whom were first time contacts with drug treatment services. Summary of Introduction of Interventions for Drug Users in Irish Prisons 1996-2007 1996 Introduction of a limited level of detoxification and counselling 1999 Agreement of draft action plan to deal with Prison based substance abuse 2000 Introduction of limited Methadone Maintenance and drug free units 2002 Review of the Prison Service for Drug Users recommends a partnership between the Department of Equality Justice and Law Reform, The IPS and the Health Service 2006 1576 individuals are treated with methadone, 162 of whom were first time contacts with drug treatment services. 2007 Initial roll out of Drug Services Plan for prisons, 3 addiction counsellors commenced in Mountjoy prison Key Study Findings Drug Use This study found no officially recorded figures are available on the extent of illicit drug use in Limerick prison. In this study reports on the frequency at which drugs were used were less consistent across groups interviewed and varied according to the particular drug being discussed. Reports from prisoners and staff suggest that 80% of the prison population have used drugs whilst in prison. Many of the staff interviewed believed that prisoners have easy access to illicit drugs. Groups were consistent in reporting illicit drugs as being available in all prison wings. In discussions about which drugs are available in the prison, heroin, cannabis and prescription drugs were most frequently mentioned. All groups reported that it was relatively easy to bring drugs into the prison and that sanctions were a minor deterrent in preventing supplies entering the prison. Coercion was cited as a means for access to drugs. Prison staff pointed out that prisoners frequently switched drug carriers once a particular prisoner was under suspicion of drug trafficking. Little discussion took place on how drugs were smuggled into prison but the lack of consistent of searches was cited as a reason for ease of access. Comments were made on the use of visits to outside health care, court and other facilities as a means of drug trafficking. Reducing or stopping the supply of drugs was seen by family members, service providers and prison officers as a significant first step in addressing drug use by Limerick prisoners. Tolerance of drugs The high estimate of drug use in the prison appears to be a tolerated and accepted part of the culture. In particular cannabis use in the prison appears to be tolerated by most groups. Most of the prisoners interviewed did not view cannabis or its related harm in the same light as other illicit drugs. This view was also shared by some staff members. Method of administration Much discussion took place in groups in relation to the use of heroin in Limerick prison. There were few reports of injecting drug use. Smoking was the most frequently cited method of administration. This finding is inconsistent with other studies conducted in Irish Prisons. When this inconsistency was explored further with groups it was justified on the bases that there is no culture of IDU in the Limerick community. Heroin use is still considered a relatively new phenomenon in Limerick with suggestions that it has only been an issue for drug users and service providers for the previous three years. First introduction to opiate use Consistent with other studies Limerick prison is cited as a place where young offenders are introduced to opiate use. Prisoners, Family Members and Prison Officers expressed dismay and anger about the introduction of young offenders to opiate use in the prison. Responsibility A lack of individual responsibility for drug use was shared by both prisoners and those charged with their detention and care. In most groups there was a lassitude about drugs, expression of the belief that little or nothing could be done to stem the supply and that change was not possible. Many participants expressed the view that the responsibility for stopping drug use lay outside their locus of control. Typically family members expressed the belief that services outside and within the prison did little or nothing to help the prisoners even when they expressed motivation to change. Prison Officers tended to blame central Government and Local Prison Management for the extent of drug use in the prison. Reasons cited were lack of facilities, poor staffing levels and reduced budgets. Voluntary Service Providers who provided housing and social care to ex-prisoners blamed poor planning around release as a reason for continued drug use and the creation of a revolving door scenario. Educators in the prison were critical of resources. Prisoners were critical of the level of services provided and of the attitude of all prison staff. Few comments were made by any participants that acknowledged their individual responsibility to contain their own drug use, prevent others using drugs, or provide others with the services they required to make changes. Service Provision There was a general agreement both among prisoners and staff that services in the prison were not adequate to cope with the number of prisoners. Issues that were repeatedly identified by prisoners and staff included lack of experienced professionals, waiting lists for services, quality of services available and lack of organisation and facilitation of services. There was much criticism of access to services by prisoners, prison staff, family members and staff from the voluntary sector. Much of what participants reported related to access to services on release, the lack of consistent links between community based and prison based services and the length of time it takes between identifying the need or request for a service and receiving same. In this study Prison staff were critical of each other’s ability and willingness to provide services. Some of this criticism was indicative of professional rivalry. All groups questioned the ability of staff to provide appropriate services. Some of this questioning was a reflection of a lack of knowledge about the remit of other staff or of their approach to intervening on a substance abuse problem. Prisoners need a range of treatment modalities and the existing delivery of treatment is inadequate relative to need. This finding indicates both a lack of appropriate services and/or a lack of skills on the part of staff in identifying prisoners at risk and matching them to appropriate interventions. In line with previous research this study found negative comments in relation to staff’s attitude towards prisoners and their families. Some prisoners and their families felt demeaned by the attitude of some members of the Health Care Staff. This need to provide training in relation to attitudes was reflected in the language used by both Prison Officers and some Health Care Staff to describe Prisoners. Most comments emphasised the need for appropriate staff education and training aimed at improving their understanding of prisoners who require help in relation to drug use. Dual diagnosis Co-morbidity of mental illness and addiction was identified as issues by prison and health care staff as well as prisoners. In some cases the link was viewed negatively and staff indicated that prisoners may use mental illness as a means to access services for addiction. Other participants felt that issues of dual diagnosis were inadequately addressed. Counselling approaches in Limerick Prison There are mixed reports about what kind of counselling services are available, on what days and times they are available and what services therapists provide. For example many staff and prisoners appeared to be unaware that during a crisis they could call a telephone help-line and / or that a phone hand set was available to make such a call from a prison cell. There appears to be no coordinated approach when it comes to counselling provision in the prison. There was a lot of mistrust among prisoners of counsellors delivering services. This confusion about who was providing services was also reflected by staff who sometimes professed to know little or nothing about each others skills or work practices and who openly commented that they could not get to meet other therapy providers even following direct requests for meetings. The research team also experienced difficulty in identifying the number and range of therapists engaged in working with prisoners who abuse substances. Service providers suggested that both abstinence and harm reduction were valid approaches. Integrative models of therapy, Cognitive Behavioural Therapy and Psychoanalysis were preferenced as appropriate for use with the Limerick prison population. Group therapy was advocated but current service providers did not seem anxious to be involved in the provision of group work. Peer support was seen as appropriate by some prisoners but was less favored by staff. 12 step fellowship groups were considered useful by some service providers but prisoners complained of lack of access to same. Many staff were in agreement that motivational interviewing was helpful. Some prisoners expressed a lack of faith in psychotherapeutic services which was attributed to having little faith in the skills and qualities of practitioners, disagreement with their philosophies of care, concerns over confidentiality and a sense of lack of engagement in any process of change. Prisoners who expressed positive responses to the current available psychotherapeutic services commented on three key aspects of the therapy process that they found positive; Confidentiality, Respect Commitment to the therapy process. Many prisoners were very concerned about the lack of incentives, activities, education and work in Limerick prison. It was apparent that most prisoners met by the research team were at pre-contemplative or contemplative stages in relation to substance use and therefore would benefit from a psycho-education approach as a first step towards engagement in therapy and a process of change. Harm reduction A consistent harm reduction policy did not appear to be part of the current approach to treating substance abusers in Limerick prison. Prison staff expressed few concerns about contact with drug taking paraphernalia. Prisoners who enter the prison with drug dependency can be prescribed a detoxification regime by the prison doctor. Prisoners are not maintained on methadone unless they have come directly from a methadone maintenance program outside the prison. Provision of a drug free wing in the prison was seen by family members, prisoners and staff as being beneficial to those who had a desire to change. Many staff commented that this was part of a previous plan for the prison that had not been fulfilled. Several staff members expressed hope that a new prison building due to open in 2007 would improve the opportunities for treatment facilities and harm reduction approaches. A model for addiction treatment in Limerick Prison Planning the delivery of health care in any environment is a challenge. The challenge is more acute when it involves incorporating a new system or approach into current services. Limerick Prison is not a Greenfield site in terms of the management of prisoners who use drugs, before during and after imprisonment and developing an ideal service for Limerick prisoners and their families will be a challenge to prisoners, the prison and local health care providers. However it is imperative that the ideal is presented and that work commences towards making the ideal a reality. Limerick Prison counselling and prison based addiction treatment model The data generated in this study indicated that the affected population is likely to respond to, and participate in, treatment and assistance when it is made available and easily accessible on a fair and equitable basis in relation to substance use. The Following recommendations are offered; Development of a drug court system in the Limerick and Cork regions that would enable some offenders access to treatment services as an alternative to prison A comprehensive assessment for all prisoners at the point of entry to the prison to assess them for drug use / abuse / dependency A strict transparent detoxification protocol available for all prisoners who wish to engage in a drug free lifestyle Access to a drug free wing which includes active therapy inputs from a team with a shared philosophy of care for all prisoners who wish to avail of a drug treatment programme staffed with experienced qualified personnel A contract system for prisoners to engage in treatment with incentives for those who abstain from illicit drug use Harm reduction services available in all prison wings A drug education programme and social skills training programme available on an on-going basis for all prisoners Flexible arrangements for counselling and psychotherapy appointments Structured engagement of concerned persons in the treatment process, e.g. partners, family members, friends or employers A broad team of heath professionals which may include, Outreach Workers, Nurses, Doctors, Social Workers, Educators, Psychologists, Pharmacists, Probation and Welfare officers, Addiction Counsellors and Psychotherapists Flexible approaches to treatment including individual, couple and group options Encouragement and access to engage in peer support and 12 step fellowships Quick and easy access to relapse prevention Planned and prearranged access to treatment centers and aftercare support groups on release Planned and prearranged access to social and housing supports on release Commitment to research, training and development  Counselling and Prison Based Addiction Treatment Model for Limerick Prison Prison Drugs Policy Working Party Assessment Psychiatric Medical Psychoeducational Services Intervention  The Ideal Prison based addiction counselling and treatment programme The flow chart above outlines in diagrammatic form the overall structure required of a model for counselling and prison based addiction treatment for Limerick Prison. An ideal prison based addiction counselling and treatment programme would commence with all prisoner being comprehensively assessed to ensure that base line information is collected and that prisoners can access appropriate interventions. A comprehensive assessment would allow for prison service providers to make appropriate decisions in relation to streaming prisoners with a history of drug use into services. As well as identifying current levels of drug use, it should identify the individual’s position in relation to change and the extent of their current motivation. Ongoing assessment and formal reassessment at appropriate intervals during a prisoner’s sentence would provide a useful link between, prison, probation and welfare, and health care staff in making recommendations for prisoner management. This report has identified that drug use can be broadly categorised under three headings; Drug Use Drug Abuse Dependence Outlined below are four frameworks for treatment, one relating to each level of drug use, and one that relates to dual diagnosis, that could then be utilised in the process of collaborative health care planning to ensure that all prisoners, following initial assessment would be in a position to receive appropriate interventions. Each level one through to level four should be seen as an opportunity to motivate prisoners to change, making an incentive based approach a workable model for the prison staff to institute. Each level of intervention, level one through to level four, have psycho-education, work/activity programmes and drug free environments as fundamental supports. The research generated in this study indicates that Limerick prisoners are currently insufficiently prepared and supported to engage effectively in psychotherapeutic interventions. Counselling alone would only be effective for a minority group of highly motivated prisoners. Psycho-education, meaningful work/activity programmes and drug free environments will be essential to enable prisoners to reach a level at which psychotherapeutic interventions will become meaningful and desirable. Interventions Level 1 - for Drug Use Prisoners who present on assessment as being engaged in drug use should receive interventions at level 1. This should not preclude them form accessing counselling for other issues that they have encountered in their lives however the scarce resource of addiction counselling should not be required. Intervention Level 2 - for Drug Abuse Level 2 interventions for drug abuse requires a more intensive input on behalf of prison based addiction services. Prisoners at this level need input to enable them to make informed decisions about their drug use which should include the decision to reduce, control or stop using drugs. All prisoners in this group should have access to psychoeducation programmes on the harmful effects of drug use. Psychoeducation programmes should be delivered to groups of inmates to facilitate peer learning and should incorporate opportunities for group discussion. When possible these interventions should include inputs from peer advocates. The emphasis at this level of treatment should be mindful of providing motivation to stop engaging in drug taking and encouragement to become involved in alternative lifestyles. It would be essential that prisoners at this level of use are incentivised and encouraged to engage in education and work skill programmes. Opportunities should exist in the prison for prisoners at this level to be accommodated in drug free environments. Prisoners who opt to stop using should have the option to avail of individual, group and peer support services. Medical intervention for detox may be required. Appropriate contract arrangements for ongoing random drug testing and incentives for remaining drug free should be considered. Intervention Level 3 - for Drug Dependence Prisoners identified as being drug dependant require careful medical assessment and need to be engaged in collaborative care planning in relation to their lifestyle choices. Drug dependant prisoners, regardless of their treatment plan prior to incarceration, should be considered for maintenance programmes as a first step towards a drug free lifestyle. This group of prisoners should also be carefully assessed for appropriate psychotherapy inputs and may require specialist intervention in the areas of Psychoanalytic, CBT, Humanistic, Systemic or Integrative therapy. Every effort should be made to ensure that prisoners identified as requiring interventions at Level 3 are actively involved in planning for release and that they are carefully matched to community services to ensure continuity of care. Intervention Level 4 - Dual Diagnosis Level 4 interventions apply specifically to prisoners identified as having a dual diagnosis. In this case having a co-morbid mental health treatment requirement should not exclude an individual from accessing addiction interventions as outlined in level 1-3. However health care providers should be mindful to provide a timely appropriate assessment and treatment package for addressing the mental health needs of the prisoner. Prison staff may also need to be mindful that individuals with identified mental health treatment needs may need additional consideration in terms of accommodation within the prison system. It would also be essential that the provider of mental health services within the prison is linked appropriately with external service providers to ensure continuity of care on release. Recommended steps towards making the ideal model the real model A series of steps needs to take place on phased bases to make Limerick prison a place where prisoners who use drugs are afforded every possible opportunity to engage with meaningful therapeutic supports that will enable them to address their drug taking behaviors. It is acknowledged that change need to be implemented on a phased base and that it involves consideration from philosophical, social, physical and financial perspectives. The recommendations are challenging for service providers and will require cooperation across disciplines and organisations but have been constructed to address the welfare of both the individual prisoner and the broader community. Drug use in Limerick Prison In order to address the extent of addiction treatment needs within the Limerick prison population there is a need to shift from a reporting system that relies on staff and prisoner beliefs and attitudes towards drug use towards a system based on accurate information gathering and clear accessible record keeping. Coupled with this there is a need to provide on-going staff education about the impact of drug use that tackles knowledge of and attitude toward substance use. Six recommendation are given below which should be addressed immediately. Development and implementation of clear written policy on the management of drug service in Limerick prison The appointment of a coordinator who would have responsibility for implementation of the drugs policy and the coordination of drug services provision The prison services should have a clear mechanism for recording and collating information on drug use in the prison A consistent approach to reducing the illicit drug supply in the prison On-going staff education for all grades of staff on the harmful effects and methods of administration of all illicit drugs aimed at improving knowledge and attitudes towards illicit drug use Education to equip staff to distinguish between drug use, abuse and dependence Treatment options Outlined below are seventeen recommendations designed to assist the HSE, the IPS and other relevant agencies in a collaborative planning process for the provision of appropriate drug treatment interventions in the HSE Mid-Western Region. These recommendations require consideration and should be introduced on planned phased bases over a period of 12 months. While it would be ideal that they could be immediately implemented it is recommended that the Limerick prison service in conjunction with its health care partners put in place a working group charged with implementing these goals. The working group should be required to abide by a specified timescale for the introduction of these recommendations and should be answerable to the current MDT. The working group should be chaired by the coordinator as outlined in the recommendations above. A comprehensive assessment package that includes an appropriate assessment for all individuals on detention to Limerick prison is required for baseline assessment Assessment should distinguish whether an individuals current drug use is classified as use, abuse or dependence As a pre-contemplative and contemplative approach to the provision of treatment psycho-education programmes should be developed and delivered on an on-going bases to all prisoners on the harmful effects of illicit drug use All staff need skills development in motivational interviewing Personal development groups on communication, social skills and anger management should be provided on an on-going bases for all prisoners Detoxification and medical support for withdrawal from a substance of abuse should be conducted under a strict protocol which is transparent and is available to all prisoners with a history of dependence regardless of their residential address prior to imprisonment MMT needs to be carefully monitored to ensure that they are not being used by prisoners to tide them over when illicit drugs are not available Access to and the frequency of 12-step group meetings needs to be increased particularly for narcotic drug use and gambling Providers of Counselling and Psychotherapy should provide group as well as individual therapy in order to maximise the use of limited resources and to enable peer learning Greater emphasis should be given to regular access to addiction counselling and CBT Prisoners need to be made aware of current crisis intervention services such as access to telephone help-line counselling services Efforts should be made to engage concerned person and family members in treatment programmes Signed contracts with prisoners should be introduced as an engagement tool in treatment regimes Compliance with treatment programmes should be rewarded with privileges and better conditions In order to maintain motivation in prisoners a comprehensive review of the limited skills training and education services needs to undertaken. This is particularly significant for services available to female prisoners Services to prisoners need to be more evenly distributed, for example all prisoners should have equal access to outdoor recreation, computer skills training and gym facilities The current delivery of Psychology services needs to be reviewed in order to redress the balance between the percentage of psychologist time spent with male and female prisoners Communication The data generated in this study indicated there is a lack in communication between service providers. Consequently both staff and prisoners claimed to be unaware of the variety of services that are currently available in the prison. This level of information sharing and communication issues needs to be addressed immediately. Outlined below are eight recommendations that could be addressed over a six month period and that require minimal investment in terms of new resources. The MDT need to agree a philosophy of care in relation to substance abuse The MDT should reconsider when it schedules its meetings to ensure that all team members participate on a regular basis The MDT meeting should be a forum in which therapists clearly identify which prisoners they are working with Health Care providers and Counselling and Psychotherapy staff need to set aside 1-2 training days each year when the can meet and share information in order to improve their working relationships and to develop shared goals A database of counsellors and psychotherapists working in the prison needs to be developed and maintained by the drug service coordinator. It should be available to all staff and list all of the counsellors and psychotherapists, the hours they are available, their registration details, qualifications, supervision arrangements and a brief outline of their approach to the treatment of substance abuse There should be an agreed defined and written statement of who is allowed to deliver counselling and psychotherapy to prisoners. This should include an arrangement to include therapists in training The establishment of a biannual prisoner / staff forum where verbal feedback on the range and quality of services available can be evaluated should be given immediate consideration Formal systems need to be develop to ensure that prisoners are linked to substance abuse services on their release from prison for prisoners normally resident in Limerick and other geographic locations Facilities Part of the establishment of best practice in relation to the type of counselling services that might support and integrate well with existing health-related assistance to the affected population such as MMT and detoxification involves examining basic facilities which are current incompatible with the provision of a therapy service for prisoners who use drugs. Three recommendations are made in relation to the provision of a prison environment that would enable prisoners to make and sustain changes in relation to their drug use. These recommendations require a physical, psychological and philosophical shift on the part of all grades of prison staff. The coordinator of the drug services for the prison will need to work closely with prison management and the working group to plan and implement these changes. Changes of this nature should not be introduced prior to the establishment of the recommendations outlined above. However there is a requirement that planning for these changes should commence immediately with a view towards their introduction over an 18 – 24 month period. Prison management in conjunction with the MDT should review current arrangements for the placing of prisoners in different wings. It is desirable that all prison wings should be drug free, however the reality of the endemic substance abuse requires a pragmatic harm reduction orientated approach that facilitates prisoners with a genuine desire to change Drug free environments should be managed appropriately and should include access to a comprehensive treatment programme commencing with detoxification, progressing through the provision of individual and group psychotherapy towards community links which are gained through successful engagement in treatment The issue of overcrowding in the prison needs to be addressed. This is particularly obvious in the female wing In conclusion the study has found that those who occupy and work in Limerick Prison have much work to do to address currently relatively high rates of substance use. There are significant resources available in terms of prison, health care and voluntary staff. However, the lack of a shared philosophy towards substance use in the prison is a hindrance to the development of services. Not least in the available resources are the prisoners themselves more than 300 men and women who are confined on a daily bases within the wall of Limerick prison, there is real potential and opportunity to enable this group of people to change and progress, provided fundamental work in terms of respect for the individual and motivation to change can be instituted.  Chapter 1 Introduction and Methodology Background Substance abuse and addictive behaviour are universal phenomena and are regarded, in the twentieth century, as a major public health problem (Rassool 1998). In Ireland, over the last number of years there has been an increase in alcohol consumption and a growing trend in the consumption of recreational, prescribed and illicit psychoactive substances, and subsequently an increase in the health problems and crime associated with such use. Compared with other European countries, the drug problem in Ireland is a relatively recent phenomenon and drug misuse did not constitute a social problem in any real sense until the early 1980’s (Ruddle et al, 2000). There is extensive scope for health and social gain among problem drug users, particularly among groups that are challenging to engage, such as young drug users and those who are homeless or in prison, (Moore et al 2004). Within the prison population, research has shown that a significant proportion of individuals have a history of illicit drug use. According to several European studies, approximately half of all drug users (Injecting Drug Users, IDU’s) continue drug use, predominantly opiates, during imprisonment (Stoever, 2002). Health care in prison is an area of increasing international concern with research from countries worldwide testifying to this (World Health Organisation, 1999). The Prison Health Care Services endorses the equivalence of health care between the community and the prison population (Irish Prison Services, 2001). In December 2005 the Bedford Row Family Project commissioned a research project to investigate the needs of Limerick Prisoners for prison based addiction treatment services in the context of planning the development of a high-quality, coherent and effective Addiction Treatment Service within Limerick Prison, there was a need for accurate information regarding; The extent of addiction treatment needs within the Limerick Prison Population The extent of the affected population likely to respond to, and participate in, treatments/assistances made available The form of counselling service that might support and integrate well with existing health related assistance to the affected population such as methadone maintenance and detoxification. The following study aims were identified: To estimate the extent of addiction treatment needs within the Limerick Prison population. To estimate the extent of the affected population likely to respond to, and participate in, treatment and assistance that may be made available in relation to substance use. To establish what constitutes best practice in relation to the type of counselling services that might support and integrate well with existing health-related assistance to the affected population such as methadone maintenance and detoxification. To assist the Health Service Employers (HSE), the Irish Prison Service (IPS) and other relevant agencies in a collaborative planning process for the provision of appropriate drug treatment interventions in the HSE Mid-Western Region. It was agreed that data for the review would be collected by; A literature review Focus Groups Individual Interviews A self – report form Report Outline This report presents a literature review and the findings of a project of research into the needs of Limerick prisoners for prison based addiction counselling and psychotherapy services. The report is presented as six separate chapters. Chapter one, as well as describing the methodology employed presents information on the Bedford Row Family Project brief for this report. This is followed by chapter two which gives an account of substance abuse both on an international and domestic front. Chapter three concentrates on the issues of substance use in prisons and chapter four address the treatment of substance use in prison environments. Chapter five presents the data collected through focus groups, individual interviews and the self report form. Finally chapter six draws together the report’s conclusions and presents recommendations for a prison based counselling and psychotherapy service for Limerick Prison. Literature review search strategy The literature review for the study was based on a structured search of relevant databases, libraries, and other sources, the compilation of primary conceptual, methodological and empirical research, an analysis of the research and integration of the findings. The review specifically explores: A national and international review of Counselling and Prison–Based Addiction Treatment Best practice for Counselling and Prison–Based Addiction Treatment Alternative and innovative initiatives which may have potential application to the Limerick Prison Services Issues involved in operating such schemes including examples of how these have been addressed A series of search terms were used to find relevant research literature/studies. Search terms included the following: drug use in prisons, drug use, counselling in prisons, family interventions, dual diagnosis, harm reduction models, women prisoners. Researcher and workers in the area were contacted for information that would contribute to the literature review. The Bedford Row Family Project Research Committee provided expert input into the design of the project. Search engines including CINAHL, Psyclit, Medline, PubMed, Science Direct, Cochrane Library, Social Science Citation Index were accessed to ensure information from bio – psycho – social and other relevant disciplines were included. Websites of relevant organisations were visited for information including www.hrb.ie, www.mqi.ie, www.dailydose.com, www.justice.ie, www.ips.ie, www.iprt.ie. Selection criteria Reviewed material was restricted to the English language. Research and reports published up until April 2007 was included in the literature review. Data collection and analysis A number of the search terms were broad; therefore each abstract was reviewed in the strict defined terms of the report Counselling and Prison Based Addiction Treatment. A general review of broad terms was conducted to ensure comprehensiveness of the research. When an abstract was noted to be relevant, the full article was sought for review by a minimum of two authors of this report. In the case of annual reports, books and Government publication, the complete report was sought and reviewed for consideration of inclusion in the report. This resulted in the inclusion of 101 published works in the final report. Service Review This section of the research is primarily concerned with identifying the perspectives of Prisoners and their Families, the Prison Management team, the Probation and Welfare Service in the Prison, Prison Health Care Staff, Community Health Care Personnel and the Voluntary Sector and was conducted in three stages. Initial contact was made with service providers seeking ethical clearance to conduct the study. Following the establishment of permission to conduct the study service providers and voluntary agencies were invited to provide written and verbal information on their services, remit and policies for practice. The Prison Management were contacted to elicit information on services within the prison. A self-report form (appendix A) was circulated to all of the identified groups to collect data to quantify the uptake of the services provided. This was followed by individual and focus group interviews to investigate and elicit perspectives of Prisoners and their Families, the Prison Management Team, the Probation and Welfare Service in the Prison, Prison Health Care Staff, Community Health Care Staff and Voluntary Sector Personnel on counselling and prison-based addiction treatment. An interview guide generated by information from the literature review was used when conducting the focus groups (Appendix B). The data collection was orientated toward defining best practice for Limerick Prison giving due regard to the information generated by the literature review, current practices in Limerick Prison and the perspectives that emerge from the identified groups. A total of fifteen focus groups were conducted to collect sufficient interview data to saturate the categories. Fifteen focus groups with approximately 6-8 participants in each were conducted. 6 with Prisoners 3 with Prison Staff 1 with Voluntary Groups 1 with Probation and Welfare Services 2 with Health Care Staff 2 with Prisoners Families All focus groups and interviews were audio taped. This material was then transcribed and analysed. The results of this analysis are presented in chapter 6. The growing trend, in Ireland, in the consumption of recreational, prescribed and illicit psychoactive substances, and the increase in the health problems and crime associated with problematic drug use provides a clear rationale for conducting the study. The provision of health care in prison has become the subject of much national and international debate and research which justifies conducting a study of this nature in Limerick Prison. This chapter has outlined the aims and chosen methodology for conducting the study. Chapter two explores the issue of substance abuse from a national and internationally perspective. Chapter 2 Substance Abuse _____________________________________________________________________ This chapter explores the concept of addiction followed by a review of the prevalence of alcohol and drug use in Ireland. This chapter also examines substance abuse in prisons across the European Union (EU). It explores the treatment options and assistance offered to prisoners who abuse drugs. The issues facing women prisoners are also examined. The chapter concludes with a section on the risk factors surrounding illicit drug use in the prison setting. Drug Use Often the language used concerning drug use can be emotive and value laden. The terms “drug abuse”, “drug misuse” and “problem drug use” are used interchangeably. According to Lawless and Cox (1999) the term “problem drug use” refers to those who as a result of taking psychoactive drugs suffer either medical, psychological or social implications. Drug use can cause a range of problems among regular consumers who may or may not be IDU’s. Not all people who use drugs are problem drugs users. Some forms of drug use (i.e. injecting, smoking) make people vulnerable to particular diseases or illnesses (HIV/AIDS, Hepatitis C, respiratory illnesses, cancer) (MQI 2007). While problematic drug use occurs in many communities irrespective of gender, class, race or nationality it is widely accepted that some individuals may be more vulnerable to becoming addicted than others, particularly those who live in communities that are socially and economically marginalised. The link between poverty and drug use has been widely recognised in Ireland and internationally. Problem drug use is particularly visible in communities with high levels of poverty, unemployment, poor housing, early school leaving and urban neglect. It is highly likely a substantial percentage of the prison population come from ‘disadvantaged’ communities where maintaining problematic drug use has led to criminal activity or that they have been ‘criminalised’ precisely because of their drug use. Definition of Addiction Addiction is continued involvement with a substance or activity despite ongoing negative consequences. (Donatella 2006 p332). Addiction occurs on a continuum where the behaviors’ initially provide pleasure or stability that is beyond the person’s ability to achieve otherwise. Over time it becomes necessary to engage with the substance or activity to feel normal. Current conceptualisation of drug taking behaviour, in reference to all psychoactive substances suggests three categories under which use can be defined; Drug use: simply refers to the taking of drugs Drug abuse: refers to any harmful use even if it does not constitute sufficient markers for a diagnosis with DSM – IV criteria Dependence: refers to substance dependence as defined in the DSM-IV or addiction as defined in the ICD 10 (Donatell, 2006:332). Bio – Psycho – Social Factors in Dependence Addiction can be understood both as a health and a social problem. Without a broad perspective it is not possible to address the multiple issues that arise from acute and chronic substance abuse. Social Factors: Social deprivation and stress have been associated with the development of substance abuse and dependence. It is a significant factor in the spread of major infectious diseases such as AIDS, Hepatitis and Tuberculosis and closely associated with both domestic violence and crime. Economic and social/cultural marginalisation is often viewed as factors that contribute to drug use and drug abuse. The marginalisation of working class youth results in the blocking of legitimate means to wealth. Lower working classes must use illegitimate means (such as drug behaviour and criminal activity) to achieve status and wealth in society (Moore, 2007:5). It can be argued that the high level of ‘problematic’ drug use in many working class communities is a consequence of inequality, poverty and a lack of resources in areas of education and employment. In this context drug use cannot be examined purely as an individual choice but must be situated within the wider structural inequalities. Drug use occurs across all communities but it is only when it becomes problematic that it becomes an issue for the criminal justice and health services. In the 1980’s in Ireland problematic drug use was predominantly dealt with as a criminal rather than a health issue. There ensued a moral panic around drug use, in particular heroin use which, left many communities further marginalised without the resources and support to combat the issues associated with drug use. During the past two decades there have been significant changes in the approaches to drug users, predominately coming from health service providers. Most drug services in the community employ a harm reduction model to problematic drug use. In an effort to keep drug users out of the criminal justice system a Drugs Court Treatment Programme was set up in Dublin in 2001. This programme gives drug addicts who are convicted of non-violent crimes a chance to escape the cycle of drugs, crime and prison (www.courts.ie/offices.nsf). It enables individuals to avail of a menu of services that includes; Detoxify in the community or in a residential setting Participation in drug free, methadone maintenance or methadone reduction treatment programmes Availing of counselling, educational and work programmes within the community. The Drug Court is a welcome step in the range of services available however its application remains limited. Not everyone who applies to get on the treatment programme will be successful. Decisions are made by a judge in consultation with health professionals and limited by available resources. Currently access to a Drug Court Programme is limited to Dublin’s North Inner City, parts of Dublin 3 and Dublin 7. Participation is additionally limited to those who are 17 years of age or older. No tolerance of illicit drug use is acceptable. Biological factors: In relation to a biological understanding of drug use dependence is viewed as a chronic brain disease because it is reported to produce changes in the dynamic functioning of the brain (Qureshi et al 2000 p724). Exposure to drugs activates specific structures, neurotransmitters and other related chemicals within neurons and associated receptors. This leave behind memory traces long after the drug has been excreted. When this is paired with environmental and social cues through a process of conditioning, even in the absence of drugs, the same or complimentary brain circuits can be activated. Changes in brain metabolic activity and hormones, genetic expression, receptor density, and responsiveness to environmental queues differentiate the brains of addicted people from those of non-addicted individuals (Qureshi et al 2000 p 725). There is still insufficient evidence to show what governs the initial drug taking behavior changing from a voluntary to an involuntary habit. The biological evidence to date indicates that every drug that is abused has some individual effect on the function of the brain, yet the underlying mechanism of addiction appear to be common to all drugs in that they all cause similar neuro-adaptations in the brain. Psychological Factors: Dependency on an addictive drug has a psychological impact. People who experience withdrawal symptoms are more likely to show more severe dependence characterised by increased consumption of the substance, reporting of more substance related problems in their life and increased emotional and mental health symptoms often defined as anxiety and depression. This process contributes to the creation of a cycle of addictive behaviour in which the individual continues to abuse the substance in order to avoid the symptoms. Paradoxically increased consumption leads to more severe psychological distress compounding the individual’s lack of ability to be rational about or exert conscious control on their addiction. Prevalence of Alcohol and Drug use in Ireland In the last two decades Ireland has had the highest increase in alcohol consumption amongst EU countries. Between 1989 and 1999 this increased per capita was 41% while 10 EU countries showed a decrease in the same period. Top of the League for increase is Ireland (41%) followed by the UK (10%) and Portugal (8%) Germany (2%), (Government of Ireland 2002). There is a relatively high rate of drug use in Ireland generally estimated at 5.6 per thousand of the population (Moore et al 2004). In a European context the highest estimates are reported for Italy, Luxemburg, Portugal and the United Kingdom. Estimates are lowest in Austria, Germany and the Netherlands placing Ireland in the middle band of the estimates for problem drug users in the population. Substance use is a major preventable cause of morbidity and mortality in most regions of the world; with epidemics switching from one region to another and new and often more harmful drugs replacing traditional practices (Nakajima, 1995). The first Irish drug prevalence household study were published by the National Advisory Committee on Drugs (NACD) in 2003. This study found that 3% of the adult population (aged 15-64) reported using cocaine (powder) in their lifetime. After cannabis (18%), magic mushrooms (4%), and ecstasy (4%), cocaine was the next most common used illicit drug (NACD 2003 p10). The number of people in treatment for opiate use supports the relatively high estimated rate of drug use in Ireland. There is an increase in the number of opiate users in the eastern region in receipt of methadone rising from 150 in 1992 to 6,672 by January 2003 (Moore et al 2004 p.41). There was a reduction in the overall percentage of followed–up individuals reporting heroin use, from 81% at treatment intake to 48% at 1-year. Increases in the percentage of individual reporting abstinence from all drugs (excluding alcohol) were observed for the followed up population, from 7% at treatment intake to 27% at 1-year. This study also found reductions in the percentage reporting acquisitive crimes from 31% at treatment intake to 14% at 1-year follow-up (NACD 2003). A reduction in 5 of the 10 physical health symptoms was observed for the followed up population. A reduction in 7 of the 10 mental health symptoms was observed for the followed up population, (Cox, et al. 2006). Cox et al. (2006) study indicates that on 1 year follow-up individuals in treatment display reductions in key physical and mental health symptoms alongside drug related criminal activity. The increase in substance abuse disorders is reflected in the number of people seeking treatment both in designated addiction services as outlined above and in the mental health system. In 1971 2.4% of people attending Irish Psychiatric Units and Hospitals were diagnosed with alcoholic disorders, by 2006 this figure had risen to 4.8%. During the same period of time other drug disorders had risen from 0.1% to 0.8% (Daly & Walsh 2006 p23). This finding is supported by the Activities of Psychiatric Units and Hospitals report (Daly et al 2005 p17) which shows that alcoholic disorders have the second highest rate of first admissions in all Health Service Executive (HSE) areas with rates ranging from 37.0 per 100,000 in the Dublin / Mid-Leinster region to 26.1 per 100,000 in the Dublin North-East region. According to the Interim report of the Strategic Task Force on Alcohol (DOHC 2002 p5), Ireland has had the highest increase in alcohol consumption among EU countries. In 2002 alcohol consumption per adult in Ireland hit 14.2 litres whereas the EU average was only 9.1 litres per capita. The relatively high rate of admission to the mental health services indicates that issues of dual diagnosis, that is, persons diagnosed with both mental health and substance abuse problems, have the potential to add to the complexity of managing an addiction problem. Dual Diagnosis People who present with a dual diagnosis can be understood as having multiple complex needs associated with both mental health and substance use issues. A proportion of people with a dual diagnosis are imprisoned each year. The extent of people with a dual diagnosis, in Ireland is unknown, studies conducted in other jurisdictions suggests various prevalence rates from ranging from 15-65% of individuals with a serious mental illness. An early study conducted by Meuser et al (1990) found a high rate of dual diagnosis suggesting that up to 65% of people with psychotic illness meet the criteria. A study conducted in 1996 suggested a much lower rate of 15% (Menezes et al 1996). Kamali (2000) found that 39% of Irish people with a diagnosis of schizophrenia fulfilled diagnostic criteria for a lifetime history of substance abuse. In the following year a study conducted with outpatients in Dublin broadly supported this finding indicating that 45% of people with schizophrenia meet dual diagnosis criteria (Condron et al. 2001:18). The relationship between diagnoses in an individual with dual diagnosis is more complex than simply having two conditions. Dual diagnosis can be understood as ‘the co-existence of both mental health and substance misuse problems for an individual’ (McGabhann et al. 2004:25). The Expert Group on Mental Health (2006:146) stated that co-morbidity contributes to greater severity of addiction and mental disorder. Substance misuse may often lead to an exacerbation of symptoms and relapse in major illness (Gournay et al 1997). There are a number of possibilities about the relationship that develops between mental health and substance abuse to be taken into account when assessing the individual and planning care. Substance use (even a single dose) may lead to psychiatric syndromes or symptoms Harmful use may produce psychiatric syndromes Dependence may produce psychological symptoms Intoxication from substance may produce psychological symptoms Withdrawal from substances may produce psychological symptoms Withdrawal from substances may lead to psychiatric symptoms Substance use may exacerbate pre-existing psychiatric disorders Psychological morbidity not amounting to a disorder may precipitate substance use Primary psychiatric disorder may lead to substance use disorder Primary psychiatric disorder may precipitate substance use disorder which, in turn, may lead to psychiatric syndromes. Crome (1999:160) Individuals with a dual diagnosis are mostly likely to come from four particular categories, A primary psychiatric disorder with a secondary substance misuse disorder A primary substance misuse disorder with psychiatric complications Concurrent substance misuse and psychiatric disorders An underlying traumatic experience, for example, post-traumatic stress disorder resulting in both substance abuse and mood disorders. Gafoor and Rassoul (1998:499) Careful and timely management of dual diagnosis is essential as rates of relapse are higher, service utilisation is increased, in-patient treatment is more common and treatment outcomes is poor for both conditions (Expert Group on Mental Health 2006). Clinical implications include, worsening psychiatric symptoms, increased use of institutional services, poor medication adherence, homelessness, increased risk of HIV infection, poor social outcomes, including impact on carers and families and contact with criminal justice system, (DoH 2002:8). The increasing separation of substance abuse from the field of mental health indicates that the first presentation of a percentage of individuals with a dual diagnosis may be to the criminal justice system. Therefore, assessment should serve a number of different purposes; Screening the individual, As a tool to aid diagnosis, As a guide to creating a treatment plan, and The provision of a baseline from which to measure outcomes of any interventions. Few assessment tools have been developed in relation to dual diagnosis, and reliability and validity of those that do exist are still being established (McGabhann et al 2004). This difficulty in the establishment of an accurate assessment tool for dual diagnosis is well reported by Wolford et al (1999) who found that many of the available tools used to measure substance abuse when used in a population with a mental illness were insensitive. As individuals with severe mental illness differ in their patterns of substance misuse (e.g. they tend to use lower quantities of substances) therefore norms established for the general population may not be applicable to psychiatric patients (McGabhann et al 2004). Prisons, Mental Health and Substance Abuse Services come from different educational and philosophical traditions and have different priorities in relation to their primary functions. Consequently the service providers for these different institutions may occasionally hold conflicting and contradictory approaches to care. Three distinct models to address dual diagnosis have emerged; Serial services Parallel services Integrated model In serial or sequential services the person initially receives treatment for one condition. Once initial treatment has succeeded in stabilising the condition the person is then referred for treatment of the second or dual disorder. Treatment for the mental health disorder in the absence of treatment for the substance abuse disorder is ineffective for both disorders (Pratt et al 2007). With parallel services both disorders are treated simultaneously. Different staff that may be working for different agencies carry out this treatment. This reduces the possibility of the symptoms of one disorder impairing the treatment outcomes of the other. This model is not without its critics, Drake et al (1993) argues that parallel services can lead to fragmented, contradictory and inadequate care. With integrated services the person receives treatment in the same place at the same time by the same practitioners (Pratt et al 2007). Within an integrated service there are nine principles identified by Drake et al (2004), which have been shown to be critical for effective treatment. The same clinical team who are knowledgeable in both disorders and their interaction provides integrated treatment Stage wise approach; Services are alert to the specific stage of change as outlined by Prochaska et al (1994). Engagement interventions; Motivational counselling is used to increase the likelihood of individuals engaging in treatment. This includes active outreach, flexibility in approach, practical as well as psychological support and culturally sensitive services models. Motivational counselling interventions; services use counselling techniques that develop readiness for a shift towards individualised goals. Active treatment interventions; Services include interventions such as motivational counselling, cognitive behavioural approaches and family interventions that all allow individuals to manage their own illness. Relapse prevention interventions; Services assist the individual in planning towards relapse interventions as they recognise that those with a dual diagnosis are more at risk of relapse. Long-term perspective; Services are designed to support people not just through crisis but also on the longer term as they recognise both the increased risk of relapse and that recovery is a long-term process. Comprehensive service; Services address all of the persons needs and liaise closely with other agencies particularly in the areas of housing, employment and justice. Interventions for treatment of non respondents; The individuals needs are considered in terms of addressing social issues in relation to money management, family intervention and occasionally the need for residential treatment. People who use and abuse substances may access addiction services, mental health treatment centres or as noted in the beginning of the chapter may come to the attention of the criminal justice system and be imprisoned. In A Vision for Change (2006), the expert group on mental health policy, recommends the importance of integrative services for those prisoners who have complex mental health and co-morbid addiction problems. The report recommends that, “Prison health services should be integrated and coordinated with social work, psychology and addiction services to ensure provision of integrated and effective care. Efforts should be made to improve relationships and liaison between forensic mental health services and other specialist community mental health services” (pg.140: 2006). Substance Abuse and Prisons There is a correlation between imprisonment and problematic drug use. Studies into the prevalence of drug use amongst offenders, or offending amongst drug users, show that in both cases the correlation is high. A series of studies has shown that drug use in prison is now commonplace and that many inmates come into custody with severe drug use problems (Maden et al., 1991; Turnbull et al., 1994; Singleton et al., 1999). The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) estimates that at least half of the European Union’s 356,000 prison population has a drug history and many of those entering prison have a severe drug problem, this issue affects a considerable number of prisoners. In Ireland, a national census survey in 1999 reported that 52% of a national sample of prisoners reported a history of opiate use and 43% reported a history of injecting drug use (Allwright at al, 1999). Drug possession offences account for most drug offences recorded. The latest figures available (2004) show that 69% of the total number of prosecutions were for simple possession, while supply offences accounted for 22% of the total, (Connolly, 2006). In 2004 cannabis-related prosecutions accounted for 62% of the total number of drug-related prosecutions, where heroin-related prosecutions accounted for 11.2% of the total number of prosecutions by drug type, (Connolly, 2006). The harmful affects of drug use and especially high-risk behaviours, which occurs in prisons, are well documented. Imprisonment has been found to impact on an individual’s pattern of drug use (Dillon, 2001). Drug use in prison is usually carried out in a hurried secret fashion with little regard for safety. O’ Mahony (1997) and Allwright at al (1999) have found that as many as one in three drug users inject in prison, some for the first time. Dillon (2001) reports that drug use in prison was synonymous with the sharing of equipment and the advantages of using drugs were seen as outweighing the risks involved in sharing equipment. European Prisons In most European prisons the spread of drug use is recognised as problematic. Some experts suggest that prisons provide environments that sustain problematic drug use among users and may even foster drug use in non users, (EMCDDA 2001). Drugs are used in prisons for a variety of reasons, they can be used as addictive substances, to cope with the stress and boredom of life behind bars, and the lack of work and educational opportunities, (EMCDDA, 2001). The frequency of use and availability of drugs not only vary from prison to prison but also differs from drug use in the community. How a ‘drug user’ is defined also varies across European States, while all European Union countries report that drug users are a significant and extremely problematic part of the total prison population, it has been noted that none of the reporting countries in the Council of Europe survey “has a comprehensive system to quantify the scale of this problem, even though in most countries it is assumed that this group makes up a significant part of criminal justice and prison populations” (EMCDDA 2001). Because prison drug use tends to take place in extreme secrecy and isolation it is difficult to have a detailed picture of drug use in prisons. A report in 2001 by the EMCDDA which looked at assistance to drug users in EU prisons put the number of drug users in Irish Prisons at 30-52%; this figure is from data collected in 1998. As the prison population has increased it is highly likely that the number of prisoners using drugs has also increased. Of 15 European countries, Spain and Portugal had the highest levels of drug use among prisons, (EMCDDA, 2001). Assistance to prison based drug users also varied across EU countries. In most European countries treatment plans are provided for every prisoner for the duration of their prison sentence. Abstinence oriented treatment for prisoners is provided predominantly in special facilities such as drug-free wings and therapeutic communities. Abstinence orientated treatment is the dominant approach in existing prison based interventions. The ‘twelve steps’ concept is the most common approach. Drug free wings have been developed particularly in Austrian, Dutch, Finnish and Swedish prisons (EMCDDA, 2001). Substitution and harm reduction treatment has become part of the normal range of services available in prisons only since the 1990’s. Methadone Provision Provision of methadone treatment varies considerably between countries. Austria and Spain have high levels of provision. In Spain an estimated 60% of drug users in prison receive methadone. In Austria methadone maintenance is available to all prisoners who seek it. Prisons in Portugal provide methadone for maintenance purposes but in Belgium, Germany, Ireland, Italy, the Netherlands and the UK, provision is minimal, apart from for the purposes of detoxification (EMCDDA, 2001). The EMCDDA (2001) notes that in Ireland, “prison policy is to provide the same level of substitution treatment inside prison as outside, but in practice this does not happen” (18:2001). Prisoners, unless they have been stable on a methadone maintenance programme in the community are generally detoxified upon incarceration. This is also the case for many European prisons where short-term methadone detoxification is the most widespread approach for drug users. Drug users in many European prisons are still subject to ‘cold turkey’ (immediate reduction of the dosage to zero without the provision of a substitute drug) upon incarceration. (2001). Drug Free Environments The availability of drug-free units and drug-free wings also vary across different EU countries. Irish Prison policy aims at a total drug free environment in all prisons (Irish Prisons Services, 2006). As distinct from ‘drug-free units, the term ‘drug-free wings’ usually do not include an addiction treatment offer. The sole aim of a drug free wing is to offer a drug-free environment for those who wish to stay at a distance from drug-using prisoners. The essential difference between ‘drug-free units’ and ‘drug-free wings’ is that prisoners entering the latter are not necessarily addicted to drugs (EMCDDA 2001). The basic characteristics of drug-free units are: The prisoner stays in these units on a voluntary basis He/she is committed (sometimes with a contract) to abstinence from using drugs and importing drugs to the unit, and He/she agrees to regular medical check-ups often including drug testing. The prison’s system is committed to prisoners staying in these units to enjoy a regime with more favours, such as additional leave, education or work outside, excursions, and more frequent contact with the family, (EMCDDA 2001). Research in relation to the provision of prison based treatment A recent study by the British Home Office (2003) tailgates seven research studies on prisoners’ drug use and treatment to explore the best options for prison based addiction treatment. Of particular note the authors found that on entering prison drug use decreased. Reasons cited for the decrease in drug use following imprisonment included; Lack of availability of drugs(61% ), Attempting to stay off drugs (14%) Not being able to afford drugs (13%) Concerns about being punishment (6%) Swann and James (2003, p.31) suggest that the very act of imprisonment may encourage inmates to address their drug use. Therefore the impact of imprisonment could be a factor in a process of self-change. The British Home Office report (2003) suggests that cannabis is the most widely reported illicit substance used before and during custody. However heroin was used by a substantial proportion (27%) of prisoners. ‘Relaxation’ and the ‘relief of boredom’ are the two most frequency cited reasons for the use drugs in prison. ‘Enjoyment’ is also frequently cited, particularly by cannabis users, as is the need to ‘block out their situation’, particularly be heroin users (Home Office 2003, p.33). Swann and James (2003) and Dillon (2003) also suggest that heroin use has become a ‘cultural’ aspect of prison life arguing that it is important for drug users to be part of a group in prison; both for protection and to ensure a more consistent supply of drugs. Keene (1997) notes that prisoners attach a degree of importance to the ‘calming effects’ of certain drugs – particularly cannabis and tranquillisers as they lead to better behaviour, a better atmosphere and improved psychological health (British Home Office, 2003, p.34). Additionally the choices that drug users in the community have to minimise the risks entailed by their drug use, through accessing counselling, needle exchange programmes and information on safer injection are removed from those who decide to continue to inject while in prison, (O Driscoll 2005). Issues for Female Prisoners A recent study looking at the care pathways of women admitted to the Dochas Centre, Mountjoy Prison (Comiskey,2006) notes that of the 40 women surveyed, 34 women had received methadone treatment in prison and only 11 had received some form of counselling (Comiskey, 2006). Common problems reported by the women were; The rapid detoxified process, The lack of follow up and Difficulties in remaining drug free. At six months follow up after their initial interview within the Dochas Centre the study found a reduction in drug use. At recruitment on average the women were using heroin at least daily while six months later this reduced to less than twice a week. A major finding in this study was the lack of service co-ordination within the prison and also services feeding into the prison. Service providers reported difficulties in setting up post-release accommodation and other supports for women, as frequently individuals were released early from prison prior to appropriate community supports and appropriate accommodation being put in place. This resulted in a number of women leaving the Dochas Centre finding themselves homeless. When accommodation was secured, with adequate support for women leaving the prison it was frequently unsuitable. This normally related to individuals not meeting drug free criteria, (Comiskey, 2006). Consequently on release women were frequently housed in Bed and Breakfast and hostel accommodation. Transient accommodation and frequent address changes create difficulties for service providers to engage with individuals. Service providers may not be able to locate individuals or they may move out of the service provider’s geographical area. Significantly some women find themselves having to sign up with another service or will fall out of the net of services altogether (Comiskey, 2006). Harm reduction measures offered to female prisoners Most EU countries provide information on health risks, health education and hepatitis vaccination to female drug using prisoners (Zurhold, 2004). Furthermore 14 European countries provide to some extend drug-free wings, self-help groups, and peer-support to female drug using prisoners. Some EU countries do not meet this level of service provision although they claim to be addressing drug-related health problems (Zurhold, 2004). The prison system in Belgium Latvia, Lithuania, Northern Ireland, Poland and Slovakia do not offer any hepatitis vaccination, (Zurhold, 2004). The main findings from the report are: 49% of the women in this study continued the use of illicit drugs in the first weeks after entering prison however during their imprisonment this number decreased to 37.8% In prison the smoking of cannabis along with the oral use of non-prescribed pharmaceuticals such as buprenorphine, morphine and benzodiazepines, the use of heroin and in Hamburg the use of crack are most common among the drug using prisoners Different to the prevalence of drug injection outside prison, inside prison IDU remained an exception. Of all respondents’ only three women from Vienna injected drugs in prison in the last month preceding the interview. Since entering prison altogether 91.4% of respondents (number169) have ever made use of any available drug and treatment service. Even though differences were found in all five study sites most women prisoners made use of prison medical care along with counselling offers, substitution maintenance and to some extent psychiatric treatment and health education training. Illicit drug use and risk factors in prison There are many reasons why prisoners continue to use drugs and alcohol both in prison and on release. Dillon (2001) writes that drugs were reported to play an important role in shaping many aspects of the prison environment. They help to alleviate boredom and depression; they are used because of peer pressure and trying to be accepted, as well as drug use providing a focus and a sense of identity. Drugs provide a means of escaping the reality of being locked up, and help prisoners cope with the harshness of prison life (Dillon 2001, EMCDDA 2001). Many prisoners would have used drugs as a means of coping with life outside prison, and incarceration alone does not alter this psychosocial coping mechanism. To stay or become drug free in a prison environment characterised by a drugs culture was not perceived as feasible for those with a history of drug use (Dillon, 2001). However, some prisoners do manage to cease drug use while in prison or to reduce the quantity of drugs they use, and the frequency with which they use them when compared with their drug use in the community. Prisoners use far less drugs in prison than in the community, due to reduced availability (Crowley, 1999). Due to the scarcity of heroin, prisoners who would have previously smoked will often resort to injecting while in prison, to use the available drugs more efficiently. Respondents in Dillon’s (2001) exploratory study of drug use in prison reported that smoking heroin was perceived to be wasteful, whereas injecting was seen to use the smallest amount of heroin to the largest effect for the most people. Dolan and al (2003) reported that although injecting drugs in prison is less frequent than in the community, each episode of injecting is far more risky due to the greater scarcity of injecting equipment and the higher prevalence of syringe sharing. Conversely, the vast majority of prisoners view time in prison as an opportunity to address problems associated with substance abuse and health professionals should not miss this opportunity (Long et al 2004, Swann & James 2003). Prison can also be seen to be an ideal time to make the most of the opportunity to intervene in the cycle of addiction and crime and provide support, counselling, education and a range of treatment options to users who may not have come into contact with treatment services otherwise. Currently most prison based drug policies focus on the abstinence-based approach and advocate ways of ensuring drugs do not enter the prison environment, by such measures as closed visits and covering over exercise yards, (O Driscoll 2005). This Chapter explored concepts of drug use and distinguishes between drug use, abuse and dependence. The prevalence of drug use in Ireland in comparison to other EU countries was explored and shown to be relatively high estimated at 5.6 per thousand of the population. Consequently, the increase in people seeking treatment and the prosecution rate, 69% in 2004, for drug offences is noted as an important issue for the Irish Prison Services. Bio/psycho/social factors that influence drug use have been examined with evidence from the national and international literature indicating a correlation between social factors and criminality in relation to drug use. The complexity of the management of addiction problems from a mental health perspective was examined with particular attention been given to the management of the individual with a dual diagnosis. The issue of substance abuse is prisons has been explored from a national and European perspective exposing the significant differences in Irish prisons in relation to the provision of less services for imprisoned drug users on a national bases. Consideration has also been given to harm reduction services in prisons that acknowledge the use of drugs and provide drug free environments for those who wish to abstain. Prisoner’s rationale for continued drug use in prison includes stress relief and the alleviation of boredom as identified in the available literature. Issues specific to female prisoners were explored. The increased risk of harmful drug use due to the opportunistic nature of drug use in prison is highlighted. The following chapter explores the different treatment approaches available to drug users. Chapter 3 Treatment Approaches This chapter explores the two main paradigms used to treat addiction. The more traditional approach, the abstinence based model is centred on the addict giving up the substance. Secondly the harm reduction model takes a more pragmatic perspective on addiction and aims to enable the addict to reduce or control their consumption thereby decreasing the harms associated with substance abuse. There are three steps common to both that need to be negotiated, detoxification, recovery and relapse prevention. In this chapter these three steps are explored. The five step model of change is presented. Specific reference is made to methadone maintenance, the recovery process and to a variety of counselling and psychotherapy interventions. Reference is also made to more controversial approaches to treatment. Treatment programmes which are available in prisons in other jurisdictions are discussed. Five Stage Model of Change The five stage model of change is a useful tool in assessing a substance user’s current relationship with their drug of choice, their readiness to engage in treatment, and it provides a template for the service provider to assist the substance user in engaging in an appropriate treatment process. 1. Pre-contemplation stage – individuals do not believe they have a problem and therefore are resistant to change. The role of treatment should be to help the person become aware of the possible and real harms they are inflicting on themselves through their substance misuse. 2. Contemplation – this is an ambivalent stage in which the individual is aware of the cost of their substance abuse but these are still outweighed by perceived benefits to continued use. The treatment task involves helping the individual understand their misperceptions. 3. Preparation – during this stage there is recognition of the need for change and small steps may be made towards it. Treatment approaches should include enabling the person to develop a realistic plan for changing their behaviour and encouraging them to move away from being ambivalent in relation to addiction. 4. Action – this is an active stage of change where new behaviours are acquired. Interventions need to be supportive in that they enable the individual to hold onto there rationale for change and that they actively provide the person with the tools they need to take action. 5. Maintenance – this stage relates to the individual developing a sustainable lifestyle. Much supportive work in relation to relapse prevention is required. The Abstinence model Abstinence is normally understood as refraining from the consumption of the addictive substance and related behaviour. For abstinence to be successful the substance user must also learn to restore a balance to their lifestyle through non compulsive engagements in other behaviours and / or substances this is both a physical and cognitive process in which the substance user adjusts to being free from the direct influence of their addiction. Abstinence efforts in prisons aim to treat and prevent any illicit drug use. Normally they include a mixture of illicit drug use prevention measures and treatment options. Detoxification The first step in treatment is detoxification, an uncomfortable and sometimes dangerous process. Painful withdrawal symptoms can be treated medical by the prescription of medications that reduce the physical and psychological distress experienced during the early stages of detoxification. Depending on the individual’s need detoxification may take place in a residential setting or on an outpatient basis. Normally following a thorough assessment the substance abuser will be prescribed medication on a sliding scale. The purpose of the sliding scale is to carefully wean the person from a dependency on a chemical solution and to avoid the most painful of the withdrawal symptoms. The Harm Reduction Model During the past two decades the shift from an abstinence model to a model of harm reduction has steady gained in popularity in addiction treatment services. This shift in the dominant paradigm has occurred for a variety of reasons. Most frequently the reason offered for a change in approach to addiction is that the user may not want to move from the pre-contemplative/contemplative stage to an active stage of addressing their addiction. Consequently for the intervening agent the challenge is to stabilise the user until a shift in their addiction can be established. Harm reduction allows the treating agent to offer a programme, which aims at reducing the risks to the users physical and mental health and also aims to address issues of danger to others caused by the addictive person’s behaviours. A variety of definitions for harm reduction emerge in the literature. According to Robertson (1998), ‘otherwise referred to as damage limitation or risk reduction the principle element is of palliative care for a group involved with potentially extremely dangerous and damaging behaviour.’ Thombs (1999) describes harm reduction programmes as tolerating some level of substance abuse’ and being ‘primarily concerned with extending help to high risk groups.’ Harm reduction programmes typically include a range of interventions, which, on a continuum, commences with communication with drug users and the general public and moves to the prescription of drug substitution treatment (Moore et al 2004). Within this understanding of harm reduction the provision of counselling services is a central factor enabling the drug user to make informed choices about continued drug use. Harm-reduction efforts in prisons aim to prevent or reduce the negative effects associated with certain behaviour patterns, imprisonment, overcrowding, and adverse effects on mental health. Initiatives such as needle-exchange programmes are viewed by many to be effective and viable for controlling the spread of HIV, and are not seen to obstruct safety or effectiveness of drug-use prevention polices. The prison systems that have achieved the most success in preventing the spread of HIV have promoted harm reduction and treatment strategies together-making bleach, condoms, methadone maintenance, needle exchange, and other drug treatment available (Moore et al 2004). Harm reduction aims at decreasing harm through information, education, provision of equipment and support, drug substitution treatment and counselling. In a report on ‘Harm Reduction for Special Populations’ in Canada, Thomas (2005), notes that abstinence is not a condition of participation in substance abuse treatment programs. For most drug abuse treatment programs abstinence is a pre-requisite for eligibility. One of the most practical applications of harm reduction in the treatment domain, however, is the removal of abstinence as a condition of participation in substance abuse treatment programs (Thomas, 2005). In the Correctional Service of Canada (CSC) programmes, for example, prisoners are not normally excluded from participating in substance abuse treatment unless their substance use becomes disruptive to the programme. Harm reduction is listed as “theoretical influence” in CSC’s recent efforts to modernize programmes for substance-using female prisoners. It was determined that internalizing strategies to reduce substance use, or reduce the harms associated with substance use, were relevant for some women prisoners as they moved into more empowered and responsible lifestyles (Thomas, 2005). While these programmes have the potential for reducing harms among persons involved in the criminal justice system, some have not been widely implemented (for example, routine provision of information on drug purity and quality to drug users). Thomas (2005) suggests that they should, therefore, be subjected to rigorous evaluations to ensure that they are effective for reducing health or social harms. Motivational interviewing Motivational Interviewing is an effective strategy for engaging and treating substance abuse disorders. It is defined as a client-centred directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Miller & Rollnick 2002, p.25). Interventions designed to increase motivation among substance abusers, such as motivational enhancement therapy may be helpful in reducing early drop out from treatment. This includes directly addressing discomfort with disclosure as well as encouraging gradual disclosure that begins with more comfortable, less threatening discussion topics. There are four basic principles: The harm reduction model and motivational interviewing fit together allowing the treatment provider to develop a consistent approach based on a careful assessment of the individual which helps to gain an understanding of where they are in relation to a trans-theoretical five stage model of change (Prochaska et al, 1992 p1108). Recognising that an individual has reached a turning point is important. Turning points are expressed as; Existential crisis Rock bottom Rational decisions Epiphany Should stop / want to stop Desire for a new identity A turning point can be understood as a point beyond which an individual is not willing to go. It is usually accompanied by some experience or event which serves to stimulate or trigger the decision e.g. a health, family or other crisis such as a criminal conviction and prison sentence. The decision to stop can be influenced by experiences that damage a person’s sense of self such as when the substance user’s identity conflicts with, and create problems for, other identities that are unrelated to substance use. The key to the recovery process lies in the realisation by the substance user that their damaged sense of self has to be restored together with a reawakening of their old identifies and/or the establishment of new ones. Cognitive shifts are required. This relates to a sense of self that is continually formed and reformed through interaction with others in which individuals internalize the attitudes which others hold towards them. For the substance abuser there is a need to move away from a spoiled identity in which the individual realises that he exhibits characteristics that are unacceptable both to themselves and others. For this to happen there are two basic requirements; A motivation to stop based upon a desire to restore a spoiled identity A sense of a future that is potentially different from the present Recovery Recovery is a process that enables the former substance user to rebuild their lives and regain independence. The recovery process can be both long and arduous involving numerous attempts at treatment before a successful change is achieved. The following characteristics are common to most treatment programmes. However all treatment programmes tend to have individual characteristics and one element of the whole package may be given stronger emphasis than another. Experienced qualified professional staff Flexible arrangements for inpatient and outpatient appointments Assessment and treatment for medical impact of substance abuse, may be provided by an off site agency Engagement of concerned persons in the treatment process, e.g. partners, family members, friends or employers A broad team of heath professionals which may include, Outreach Workers, Nurses, Doctors, Social Workers, Educators, Psychologists, Pharmacists and Psychotherapists Flexible approaches to treatment including individual, couple and group options Encouragement and access to engage in peer support and 12 step fellowships Quick and easy access to relapse prevention and aftercare support groups Commitment to research, training and development Counselling and Psychotherapy Approaches to Counselling and Psychotherapy have grown and developed through a number of phases during the past 120 years. The first wave of a psychological approach to health is dominated by psychoanalysis. Phase II consists of the development of behavioural science which have been expanded to include a range of approaches generally classed as cognitive behavioural approaches. Phase III, the humanistic approach emerged in the late 1930’s and is generally associated with the growth of counselling and psychotherapy that is accessible to a wider range of people. Changes in how we view society and interact with each other saw the emergence of systemic approaches in the latter half of the 20th century. During the last 20 years research in psychotherapy has lead more therapists to adopt an integrative approach to the provision of psychological support and treatment. The efficacy and effectiveness of counselling and psychotherapy has been subject to much debate since the 1950’s. Therapeutic drug free programmes involving individual counselling and group work are beginning to show impressive levels of impact on participants drug use and offending behaviour. Smith and Glass (1977) collated 475 controlled studies across 18 different therapy types (including placebo treatment and undifferentiated counselling) and found that the average treated person was better off than 80 per cent of non treated people, (Dryden 2007). The Consumer Reports survey (Consumer Reports, 1995) in an analysis of readers who had experiences stress or other emotional problems at any time during the previous three years found; treatment by a health professional usually worked long term therapy produced more improvement than short term therapy There was no difference between psychotherapy alone and psychotherapy and medication for any disorder No specific modality of psychotherapy did any better than any other for any problem. However Kopta et al state; ‘It seems clear though that no one believes all psychotherapies are equally effective for all disorders, (Dryden 2007). In acknowledgement of Kopta et al’s statement the five main theoretical approaches to counselling and psychotherapy are outlined below. For the purpose of clarity they have been presented in chronological order, psychoanalysis, cognitive behavioural, humanistic, systemic and integrative. Psychoanalysis and Addiction Psychoanalysis is concerned with the unconscious and its influence on the lived experience of the individual. From a psychoanalytic perspective addiction is understood as an inscription on the body of a drama that is taking place in the mind. Current understanding of addiction has excluded the subject of addiction and concentrated on the subject’s relation to the substance (Loose, 2002). Psychoanalysis rejects the premises that every psychopathology has one specific organic cause leading to the belief that if you isolate the specific cause and provide treatment for it you can affect a cure, treat it you get effect a cure. Freud suggests that it is not cocaine itself which causes addiction but a factor in the person which makes them susceptible to any addiction. In 1888 when Freud begins to publish about hysteria he listed intoxication (lead, alcohol) as a causative factor of hysteria. In relation to the treatment of hysteria he cautions against medication and says narcotic drugs are to be warned against. ‘To prescribe a narcotic drug in an acute hysteric is nothing less than a serious technical mistake’, (cited in Loose 2002). In 1925 Freud became concerned with the link between neuroses and addiction and argued that these conditions arise from an excess or lack of highly active substances, whether produced inside the body or introduced from outside, they are disturbances of the chemistry of the body, toxic conditions. He argues that pleasure is not the only aim in human life and the compulsion to repeat can be a compulsion to suffer. Humans are in conflict because they are compelled to go beyond the limit of pleasure into a realm that causes them suffering. This conflict can lead to the psychopathology of using drugs and/or alcohol. The use of drugs does not aim at paralysing the pleasure principle but instead at paralysing the compulsion to suffer in the realm beyond pleasure. The use of drugs aims at the death drive, a desire to block off sensory perception, akin to the state of sleep or intoxification with drugs or alcohol, (Loose 2002). It aims at reactivating the pleasure principle, with that aim comes the rejection of the claims of reality; drug/alcohol can paralyse the reality principle. The verification of psychodynamic approaches should not be confined just to the psychoanalytic community unless it wants to risk accusations of nepotism. There is a need to look to other researchers to strengthen the argument that psychoanalysis is a valid methodology for practice. Roth and Fonagy’s (2005) critical review of psychotherapy research, highlights the number of researchers in the field who have submitted psychoanalytic praxis to randomised controlled trials with positive results. As more randomised controlled trials on psychodynamic and relational approaches are conducted, it becomes plausible to argue that they have efficacy for more complex conditions. Psychoanalysis as a treatment requires a long-term commitment on the part of the analyst and the patient normally treatment involves 2 -3 sessions per week over a period of years. While psychoanalysis may be a desirable approach, the resource commitment involved from the perspective of a prison needs careful consideration. Cognitive-Behavioural Approaches and Addiction Cognitive-Behavioural Therapy (CBT) evolved in the 1950’s as a viable alternative approach to psychoanalysis. This approach was designed to assist clients to understand the nature of their thoughts and the impact that such thoughts have on emotions and behaviours. CBT is concerned with how individuals process information and the influence of automatic thoughts and core beliefs on their daily functioning, (Mytton, 2001). This approach is educative and collaborative. It postulates that clients can learn to exercise the mind to improve their mood, to change their thinking and their behaviour in order to improve their capacity to manage the challenges of life. CBT is goal orientated and focussed on resolving problems. It is structured and clients can measure their progress towards resolving their difficulties. The approach requires the active involvement and participation of clients who eventually are taught to become their own therapists (Beck 1993). There is compelling research evidence that CBT is highly effective is resolving problems and assisting clients to achieve long lasting results. A number of research findings have shown the supremacy of this approach over drug treatments or other forms of therapy (Roth and Fonagy 1996). CBT has relevance to the prison setting and addiction. The Cognitive strand of the therapy focuses on clarifying and questioning thoughts, perceptions and images about drug taking. It addresses distorted thinking about substance abuse and modifies beliefs that increase drug taking. Cognitive reframing assists users to cope better with cravings and supports relapse prevention programmes (Beck 1993: Marlatt & Gordon, 1985) The Behavioural strand of the therapy focuses on changing the contexts associated with drug misuse and sets in motion a logical structured process of measurable behavioural change that results in the goal of abstinence from drug use or moderation of drug taking (Prochaska et al 1992). Evidence based research has demonstrated that CBT has proved effective in supporting the Five-Stage model of change. At the Pre –Contemplative stage the CBT model elicits views and perceptions on drug taking, challenges denial, lack of motivation and resistance to engaging in harm reduction or abstinence programmes. At the Contemplative stage examination of automatic thoughts and triggers for drug taking, cost/ benefit analysing and future orienteering can help users to overcome this ambivalent stage. The Preparation stage, from a cognitive-behavioural perspective, involves defining a realistic plan for changing self-defeating or harmful behavioural in a manageable, measurable and rewarding fashion. Anticipating ways to overcome difficulties and potential blocks provides a mental map and practical options on the road to recovery. The Action Stage involves active cognitive behavioural techniques to help users cope with urges as they begin to acquire new, drug free behaviours. Clients are taught how to use thought distraction techniques, reduce destructive irrational self-talk or beliefs, develop problem solving strategies and actively identify and utilise structured regular support networks. At stage five, maintaining goals about the reduction of substance misuse benefits from identifying and using relapse prevention strategies. Tackling demoralising thoughts and feelings can enable clients to reframe set backs and develop a sustainable lifestyle in which they can abstain from drugs or moderate intake as part of a harm reduction programme. In the prison setting, a joined up approach to tackling drug misuse is vital. A joined up context links harm reduction programmes with regular CBT sessions and access to motivational interviewing. These three key elements, when fully integrated, can enhance prisoners’ chances of abstaining from or moderating drug use. The CBT treatment planning would include attendance at weekly sessions until prisoners reach the Action stage, as outlined above. Thereafter prisoners would have access to frequent intensive sessions, on a sliding scale of diminishing attendance until drug misuse has ceased. Intensive sessions can be provided on an individual basis or in a group therapy context. CBT has the potential to assist prisoners to define short and long term goals while incarcerated. This approach can enable prisoners to recognise the personal impact of imprisonment and tackle the high correlation between imprisonment, patterns of drug abuse and related high-risk behaviours. It can support and challenge prisoners to take more responsibility for their lives, choices, daily functioning, as well as, self-defeating and harmful actions. It provides hope for a changed and more productive future by dealing with anxiety, depression, boredom, and apathy, without resorting to drugs. This psychotherapeutic approach reinforces decisions to remain drug free and provides support and increases motivation during harm reduction programmes. Humanistic approaches and addiction The Humanistic approach emerged as an alternative psychotherapeutic force to psychoanalytic and behavioural approaches that had dominated the helping professions since the beginning of the twentieth century. The Humanistic approach encompasses such theoretical perspectives as Person Centred Therapy, Gestalt Therapy, Psychosynthesis Therapy and Transactional Analysis. The Humanistic approach postulates that human beings have an actualising tendency. That is to say, they are drawn towards fulfilment of their potential and achieving a sense of wholeness. The image of the person, from this perspective, is an optimistic one, which considers that individuals are fundamentally good and have the capacity to be fully functioning, creative, social and genuine persons (Merry 2000). From this philosophical stance, human beings have the capacity to be insightful, direct their own lives, engage in personal development activities and affect positive personal change, (Corey, 2001). Psychological disturbance can occur when an individual encounters rejection, criticism, and disappointment. If key parental figures withhold positive regard and impose conditions of worth, the individual can experience anxiety and begin to perform in ways that gain approval, from significant others. If this becomes an entrenched pattern, the individual may lose a sense of self; experience difficulties with self esteem and be conflicted in relation to their self-concept. (Kirschenbaum & Henderson 1989) Humanistic psychotherapies can assist those with substance users to explore issues related to the formulation of their self-concept, to gain insight into incongruence in their self-experience and to consider how such incongruence manifests itself in self-defeating or harmful ways. The Humanistic approach regards the client as the expert, with the capacity to affect positive change in their lived experience. The tone of humanistic perspectives is non-judgemental, highly supportive and empathic. It emphasises the nature of the therapeutic alliance as a positive agent of change. Humanistic approaches are likely to benefit prisoners who are currently abstaining from drugs or in remission from drug dependency. This approach can psychologically and emotionally support prisoners involved in harm reduction programmes. At a pre-dependency stage, it can assist prisoners to express their thoughts, feelings and experiences in relation to incarceration and assist them to cope with prison life, without resorting to drugs. The key to successful psychotherapeutic outcomes, from this theoretical perspective, is associated with prisoners having regular access to individual or group therapy over a sustained period of time. When this is coupled with a humanistic and respectful ethos towards prisoners, positive prognosis is increased. Systemic Approaches The systemic approach views a person within their family, local community and wider social context. The person is understood as, both influenced by and contributing to, the various sets of relational connections within this network and the values and structures that govern these networks (Dallas & Draper, 2000). Therefore, managing problems from this perspective requires attention to the individuals’ context for living. For example, social circumstances and family configuration, and the significant relationships that defines him/her within this, such as being a father and / or son. Substance use, when viewed as part of a systemic problem in addition to causing individual burden, highlights the crucial role that others can play in assisting the user in their battle to manage substance misuse. For example; Local community and families play a central role in supporting, or undermining, the management and treatment of substance misuse problems in prisons. They can be highly influential in facilitating treatment entry, or a more open attitude from the substance user towards the possibility of accessing help. Conversely, they can also undermine (either wilfully or naively) the attempts of both prisons and prisoners to address substance related problems Work with families can create the conditions that enhance motivation and engagement for the user with a potential consequent reduction in drug supply and re-offending Interventions involving family members and substance users together can help to improve outcomes Work with family members can be aimed at creating the conditions that support the user’s efforts to change addictive behaviour or support a change that is already in place. This has a major potential value in both pre- and post-release resettlement Families face high degrees of stigma, fear and isolation. The health and welfare of family members is not yet given sufficient priority. Relatively brief interventions focused on family member needs can lead to reductions in physical and psychological stress for family members and have the potential to improve general health, welfare and social functioning Many imprisoned users want to fulfil an effective family/parenting role and are concerned to protect their families from further harm A multi disciplinary/perspective approach is essential. A ‘one size fits all’ approach to family engagement and involvement will not meet the diverse needs/motivations of individual families and/or family members Development potential within existing prison and community-sector services is currently under utilised and/or under resources Families need accessible support provision within their home area, not just at the prison The prison context can also influence the individual in how he/she manages their substance use within prison through the provision of education, support and an environment that fosters individual growth and well-being. (Partners In Reduction: Engaging and Involving Families in the Reduction of Substance Related Problems in Prisons: 2005). Therefore, it is important that the needs of the user, their family and community are considered in tackling the issue of substance misuse and that all steps are taken to foster an environment within the prison that is conducive to help-seeking and self-development. Integrative Approaches The concept of integration in psychotherapy is not new, in 1975 Egan set out an eclectic framework for a ‘problem management approach’ to the counselling process, (Dryden 2007). Wachtel (1977) in Psychoanalysis and Behaviour Therapy; Towards an Integration retains the importance of psychoanalytic concepts and at the same time pays attention to behavioural principles not lest of which includes the importance of the present environmental context in which problematic behaviour takes place. This has implications for therapists in the context of delivering therapy to prisoners in the context of drug use in prison. There is an emphasis in this work on the influences of present and past relationships, the need for active interventions by the therapist and working with the client to identify goals. Four operational modes can be identified in integrative approaches Technical Eclecticism; selecting out from a range of approaches that seems to be useful for the case in hand Theoretical Integration; seeking to the points at which different therapeutic theories converge, with the intention of mixing them into a single theoretical orientation. Common Factors; identification of the factors that are effective across each of the therapies and combing them into a new approach that will have the best that all can offer. Assimilative and Accommodative Integration; here the therapist retains their mainstream orientation, (e.g. humanistic, cognitive behavioural, psychoanalytic), and at the same time practices integration. (Dryden 2007) The goal of integration is for the therapist and the client together to construct a therapy in which both will be able to engage progressively in a fully collaborative process. Although integration is much more established in the therapeutic world than it was twenty to thirty years ago, it should not be accepted without a careful critique. It is possible to argue that integrative therapists do not have sufficient depth in any approach to be of significant use to those who seek help. Therapy requires a coherence to work that may become lost if integration is undisciplined. Controversial approaches to treatment The harm reduction model in relation to opiate use includes some controversial approaches to treatment which are not currently part of the services provided in Ireland for addiction these are briefly outlined below. Drug consumption rooms Consumption room normally refers to supervised safe drug-taking facilities for the administration of drugs, which are provided by statutory, or state- recognised agencies. Supervision is provided by trained staff operating as part of a multidisciplinary team. They aim to reduce harm both for the drug user and the wider community. Safe injection facilities are part of the harm reduction approach in the Netherlands, Switzerland, Germany, Spain and Australia. The EMCDDA annual report (2002b) shows that Norway and Denmark considered and decided against the introduction of supervised consumption rooms. The goals of harm reduction is achieved by supervising injections in a controlled setting, ensuring safety and quick responses to overdoses, providing sterile injecting equipment and condoms, collecting used needles and syringes and providing counselling and primary health care. Safe injecting facilities use a humanitarian approach and function on a background of medical ethics (reducing mortality, reducing morbidity, alleviating the suffering, trying not to damage the patient by the measures taken (Haemmig 2003). Needle Exchange Programmes in Prisons Needle exchange programmes are part of the services provided by the HSE and others such as The Merchants Quay project to IDU’s in the community. These services are not available in Irish Prisons. Under a controversial new scheme to tackle the spread of HIV and hepatitis C in British jails prisoners will be given personal drug-taking kits. Inmates at Craiginches Prison in Aberdeen, where drug-taking among prisoners was particularly high, will be the first to receive the kits. They include syringes, swabs, filters and a sharps disposal box. The Scottish Prison Service (SPS 2006) has confirmed that the pilot programme was planned for early next year, after a Glasgow Caledonian University report. It concludes that prisoners regarded the drug problem in Scotland’s jails as unstoppable. The study stated that some supposedly drug-free wings were awash with illegal drugs and depicted a world of heroin, cannabis, crack and non-prescribed medications all circulated freely. Interviewees reported that obtaining drugs was relatively straightforward. Drugs entered prisons by social visits, in the mail, through new prisoners, via contact with friends on the outside after court appearances, or in bundles thrown over the perimeter wall. They were then exchanged in prison churches, gyms, workshops, education classes, during visits and in queues. The SPS have stated that if the behaviour of prisoners taking drugs could not be changed, the service had a responsibility both to inmates and to prison staff to ensure their safety. The SPS added that the kits would reflect needle exchange programmes that existed in the community and would be modelled on similar schemes in the Republic of Ireland, Switzerland, German and Spain. (Irish Penal Reform Trust: 2006) Naloxone provision Every year 2% of people who inject heroin die, which is 6-20 times the rate expected in peer controls of those who do not use drugs (Sporer 2003 p443). Most of these deaths occur in the company of other people and medical help is not sought until it is too late. Some jurisdictions have introduced naloxone, a specific opiate antagonist, prescription as a harm reduction measure. Naloxone has been sold over the counter in Italy for more than 10 years and has been distributed through needle exchange programmes since 1995 (Simini, 1998 p967). Heroin provision Pharmaceutical heroin (diamorphine) provision has been considered and tested as a treatment approach to injecting drug users. It attracts people who might not be inclined otherwise into treatment, reducing illicit drug use, undercutting the black market and protecting the physical health and social functioning of the injecting drug users. In 1992 in Switzerland, an evaluation of heroin, methadone and morphine prescribing was conducted. During the study illicit heroin and cocaine use rapidly and significantly decreased, benzodiazepine use decreased slowly and alcohol and cannabis consumption hardly reduced. Income from illegal activities decreased dramatically. By the end of the project, 8% of drug users decided to give up heroin and sought abstinence therapy. Uchtenhagen et al. (1999 p30) concluded that heroin-assisted treatment can be carried out safely and that significant health and lifestyle improvements can be obtained and maintained post treatment. Is treatment really necessary? Some research indicates that people who drop out of treatment prematurely tend to have essentially the same clinical outcome as untreated individuals with chemical dependency (Stark 1992 p101). Earlier researchers such as Winick (1962 p4) argues that most drug users eventually recover from their addiction, some with the help of treatment programmes, some recovering naturally. This is part of the maturing-out theory based on the belief that for the majority of addicts’ addiction is a self limiting process. Up to two thirds of addicts mature out of their addiction by the time they reach their mid thirties. After time the drug looses its ability to confer pleasure and increasingly, maintaining the habit comes to be seen by the addict as being problematic and burdensome. The advent of an increase in the sharing of drug taking paraphernalia and the emergence of new blood borne infections such as HIV has life threatening implications even for those who mature out of substance abuse. Waldorf (1993 p240) supports Winick’s (1962) position and suggests five possible routes out of addiction. Drift Retirement Religious or political conversion Situational change Swapping addiction for mental illness. Regardless of the fundamental belief in relation to maturing out or recovering via one of Waldorf’s (1993) routes out of addiction as opposed to a harm reduction or abstinence based model there is relatively broad agreement that motivation plays a significant role in helping substance abusers change their behaviour. Contrary to the maturing out theory a recent report drug treatment programmes commissioned by the NACD (NACD 2006) provides a clear indication of the success of drug treatment programmes in the community. The research published in September 2006 involved more than 400 opiate users over the course of a year. The participants in the study had poor levels of education and relied on social welfare as their main source of income. Almost one-third had left school before 15, while just one-fifth had been employed in the three months prior to treatment. The findings at one year follow up include: A halving of the proportion of people involved in crime to fund their drug habit, from 31% to 14% An increase in the proportion of users abstinent from all drugs – excluding alcohol – from 7% at the start of treatment to 27% after a year Improvements in the physical and mental health of users; and increased contact among users with GPs, employment and housing services, and a decrease in contact with A/E units, social and welfare services This report sends out a strong message that investment in services leads to benefits to the individual drug user, to their family and to the rest of the community. Methadone Treatment Programmes Treatment options for active drug users include methadone maintenance (heroin substitute) and detoxification/drug free treatment. Currently there are fewer than 150 residential drug treatment beds in Dublin and approximately 5,000 drug users engaged in methadone treatment. The remaining 8,000 are receiving no treatment. (Merchants Quay Ireland, 2007). The Drug Treatment Centre Board (DTCB), Trinity Court, is the longest established addiction treatment service in Ireland. The vast majority of clients have a primary diagnosis of opiate dependence. Treatment is provided by a multidisciplinary team led by a consultant psychiatrist. Results from a recent study of methadone maintenance treatment (MMT) outcomes in DTCB show that many clients on MMT were involved in ongoing illicit opiate misuse with only one third of people were opiate free throughout, with one in five demonstrating occasional opiate misuse while on MMT. The study sought to measure the rates of ongoing heroin abuse among clients on MMT and sought to identify patient and treatment characteristics associated with poorer outcome, (Kamal et al. 2007). Overall, 72% of urine samples provided by clients were opiate negative. The results also indicate that higher dose of methadone is associated with better outcome in terms of opiate. Clients treated with inadequate doses of methadone commonly supplement their dose with illicit opiates, (Kamal, 2007). The findings report that younger clients tended to demonstrate poorer outcome. A number of explanations for poor outcomes are offered; Peer Pressure More chaotic life styles and Lack of education and awareness in this group, (Kamal, 2007). Although the study points to varying degrees of success in terms of outcome for those on MMT it failed to demonstrate any beneficial effects of counselling. The authors suggest that this finding reflects the manner in which clients access counselling rather than counselling itself, “Both our clinical experience and previous evidence suggest that the role of the counsellor is very important in treatment for substance misuse.” (Kamal, 2007). An interesting finding from this study was that clients with dual diagnosis tended to do well in terms of opiate abstinence. The report suggest a reason for this may be that these particular clients were receiving more intensive treatment from the adult mental health teams and consequently fared as well as the other patients attending this specialist service. Methadone can be prescribed under a strict protocol as a maintenance, (potentially lifelong programme), for opiate users. Dosage Threshold Potential recipients Rationale Low Regular low dosage for pre contemplative to contemplative stage – administered under supervision with harm reduction input aimed at engaging the user in regular treatment Some tolerance of continued use Medium Regular prescription administered under prescription with harm reduction interventions aimed at enabling the user to stabilise and regularise their day to day life and improve their general health status Some tolerance of occasional slips High Regular dosage for committed abstainers from illicit substances – administered under supervision – social and psychological supports available on individualised bases. This may include self administration. No tolerance of continued use Tackling drug use in Prisons The mission statement from the IPS in relation to the care provided to prisoners with a history of drug abuse states; ‘the mission of the IPS is to provide safe, secure and humane custody for people who are sent to prison. The Service is committed to ‘managing custodial sentences in a way which encourages and supports prisoners in their endeavour to live law abiding and purposeful lives as valued members of society,’ (IPS 2006). In ‘Keeping Drugs out of Prison’, the IPS outlines its key statements of principle with regards to the issue of drugs in Irish Prisons (2006), The presence of drugs in prison will not be tolerated Prisoners will be encouraged and supported to develop a responsible attitude to drugs, both while in prison and following release, through a range of measures including education and counselling. Prisoners who are addicted to drugs or have other problems caused by the misuse of drugs will be offered every reasonable care and assistance. (IPS, 2006) The IPS (2006) report is of some importance in that it reflects a particular position in relation to prisoners who use illicit substances. It is important to note that the central aim in this report is the elimination of illicit substances from the prison environment and not the provision of treatment. This is a reflection of both the function of a prison, providing an enclosed secure detention centre and the competing need to provide equivalents of health care that individuals may enjoy in the community. The policy claims that ending demand for drugs in prison ‘should lead to a reduced demand on their release’ (IPS,:2006). Identifying and engaging drug misusers, providing treatment options, ensuring through-care and meeting healthcare needs are the main aims. The policy sets out a structure and target dates for the implementation of the objectives and goals of the strategy. The policy document will be delivered in each institution by a prison based drug team. An example of this is the IPS policy of providing treatment options to prisoners who use drugs which is as follows: The IPS will provide a range of evidence informed treatment options as part of a planned progression for each prisoner who has been identified as a drug user These support and treatment initiatives should adequately address both physical and psychological dependence/ social factors associated with drug abuse and be cognisant of the distinct needs of short term and longer term prisoners The IPS recognises the need to target high intensity interventions to those presenting with the greatest risk or need in relation to their drug abuse and offending behaviour. As part of their treatment services the IPS offer a methadone treatment program for prisoners. Under these guidelines, if a prisoner has been on a methadone programme in the community immediately prior to entering prison, then, if clinically appropriate, this treatment should be continued. Those prisoners who begin opiate use in prison will not be maintained on methadone but will be given the option of detoxification. Even where effective programmes of detoxification and rehabilitation are available, and security measure are tight, some level of drug use within prisons is inevitable. Some prisons have found that encouraging prisoners to voluntary sign up a promise not to use drugs, and rewarding compliance with better privileges and conditions, results in a very low level of drug use as the prisoners create an anti-drug culture and effectively police themselves. Development of treatment programmes in prison means targeting resources at those drug users whose behaviour causes most problems. The literature reviewed and the models of understanding addiction outlined above indicate that arrest, a court appearance, imprisonment and release from prison; could all be considered as potential opportunities for the individual to contemplate, reflect on and make changes to their drug using behaviours. Treatment providers of addiction services in the community generally expect a large number of clients to leave the service early, due to the ambivalent relationship the substance user has with an addictive substance. Having a range of treatments available in prison may address this ambivalence for some individuals as the opportunities to opt out of treatment and reengage in drug use are reduced and incentives to comply with treatment can be clearly identified. Enabling long term change Some jurisdictions such as Rhode Island in the USA are among the states beginning to make progress in easing offenders’ re-entry to society with the goal of bringing the revolving door to a halt, or at least slowing it. The 1980’s and 90’s were an era of get-tough, no frills punishment; inmate populations climbed to record levels while education and training withered. Prisoners with little chance of getting a job and histories of substance abuse were sent home without help. The literature reviewed reflects similar trends in the Irish Prison Services. However a counter-trend is gathering force, part of an unfolding transformation in the way the criminal justice system deals with repeat offenders. Inmates now meet with planners before their release to explored housing, drug treatment and job possibilities. Once the inmates are released, churches and community groups have been enlisted to provide them with individualised support packages and enable them to make successful transition from prison to community life, (Family Life Centre, South Providence, 2003). In conclusion substance abuse is a significant problem for the Irish prison population (Allwright et al 1999, Dillon 2001, O Driscoll 2004, Long 2004). Both nationally and internationally there is recognition that this group require care, which should be equivalent to what is available in the community. (WHO 1999, IPS 2001, Stover 2002, Lines 2004). Both prisoners and researchers have identified the need for and benefits of prison based counselling services; however the type of services provided is a factor both in uptake and outcomes, (Long et al 2004). Harm reduction aims at decreasing harm through information, education, provision of equipment and support, drug substitution treatment and counselling. Both the abstinence and harm reduction paradigms have been examined. National policy of the management of drug use in prisons recommend an abstinence approach, however, the more pragmatic harm reduction approach is favoured in the international literature. While drug free prisons and an abstinence model may be a valid aspiration it is appropriate to put in place harm reduction measures that aim towards reducing the harms associated with continued use and motivating the drug user to make changes. Harm reduction programmes offer services on a continuum commencing with engagement of the drug user with services, moving towards psycho education, provision of clean drug taking paraphernalia in the form of exchanges and introduction to the user of counselling and detoxification services. Counselling and psychotherapy services have been explored under the headings of Psychoanalysis, CBT, Humanistic, Systemic and Integrative models. All of which have been shown to have a positive effect with drug users provided the model of therapy offered is compatible with the needs of the individual. Attention has been given to programmes that tackle drug use in prisons as well as new and innovative approaches such as naloxone provision and safe injecting facilities. International literature and experience suggests that a pragmatic harm reduction approach which includes the provision of incentives to change has been successful in some jurisdictions. In the next chapter the challenges of provision of health care in prisons is given a more detailed exploration. Chapter 4 Health care in prison In this chapter there is an exploration of the challenges in providing health care in prisons. In particular the treatment options for drug users in Irish Prisons are explored. Prison detoxification programmes are examined and information on international practice in the provision of services in prisons for drug users is described. In the prison service, ideally there should be a health care service of the same quality and availability of services that is present in the community, which ensures equivalence of care between the prison population and the general population, (O’ Driscoll 2005). The overall objective of the prison health care services is the creation of a healthy environment in each prison. The IPS statement of its core values declares that it is committed to making available to each person in custody the conditions and services that is appropriate to their well-being and personal development (www.oasis.gov.ie). Prisoners often have health care problems that have not been dealt with prior to imprisonment, and life in prison may in fact cause certain health problems or aggravate conditions that are already present. Stoever (2002) writes that prisoners often belong to poor deprived and marginalized population groups who are particularly vulnerable to HIV and Tuberculosis infection fostering the spread of communicable diseases in prison. In a European study on health problems arising in prison health, three distinct health issues were identified; Substance abuse, Mental health Communicable diseases. (Tomasevski 1992). Challenges in Providing Health Care in Prisons Imprisonment can be damaging to individuals and so should be used sparingly, and ‘every effort must be made to minimise the pains of confinement and prepare prisoners for release, (Irish Prison Reform Trust, 2000). A prison sentence ought to mean deprivation of liberty only, and prisoners should not leave prison with their health care needs compromised beyond what is was when they were incarcerated. Prison is designed with punishment, correction and rehabilitation to the community in mind, and these goals may conflict with the aims of health care (Watson et al, 2004). However Prisons are not, primarily, concerned with the health of the prison population and, indeed, the need for security and discipline can cut across the perception of individuals as patients (Her Majesty’s Inspector of Prisons, 1996). There is also a difficulty in providing health care in prison in terms of different government departments being involved. According to Warding (1997), prison medicine has a strange identity; stranded in a no-man’s land between two major social systems. Currently the Department of Justice, Equality and Law reform is responsible for running the prisons in conjunction with the IPS. The group charged with reviewing the prison services in 2002 recommended that a partnership between the Department of Equality, Justice and Law reform, the IPS and the statutory health boards is essential in order to ensure equivalence of health care between prisons and the general community, (O Driscoll 2005). Prison health care is a public health issue. Health problems in prison largely reflect, but magnify, the problems present in the communities, which the prison serves (Watson et al, 2003). Prisoners are part of the community and will return there, so it is in the best interest of the whole community that prison health is of an equivalent standard. The high degree of mobility between prisons and community means that communicable diseases and related illnesses transmitted or exacerbated in prison do not remain there, so everyone in the prison environment, including staff, prisoners and their family members benefits from enhancing the health of prisoners’ (Lines 2004). Drug Treatment Options in Irish Prisons The co-ordination of drug treatment services in Irish Prisons is relatively recent and has taken place as a response to identification of the needs of prisoners. Initial reaction to the growing awareness of a persistent problem with drug using prisoners commenced with detoxification and counselling services in 1996. In 1999, a draft action plan was agreed between the Department of Justice, Equality and Law Reform and the Eastern Health Board to deal with substance abuse and drug treatment in the prison system (Report of the Group to review the Structure and Organisation of Prison Health Care Services, 2001). This plan included the development of drug free areas, introducing disinfectant tablets as a harm reduction measure, and methadone treatment for those who were already receiving methadone in the community, (O Driscoll 2005). Since 1996, some progress has been made on these planned reforms. For example in Moutjoy Prison a drug free wing has been established, which accommodates adult male prisoners. There is a drug free wing in St Patrick’s Institution and drug free houses in the Dochas Centre. The Training Unit is a drug free prison. Wheatfield Prison also has established drug free units. All prisoners, regardless of whether they have a drug using history or not, contract to undergo random urinalysis in order to maintain the drug free environment. Respondents in Dillon’s (2001) exploratory study, conducted in Mountjoy Prison, of drug use among prisoners viewed the unit, positively, and also perceived it to have particular benefits in fostering motivations to cease drug use, for those with a history of illicit drug use. For those who were not involved in drug use, a drug free wing was seen as removing them from the environment they perceived to be dominated by a drugs culture. Since 2000, methadone maintenance is available in Mountjoy Prison, and other prisons, to those prisoners who were already on a methadone programme prior to incarceration. . Prior to this, prisoners on methadone programmes in the community were forced to detoxify when incarcerated, as no maintenance was available, except to those prisoners who were HIV positive. Methadone maintenance has been recognized internationally as an important harm reduction option, especially in the prevention of harm associated with injecting drug use, and is the treatment of choice in Ireland for those drug users with an opiate addiction, (O Driscoll 2005). However, there are still limitations in the provision of methadone treatment in the prison as in the community, as previously stated substitution treatment is available to all those entering prison that are on established treatment programmes. Methadone maintenance can be initiated in prison if clinically indicated and a community place can be secured. The prioritisation criteria used in the community also apply in the prison setting. The limiting factors in service provision are two fold; Availability of community places Human resource allocation at prison level. Not withstanding these factors the IPS have treated with methadone 1576 individuals in the year 2006 , 162 of whom were first time contacts with drug treatment services, (CTL data 2006). The Prison Officers Association (2000) stated, in a deposition to the National Drugs Strategy, that it is imperative that the national methadone policy be reviewed immediately, so that methadone be made available to all Prisoners regardless of what geographic location or what Health Board area they are incarcerated in. They advocate that all drug users who are committed to prison should be assessed for suitability for MMT, and the availability of such programmes should not be prejudiced by whether or not a drug user was in receipt of a drug treatment programme before his committal to prison. Long (2004) in a qualitative study on prisoners views of injecting drug use and harm reduction in Irish prisons reports that prisoners appreciate information sessions on drugs, and individual counselling for self-selected prisoners was useful. In this study conducted with 31 prisoners in Mountjoy Prison Long (2004) found that the majority of respondents said they would value individual counselling. The most recent Inspector of Prisons report (IPS, 2006) has strongly criticised the conditions in the female section of Limerick Prison. Justice Kinlen criticised the conditions in the female section of the prison, where 20 prisoners are held in 10 cells designed for single occupancy, describing them as “extremely small and cramped”. The report highlights a serious problem with drugs in Limerick prison, which has led to gangland feuding, and the annualised hours introduced for prison officers has led to cutbacks in facilities for prisoners, (IPS, 2006). At present, there is a drug services plan proposed for five of the six Dublin prisons and an intention to approve a plan for the remaining prison. These services include prevention, detoxification, methadone maintenance, counselling and education. The plan has made budgetary provision and is time bound with an initial rollout planned for 2007. The initial phase of the implementation of the counselling service has begun with the employment of three Addiction Counsellors in Mountjoy, with others to follow nation wide. Long (Long et, al 2004) examining prisoners’ views of drug injecting practices and harm reduction interventions in Dublin Prisons and found that both non-injectors and IDU’s interviewed supported harm reduction interventions in prison and felt that the range of drug services available in prison should mirror those currently available in the community. Half of those interviewed opposed or had reservations about syringe exchange in prison. Two themes to emerge from the literature are; IDU’s take risks during detention that they would not take outside prison, Prisoners want and will support programmes to address drug misuse. The findings from this research are similar to the findings from other studies in the area (Dillon, 2001, Dolan et al; 1996; Gore et al; and Turnbull et al. 1994). The report suggests that prisoners could be an important resource when planning health services and that their needs are realistic and humane (Long et, al 2004). The study also describes the shift in prison from smoking to injecting heroin, this in turn increases the risk of contracting HIV, hepatitis B and, in particular, hepatitis C in prison. The study acknowledges that community drug treatment services in Ireland have evolved significantly however the Irish prison health care system has not kept pace with this change. The report concludes with a call to pilot harm minimisation interventions in Irish prisons, to examine their strengths and weaknesses in the Irish setting and to measure their effects, (Long et al., 2004 p15). Summary of Introduction of Interventions in Irish Prisons 1996-2007 1996 Introduction of a limited level of detoxification and counselling 1999 Agreement of draft action plan to deal with Prison based substance abuse 2000 Introduction of limited Methadone Maintenance and drug free units 2002 Review of the Prison Service for Drug Users recommends a partnership between the Department of Equality Justice and Law Reform, The IPS and the Health Service 2006 Justice Kinlen criticised conditions for Female prisoners in Limerick and described the drug problem in the prison as serious 2007 Initial roll out of Drug Services Plan for prisons, 3 addiction counsellors commenced in Mountjoy prison Drug Treatment Options in Prisons outside Ireland While a limited number of countries have made progress by implementing educational programmes, methadone maintenance therapy, bleach distribution and needle exchange, in most areas of the world, a substantially greater effort is needed to ensure that prisoners receive the same level of care offered in community settings, (Kerr et al., 2004). Using a rights-based analysis, this article argues that governments have an obligation to honour the ‘principle of equivalence’, which states that prisoners are entitled to the same level of healthcare that is provided in the community (Kerr et al., 2004, p355). Access to harm-reduction programmes that target the reduction of HIV and other infectious diseases associated with drug use address the right to health of the individual and are appropriate interventions given the evidence of their effectiveness at preventing severe harm associated with drug dependency and IDU in particular. Prison systems and governments have argued that preventive measures such as those mentioned above cannot be introduced in prisons for safety reasons, and that making them available would be tantamount to condoning drug use in prisons, (Keer 2004). However, the article suggests that any measure taken to prevent the spread of HIV will benefit prisoners, staff and the public. The high proportion of prisoners who experience problem drug use suggests that prisons should, in principle, provide an ideal opportunity for treatment. However, delivering drug treatment in a prison setting is not without its challenges. A recent study of a large Scottish prison identified three key factors that influence prison based harm reduction and drug treatment programmes; The prison regime and culture, The attitudes of staff towards drug use and drug users, The relationship between officers and prisoners, (McIntosh 2006). While the prison provided a drug-free hall for up to 50 prisoners and offered them the opportunity to be drug free, treatment for drug use was a secondary function of prison and has to defer at all times to the primary function of maintaining a secure environment, (McIntosh, 2006, p235). As a consequence of this, prisoners were restricted to the amount of time available to participate in drug treatment. Boredom was identified as a major feature of the prison experience and aggression and violence amongst prisoners was reported as a common aspect of prison life. The research suggests that these aspects of prison life may have direct or indirect influences upon the prospect of successful treatment for drug use. Likewise, the ready availability of drugs in the prison was seen to significantly impede the efforts of those prisoners who were motivated to stop using drugs, (McIntosh, 2006 p236). The study also identified the importance of attitudes held by prison staff towards drug use. Prison officers are not primarily drug workers and even those who are involved in drug treatment have other competing priorities and responsibilities. (McIntosh, 2006, p236). The opportunity that prison provides for intervening with problem drug users is potentially as valuable to the individuals and to society as a whole that it would be remiss not to attempt to exploit it as far as possible, (McIntosh, 2006, p236). The main objective, therefore, must be to increase prisoners’ access to the range of treatments that are likely to be most beneficial to them, (McIntosh, 2006, p245). The study concludes by suggesting that targeting services according to prisoners’ readiness to give up drugs might be the most appropriate way of allocating scarce resources. Alongside this, there is a case for attempting to encourage in prisoners the motivation to give up drugs through a combination of one-to-one interventions and group work, perhaps using ‘motivated’ prisoners as advocates and exemplars, (McIntosh:2006). The British Prison Service has developed a treatment service framework to meet the needs of prisoners with drug problems. This framework commences with a review of the individual prisoner to identify the degree of their drug use in order to tailor interventions and target specific needs. Prisoners’ drug use and treatment options are reviewed (Ramsay, 2003) utilising information from the Prisoners Criminality Survey. The main components of the new service are detoxification, counselling, assessment, referral, advice and through care in parallel with intensive treatment programmes, (CARAT's), (Ramsay 2003). Clinical detoxification programmes are available to facilitate the withdrawal from opiate, alcohol and benzodiazepine use, (Ramsay 2003). Within the study group almost one quarter (23%) had entered a detoxification programme, with 97% completing the treatment. However, only half (49%) of those using opiates, alcohol or tranquillisers on a daily or near-daily basis prior to prison were detoxified. Most (81%) respondents completing a detoxification programmes felt that it could be improved. Criticisms of programmes by prisoners in relation to the services offered included; Programme Duration (it needs to last longer), Substitution Medication (wrong type or amount), Therapeutic Interventions (the need for more complementary therapeutic measures such as counselling and group work). Almost one third (31%) of all respondents had received a CARAT assessment (Ramsay 2003). CARAT teams treat prisoners with low-level drug problems using; one-to-one counselling, group work or relapse prevention. Prisoners with moderate to severe problems are eligible for intensive treatment programmes, either therapeutic communities or services that employ the 12-step or cognitive-behavioural approached (pg.36). CARAT Interventions following assessment of Drug Use Low –Level Drug Problems Moderate to Severe Drug Problems Individual Counselling Group Work Relapse Prevention Placement in Therapeutic Community 12 Step Programmes CBT Approaches One-to-one counselling was the most common form of intervention received by the sample. Eighty-seven respondents received this and nearly two thirds (64%) of those who had completed it found it beneficial (38% of those completing treatment thought it could have been improved). The aim of this study was to assess how imprisonment impacts on drug use. Respondents’ drug use and IDU in particular, is considerably lower in prison than in the community, partly reflecting lower levels of availability in custody. There is an apparent tendency towards that use of depressants rather than stimulants in custody. Only a minority of short-sentence respondents stated that mandatory drug testing (MDT) deterred them from using drugs in custody. Only a minority of respondents with treatment needs had received either a CARATs assessment or detoxification, at the time of the study (2000-01), when these services were in their early stages of development. Post-release reoffending is significantly related to post-release drug use (Ramsay, 2003). Growing prison populations in the U.S. are largely due to drug-related crime and drug abuse. Yet, relatively few prisoners receive treatment, existing interventions tend to be short-term or non-clinical, and better methods are needed to match drug-involved inmates to level of care (Belenko & Peugh 2005). Using data from the 1997 Survey of Inmates in State Correctional Facilities, Belenko & Peugh (2005) conducted research into the drug treatment needs among state prison inmates, the study found high levels of drug involvement, but considerable variation in severity/recovery of use and health and social consequences. The findings of this study suggest that inmates need a range of treatment modalities, and that the existing delivery of correctional treatment, especially residential, is highly inadequate relative to need. Overall, only 24% of inmates reported receiving any type of drug treatment since admission (including non-clinical interventions such as self-help groups of drug education programs). Relatively few inmates with drug abuse problems receive clinical interventions while in prison. The study argues that available treatments are not matched with the individual needs of the prisoner. The inmate population is heterogeneous: inmates have different intensities of drug involvement, and different constellations of other problems that may require service intervention (Belenko & Peugh, 2005 p14). Howells, et al (2004) reviews the national picture in Australia in relation to prison rehabilitation programs. Currently in Australia all jurisdictions deliver drug and alcohol programmes. The lack of intensive programmes (over 50 Hours) is surprising given the high percent of substance users, predominately poly-substance users, in the criminal justice system (Howells et, al 2004). Most of the drug and alcohol programmes currently offered could be described as psycho-educational, with some employing cognitive behavioural techniques. These programmes most commonly seek to educate offenders about substance use, to explore the costs and benefits of substance use, to introduce harm minimisation strategies to reduce substance intake. What is often not present in these programmes is an explicit focus on the relationship between substance use and criminal behaviour. Specific staff training packages to deliver drug and alcohol programs varied between jurisdictions. The authors conclude that it is surprising that processes for through-care and follow-up were not more systematically integrated into offender management systems (Howells 2004). This chapter explored the challenges in providing health care in prisons to prisoners who use illicit drugs. The evidence suggests that much work has been done on the development of treatment options for drug users in Mountjoy prison whereas treatment options in other Irish Prisons are less developed. The development of treatment options in Mountjoy reflects the extent of drug use in the eastern region during the 1980’s to present. However there has been significant changes in patterns of drug use in Ireland and the availability of psychoactive substances throughout the country, services have not kept pace with this. Limerick Prison in particular has been criticized for its lack of services for female prisoners. The literature reviewed indicated that prisoners should be able to enjoy equivalents of health care with those in the community however this is currently not the case. International literature highlights that prison regimes, culture, staff attitudes and their relationship with prisoners have an impact on the provision and uptake of drug treatment services. Some research indicates that treatment models such as CARATs have been successful in providing prisoners with the opportunity to change. Prisoner involvement in planning services is recommended by some researchers. Research from the USA recommends that a range of treatment modalities are required to address the subjectivity of individuals needs. European studies report success from the provision of drug free wings and the use of peer support and self-help groups. The Australian approach has revolved around psycho-education on the harmful effects of substance abuse and CBT approaches. The next chapter will explore the findings from the data collected during the study of Limerick prison’s need for counselling services for drug using prisoners. Chapter 5 Presentation of Findings ________________________________________ This chapter presents the main finding from the study. Information from 15 focus groups is presented. Appropriate, verbatim quotes from research participants are included to support the findings of this study. The findings are presented under the following headings which relate to the themes that emerged. Under some themes, to aid the reader, material is presented under additional headings or sub categories of a theme: Drug use in Limerick Prison Attitudes and beliefs Service provision Dual diagnosis Counselling approaches in Limerick Prison Self-Report Form As outlined in the introduction to the study a self-report from was circulated to key medical, probation and other key prison staff. The form was also circulated to a number of drug service providers and other voluntary groups in Limerick City. In all 30 self-report forms were distributed. The purpose of the self report form was to capture information from key respondents who were unable or chose not to attend focus groups. However, there was a very poor response rate, with only 4 forms returned to the research team. Due to the low response rate it was not possible impossible to illicit any substantial information or draw conclusions from the self report form and present the data as a separate section in this chapter. The information that was received has been used to supplement the data presented from the focus groups. Focus Groups A total of 15 focus groups with, prisoners, their families, prison officers, health, education, social and welfare staff drawn from the statutory and voluntary services were conducted. Focus groups are an ideal method for gaining access to participants’ own meanings (Wilkinson 1998a). They have the capacity to exhibit a synergy that individuals alone cannot achieve. The intent is not to generalize findings but to gain a more complete understanding of a particular topic (Krueger, 1997). A particular use of focus groups has been on improving practice and quality care through consumer input (e.g. Ivanoff et al., 1996; Makrides et al., 1997), making focus groups an ideal method of data collection that meets the aims of the study. Sufficient focus groups were conducted to achieve saturation, an exhaustive process of data collection that continues to add information until no more can be found (Creswell 1998). Ethics Ethical permission to conduct the study was sought from The IPS’s Ethical Committee. Once permission had been granted the researchers were able to access both staff and prisoners in Limerick. All participants were given written and verbal information about the study. Consent forms were used to ensure that participants’ right to remain anonymous was protected. Data was audio recorded during focus groups and later transcribed by a member of the research team. No participants’ names were transcribed. Generic terms have been used to ensure that individuals remain unidentifiable in the presentation of findings. Procedure The relevant organisations, the Prison Management team, the Probation and Welfare Service, Prison Health Care Staff, Education Staff, Community Health Care Personnel and the Voluntary Sector, were contacted and permission sought to purposively select volunteers to invite to focus group sessions held at a local venue. Prison Management were contacted to seek permission to avail of venues within the prison, to conduct focus groups with prisoners. Posters and leaflets outlining the project and seeking volunteers were sent to Limerick Prison for distribution. There was some time delay between receiving and distributing this material on the part of the prison. Initially, prisoners were reluctant to participate in the focus groups, this was partly due to lack of knowledge about the research project and also to reported prisoner apathy. Contact was made with the Prison Liaison Officer who played a key role in seeking volunteers among the prison population and in granting prison access to the research team. Initial uptake was slow from prisoners but following the first and second focus groups participation improved greatly, this was partially due to prisoners passing on information about the project to other prisoners. There was some difficulty in gaining suitable venues in which to conduct the focus group interviews in the prison. Prison staff were as helpful as they could be in this regard, however, securing appropriate venues proved to be a difficult issue throughout the research process. Timing was another issue for the research team, as on some occasion’s communication of dates and times of focus groups were not effectively transmitted from service managers to service providers. The Bedford Row Family Project research subcommittee were central in informing the project team about key personnel in both the statutory and voluntary sector who needed to be contacted for this section of the study. Posters and leaflets outlining the project and seeking volunteers to participate in the focus groups were distributed to The Bedford Row Family Project. The Bedford Row Family Project were also central in informing family members about the research project and seeking volunteers to participate in the family members focus groups. The focus groups with family members were conducted in The Bedford Row Family Project who played a key role in supporting the interview process. Potential participants were contacted by leaflets and posters outlining the study and requesting participation. Those who took part were asked to sign and return an informed consent document indicating their agreement to participate and for the session to be digital audio recorded. Each focus group was audio taped. In each focus group, there was an experienced moderator/facilitator familiar with and sensitive to the issues arising from the focus of the study and a note-taker. This two-person approach helped with the sensitive handling of the group dynamics and individual issues that arose. Participants were assured of confidentiality at all times. Some participants were given verbal explanations and agreed to participate, however, they did not return the consent form to the researcher. Issues around literacy may be an explanation for this. Interview Guide In order to elicit information on the participants’ experiences, predetermined, open-ended questions were arranged into an interview guide. Potential questions were derived from the literature review and in consultation with the project team and the research review sub-committee of the Bedford Row Family Project. A copy of the interview guide is presented as Appendix A. The interview guide was piloted in the first focus group. The pilot guide was found to be appropriate and no changes were made. Data analysis The recordings of the focus group discussions were transcribed verbatim. As the transcript does not reflect non-verbal communication, it was supplemented with some additional observational data obtained during the session. All information divulged during the focus group was treated confidentially. In transcribing the data from the focus groups, participant’s names were omitted and substituted by an identity number or by their job title or relationship in order that individual identities would not be linked to the information they provide. In order to ensure this in the final report identifying information such as job title for minority groups of staff have been removed and replaced with a generic title as outlined below; Participant’s Identification Generic Title Health Care Staff (HCS) including nurses, doctors, psychiatrists, medical orderlies, counsellors, psychotherapists and psychologists HCS Prison Officer (PO) has been used to report comments from Prison Officers regardless of rank or gender. PO The term Social / Educational Staff Provider (SESP) is utilised for Probation Officers, Welfare and Education Staff. SESP Senior Prison Staff such as Chief Officers, Class Officers and Assistant Governors have been identified as Senior Prison Staff (SPS). SPS Family Members (FM) have been identified as a family member regardless of their relationship to the prisoner or gender. FM Prisoners have been identified as Male Prisoner (MP) and Female Prisoner (FP). MP or FP The goal of the analysis was to identify themes as described by the participants and to describe the range of issues and experiences within each theme. These themes are identified both through the analysis of individuals narratives and through the analysis of the dynamic construction of social meaning that occurs in focus group interactions (Wilkinson, 1998a, 1998b). Data was analysed line by line by three members of the research team. Each team member made individual notes and identified themes. Following individual analysis and to ensure consistency each analyst notes were counter checked for recurrent themes and coding categories. The final stage of the project was to combine the information from the Literature Review, Self Report Form and the Focus Groups into a Report format, which recommends a model of Counselling Service provision most likely to progress the health and well being of the affected population in Limerick Prison. The findings will be presented under the following sections: The extent of addiction treatment needs within the Limerick Prison Population The extent of the affected population likely to respond to, and participate in, treatments/assistances made available The form of counselling service that might support and integrate well with existing health related assistance to the affected population such s methadone maintenance and detoxification. 1. The extent of addiction treatment needs within the Limerick Prison Population 1.1 Extent of Drug Use No officially recorded figures are available on the extent of illicit drug use in Limerick prison. In Ireland drug use is generally estimated at 5.6 per thousand of the population, (Moore et al 2004). All focus groups provided estimates on the extent of drug use. Remarkable the estimates were extremely consistent across groups and were higher than the estimated and recorded figures of illicit drug use available in prisons in national and international literature. A national census survey in 1999 reported that 52% of a national sample of prisoners reported a history of opiate use and 43% reported a history of injecting drug use (Allwright at al, 1999, EMCDDA 2001). Reports on the extent of drug use in Limerick varied from 100% in the women’s prison to 80% with 80% being the most frequently quoted estimate for both the male and female prison. “The instance of drug abuse is definitely high in a prison setting; about eighty percent is the norm” (HCS). “There are more drugs in my opinion in the prison than there is on the streets at times” (HCS). “You’d want a barrow to take in all the stuff that’s in here; they’re supplying (visitors) all the lads that are locked up” (PO). “In the women’s unit it’s endemic, we’d be talking about ninety percent I’d imagine who are actively using” (HCS). 1.2 Frequency of drug use In most European prisons the spread of drug use is recognised as problematic. Some experts suggest that prisons provide environments that sustain problematic drug use among users and may even foster drug use in none users, (EMCDDA 2001). In this study reports on the frequency at which drugs were used were less consistent across groups and varied according to the particular drug being discussed. Reports from prisoners and staff suggest that 80% of the prison population have used drugs whilst in prison. Many of the staff interviewed believed that prisoners have easy access to illicit drugs. Male prisoners were more reticent about availability and joked with interviewers about access to supplies of drugs indicating that this information was not going to be disclosed lightly. Contradictory reports from some prisoners indicated that drugs are not easily available and one would need to ‘go looking’ for drugs. “No, there’s no one putting flags outside with the gear, you have to go looking for it, it’s no problem staying away from it” (MP). “I’m always looking for it and it’s not that easy to find down here, and its dirt, always really bad down here, the quality is shit” (MP). “I smoke hash and that’s impossible to get, too hard to get” (MP). “Some people do get cocaine into the prison though but it’s not done in prison generally. It’s much more profitable for someone to bring heroin inside.” (MP) 1.3 Access to illicit drug supply Groups were consistent in reporting illicit drugs as being available in all prison wings. A recent study by the British Home Office (2003) found that on entering prison drug use decreased, the main reason for this is the lack of availability. In discussions about which drugs are available in the prison, heroin, cannabis and prescription drugs were most frequently mentioned. No group reported cocaine, ecstasy or alcohol use. Cannabis is the most widely taken substance used before and during custody. Heroin is also used was used by a substantial proportion of prisoners (British Home Office 2003). All groups reported that it was relatively easy to bring drugs into the prison and that sanction were a minor deterrent in preventing supplies entering the prison. Coercion was cited as a means for access to drugs. Prison staff pointed out that prisoners frequently switched drug carriers once a particular prisoner was under suspicion of drug trafficking. Little discussion took place on how drugs were smuggled into prison but the lack of consistent, thorough searches was cited as a reason for easy of access. Comments were made on the use of visits to outside health care, court and other facilities as a means of drug trafficking. Reducing or stopping the supply of drugs was seen by family members, service providers and prison officers as a significant first step in addressing drug use by Limerick prisoners. “Virtually everyone would smoke cannabis, to be realistic about it you’re probably talking eighty percent will use cannabis and then there is a proportion, a sizable enough proportion of prisoners who abuse prescription tablets” (SPS) “There’s a simple solution, stop stuff coming in at the gates, they said that there would be a dog here and we haven’t seen one yet, that was twenty five years ago” (P O). Participants noted that access to illicit drugs in prisons is not merely an issue for the prison population but also needs to be examined at an institutional level. “It is interesting which prisons have more drugs, it’s got to do with management as well, it’s not just the population” (HCS). . And we are supplying them with heroin users on a daily basis. There is a ready market here, its easily smuggled (SPS) “No, some visitors would be searched but they wouldn’t be strip searched, it would be just a pat down kind of thing”. (SPS) “Drugs have to be stopped going into the prison, they have to be stopped so make that very, very clear” (FM). “They often use these phones as well I know, anecdotal evidence, they monitor the courts at times and they knew when there’s guys coming in here and they ring them and tell them to stock up on drugs, they’ll even tell them what wings they can and can’t go on to” (PO) While heroin was viewed by many as a highly addictive drug and was thought to be used in a secretive manner this was not the case with all illicit drugs. Cannabis use was reported most frequently with little stigma attached. “In the last three years its heroin, the most popular is hash, everyone smokes hash. About eighty percent use heroin, a lot of people say, we don’t smoke it, we won’t smoke it but they do, and they lie because of the stigma of being a junkie.” (MP) “..it’s a recipe for disaster and society will pay for it eventually because people are coming out of here with addiction and addictions need to be fed and the only way they can be fed is through crime...” (MP) Drug use in the prison was also seen as a reflection of what takes place in the wider community. “Smoking heroin is very, very common; sure it’s common enough with twelve and thirteen year olds in the community in Limerick anyway” (SPS) Swann and James (2003) and Dillon (2001) suggest that heroin use has become a ‘cultural’ aspect of prison life. They argue that it is important for drug users to be part of a group in prison; both for protection and to ensure a more consistent supply. 1.4 Tolerance of drugs The high estimate of drug use in the prison appears to be a tolerated and accepted part of the culture. In particular Cannabis use in the prison appears to be tolerated by most groups. Most of the prisoners interviewed did not view cannabis or its related harm in the same light as other illicit drugs. This view was also shared by some staff members. When asked about the tolerance towards cannabis, one member of the health care team replied that “the medical attitude would be the same”. “Hash would be one of the most prevalent, there’s probably a bit of heroin around, it wouldn’t be really considered a drug though (hash)” (SESP) “Hash was always there but heroin is kind of new but now there’s more heroin than hash in Limerick prison.” (MP) The perception of cannabis being a ‘soft’ drug was frequently reported by both prisoners and prison staff resulting in a relaxed attitude to its use. “And they are getting them in, fair play to them because they do need something in here. And they know they’re getting them in, it makes their job easier” (FP). No, they’re (staff) not bothered, if you were they wouldn’t come barging in to take it off you, they let you smoke away” (FP). “If they go around stoned we can’t really, we wouldn’t be qualified to say if they were on drugs at all or if they were out of their mind every day of the week” (PO). “That’s the worst thing, sitting back and letting it happen but then again it’s happening outside as well” (PO). “Well, I suppose I’d rather see someone smoking cannabis than smoking heroin” (SESP). “That is the normal misperception in the world, they say cannabis is considered a recreational drug, they don’t think it’s a drugs but that’s where the problem started” (HCS). “One area is visits, the public see the big wall, you know, how’s it getting in? Once you close down a route, two more will open up” (SPS). In ‘Keeping Drugs out of Prison’, the IPS outlines its key statements of principle with regards to the issue of drugs in Irish Prisons (2006) which include a zero tolerance on the presences of drugs in prison, the encouragement and support of prisoners to develop a responsible attitude to drugs, both while in prison and following release and the offering of reasonable care and assistance. The elimination of drugs from Irish Prisons is identified as a key task. However this is not reflected in the comments of prisoners about the tolerance of drugs in Limerick prison. “I mean we had it here, if you wanted a screen visit, now a screened visit would stop anything but then for more of a humane approach…” (PO) “They should legalize cannabis anyway; it’s a relaxing drug” (MP). Few prisoners believed that the prison system could stop the supply of drugs, some arguing that the consequences of stopping drugs entering the prison would be more damaging for prisoners and staff. “They know themselves that there is numerous drugs coming into the prison, they could stop them, they know who’s bringing them in, they could say look you’re on screen visits, but they don’t because they know it’ll be worse in here if they do” (MP) “Some of them know, because they’d have a peaceful time once the drugs are coming in here. If the drugs are not coming in then the girls are going to be mad” (FP) “But places like Clover Hill are screened but they’re still getting drugs in. If they want drugs they’re going to get them. Where there’s a will, there’s a way” (MP) 1.5 Method of administration Much discussion took place in groups in relation to the use of heroin in Limerick prison. They were few reports of injecting drug use. Smoking was the most frequently cited method of administration. This finding is inconsistent with other studies conducted in Irish Prisons. Imprisonment has been found to impact on an individual’s pattern of drug use and drug use in prison is usually carried out in a hurried secret fashion with little regard for safety. O’ Mahony (1997) and Allwright at al (1999) found that as many as one in three drug users inject in prison, some for the first time. Dillon (2001) reports that drug use in prison was synonymous with the sharing of equipment and the advantages of using drugs were seen as outweighing the risks involved in sharing equipment. When this inconsistency was explored further with groups it was justified on the bases that there is no culture of IDU in the Limerick community. Heroin use is still considered a relatively new phenomenon in Limerick with suggestions that it has only been an issue for drug users and service providers for the past three years. Respondents in Dillon’s (2001) exploratory study of drug use in prison reported that smoking heroin was perceived to be wasteful, whereas injecting was seen to use the smallest amount of heroin to the largest effect for the most people. “Yea, mostly smoking, ninety nine percent smoke because we had an incident there last week where works were found and they weren’t happy, we don’t use needles” (M P) “At the moment people in jail haven’t had the opportunity of banging up outside, they’re just smoking but there is a new generation coming in” (MP) “…some of them here are smoking three bags of heroin a day instead of injecting it, what’s the difference,…..drugs are drugs, you’re still fucked” (MP) 2 The extent of the affected population likely to respond to, and participate in, treatments/assistances made available 2.1 First introduction to opiate use Consistent with other studies Limerick prison is cited as a place where young offenders are introduced to opiate use. This is a significant finding in that the prison houses a significant young population of remand and first offenders. Prisoners, Family Members and Prison Officers expressed dismay and anger about the introduction of young offenders to opiate use in the prison. The impact of imprisonment could be a factor in this process of self-change. Studies support the finding that the vast majority of prisoners view time in prison as an opportunity to address problems associated with substance abuse and health professionals should not miss this opportunity (Long et al 2004, Swann & James 2003). “It depends on how you were introduced to it, I’ve seen hundreds of fella’s coming in here that picked up the habit inside here and are now progressing onto needles, they wouldn’t have been taking any drugs whatsoever and people then progress from hash to heroin” (MP) “You see a lot of young fella’s coming in, nineteen and twenty and they’ve never seen heroin in their lives and they’re going out there full-blown junkies you know. And they’re back in a few weeks later. I know lots of people who never smoked and it’s destroyed them” (MP). There was concern from family member’s and prison staff that for some, prison was their first introduction to ‘hard’ drugs. “His introduction to drugs was in Limerick Prison, the first time he ever touched heroin”. (FM) “My brother never touched heroin, he went into jail and he is a violent addict, he mixes everything but I have to say that the prison system definitely failed me and my family”. (FM) “I’ve no doubt there is a lot of prisoners who have been introduced to drugs in here who never took drugs at all on the outside but become junkies in here because they’re put in the wrong place with the wrong people” (PO) “I didn’t take drugs until I came to jail, I’d never seen heroin until I came in here, I don’t take it on the outside but I took it when I came in here” (FP) 2.2 Attitudes and Beliefs Responsibility A lack of individual responsibility for drug use was shared by both prisoners and those charged with their detention and care. In most groups there was a lassitude about drugs, expression of the belief that little or nothing could be done to stem the supply and that change was not possible. Many participants expressed the view that the responsibility for stopping drug use lay outside their locus of control. Typically family members expressed the belief that services outside and within the prison done little or nothing to help the prisoners even when they expressed motivation to change. Prison Officers tended to blame central Government and Local Prison Management for the extent of drug use in the prison. Reasons cited were lack of facilities, poor staffing levels and reduced budgets. Voluntary Service Providers who provided housing and social care to ex-prisoners blamed poor planning about release as a reason for continued drug use and the creation of a revolving door scenario. Educators in the prison were critical of resources. Prisoners were critical of the level of services provided and of the attitude of all prison staff. McIntosh (2006) found that a number of aspects of prison life had significant implications for treatment. These included the prison regime and culture; the attitudes of staff towards drug use and drug users; and the relationship between officers and prisoners. Few comments were made by any participants that acknowledged their individual responsibility to contain their own drug use, prevent others using drugs, or provide others with the services they required to make changes. “Look I reckon that in twenty years time there will be two different women sitting there asking the same questions and there’ll be six or seven skeletons sitting around the table!”(MP). “I think a lot of people that I deal with are so used to failing but they’re afraid to do anything but use what they’re familiar with and also the boredom thing” (HCS). “One part of their mind wants gear and the other part wants help” (FM). There was the belief amongst some staff members that different methods of intervention are needed to enable prisoners to address their drug use. “A lot of them just aren’t motivated enough to go looking for work in the prison, there is work for some of them in the prison and education or whatever but a lot are too weak to go and push themselves but once they get into it or if they were put into it they would take to it, its just they’re not” (SPS). “If we were shown a different way, you know with training and facilities, a work programme. Some people will never be rehabilitated, that’s just the way it is. But you need to invest in those that are willing to be rehabilitated” (MP). “There seems to be no determination on the part of the authorities to stop drugs coming into the prison anyway……..then again there’s no point in stopping drugs unless you’re going to have something in place, an alternative, counselling services and things in place inside” (PO). Many participants agreed that there was an immediate need for education and work programmes in order to combat boredom and drug use in the prison. “This is the only jail in Ireland that there’s nothing going for the prisoners.” (MP) “The cultural environment that a lot of these guys are coming from, totally different, drug abuse is endemic, it’s a way of life and a lot of them like that way of life, they do not want to change” (SPS) “They don’t want you to change, they want you coming back in and out, that’s what they want”. (MP) It’s very bad, there is nobody worried about the prisoners, to them like, we’re a bit of scum, you know. It’s like a big game” (FP). Relations between staff and prisoner’s were reported by some as being marked by conflict and tension. “it’s a total shame, you can do a university course and come out with a degree and at the end of the day all the officers see that as a kick in the arse cause you’ve done better than them” (MP). “We haven’t reached the point of being overwhelmed yet and I don’t think we will. We’re very fortunate here in that the staff are extremely proactive in that they follow up and they’re not intimidated” (SPS) “It’s divide and conquer, keep us down, the more they give us the more we want, that’s their attitude” (MP) “You should be called discreetly for it, you get some of the younger ignorant fucks, and they’re shouting ‘Counsellor’ (MP). Boredom is also a major feature of the prison experience and aggression and violence amongst prisoners is common. The research suggests that these aspects of prison life may have direct or indirect influences upon the prospect of successful treatment for drug use. Likewise, the ready availability of drugs in the prison could significantly impede the efforts of those prisoners who were motivated to stop using drugs (McIntosh 2006). “I can say I’m bored and there is the responsibility gone, that needs to be challenged as well I think” (HCS) “Yea, like they would try to embarrass you and they do it deliberately, like those who are on medication are all marched over together through the gate” (MP) “You can’t even go out in that yard for a bit of air; they’re too lazy to get up off their chairs to let us out” (FP). Prisoner’s often expressed a ‘them’ and ‘us’ mentality when talking about prison staff. “Do you know when the girls are coming down from Mountjoy; they are told that they are coming down for punishment, to Limerick for punishment” (FP) “Buts that what a lot of prisoners believe like, they believe and whether they’re right or wrong that the screws are against them and they don’t want to do anything positive, that’s the mindset” (MP). “I mean people in jail don’t take heroin in jail just to take heroin, they take heroin to lie down for a couple of hours and dream the world away and then their day is over. There’s a use for it, it’s not used for any other purpose than that” (MP) Not all prisoners held negative feelings towards the prison officers, some acknowledged that training would be an advantage and would go some way to breaking down the barriers between staff and prisoners. “…..If the screws (prison officers) were made to do a few courses with the prisoners you know, that might make a difference. It might open their minds because they’re not all bad you know. Maybe not now but it might benefit five years down the line” (MP) 3. The form of counselling service that might support and integrate well with existing health related assistance to the affected population such as methadone maintenance and detoxification 3.1 Service Provision: While there was a general agreement both among prisoners and staff that services in the prison were not adequate to cope with the number of prisoners. There was also a high level of criticism regarding existing services in the Prison. Issues that were repeatedly identified by prisoners and staff included; Lack of experienced professionals, Waiting lists for services, Quality of services available, Lack of organisation and facilitation of services This concern is reflected in the literature reviewed and reflects the dichotomy that exists between the primary function of a prison and the need to provide adequate health care. However prison health care is a public health issue, as the health problems in prison largely reflect, but magnify, the problems present in the communities, which the prisons serve (Watson et al, 2003). Prison is designed with punishment, correction and rehabilitation to the community in mind, and these goals may conflict with the aims of health care (Watson et al, 2004). Prisons are not, primarily, concerned with the health of the prison population and, indeed, the need for security and discipline can cut across the perception of individuals as patients (Her Majesty’s Inspector of Prisons, 1996). “That’s another thing with counsellors, their only experience of drugs is from books, you want counsellors that’s been through it themselves, that know exactly what you’re talking about” (MP) “I have said to clients, if you’re using don’t come to me because I have to respect myself but the officers wouldn’t have the pleasure of doing something like that” (HCS). “They’ve a bad detoxing program in here, they’re just throwing people into the pads you know, I think this place should be closed down” (FP). “Because there is an outside agency coming in, it’s not a prison service agency,…..there aren’t files, nobody knows what’s going on and nobody knows why somebody is referred” (HCS). Prison staff reported feeling frustrated having to cope with drug addiction, feeling that they did not have the required knowledge and skills to deal effectively with the issue. “There should be professionals brought in, in the drug area, we’re not the professionals, we want people that are dealing with drug addicts and have been trained to deal with drug addicts” (PO) “You see that’s where you need good assessment, is it abuse or dependence? How much this man is motivated and the third is any disorders they might have as well as the drug abuse” (HCS). “There’s a room full of computers, there’s another big room underneath it and it hasn’t been used for anything either. We were told two years ago that there was going to be workshops and this, that and the other, there’s nothing there to do” (MP). According to McIntosh (2006), the opportunity that prison provides for intervening with problem drug users is potentially as valuable to the individuals and to society as a whole that it would be remiss not to attempt to exploit it as far as possible. The main objective, therefore, must be to increase prisoners’ access to the range of treatments that are likely to be most beneficial to them. The study suggests that targeting services according to prisoners’ readiness to give up drugs might be the most appropriate way of allocating scarce resources. Alongside this, there is a case for attempting to encourage in prisoners the motivation to give up drugs through a combination of one-to-one interventions and group work, perhaps using ‘motivated’ prisoners as advocates and exemplars. “People coming in and out are labeled counsellors, I don’t know what they are, I don’t know what they’re saying to people, I’ve no control or understanding of what’s going on there, I couldn’t even tell you who’s coming in or out of this establishment at the moment” (HCS). “There should be classes in the school that teach people that there are alternatives to drugs, like there’s people in here that can’t read or write so what else would they do but take drugs. They should be taught how to read and write, even the basics instead of getting stoned all day” (MP) “I think we should liaise, that should be part and parcel of what goes on, we should be interchanging a lot, what we’re treating them with and so on” (HCS) Feuding among prisoner groups was frequently cited as a reason for low take-up of education and work services. “The education system up there is good but if you’re on A landing and he’s on C landing you can’t meet in the yard so I can understand that there’s huge pressure within the prison itself because of the feuding and everything like that” (FM) “I did ask for the psychologist in Limerick Prison, and it was this dude in a suit and he didn’t give a fuck, he prescribed me medication, that’s not what I wanted so I used to save it up and take it on the weekend” (FM & Ex Female Prisoner) 3.2 Access to services: There was much criticism of access to services by prisoners, prison staff, family members and staff from the voluntary sector. The POA (POA 2000) stated, that it is imperative that the national methadone policy be reviewed immediately, so that methadone be made available to all prisoners regardless of what geographic location or what health service area they are incarcerated in. They advocate that all drug abusers and drug addicts who are committed to prison should be assessed for suitability for MMT, and the availability of such programmes should not be prejudiced by whether or not a drug addict/drug abuser was in receipt of a drug treatment programme before his committal to prison. Long (2004) reports that prisoners appreciate information sessions on drugs, and individual counselling for self-selected prisoners was useful. Long (2004) found that the majority of respondents said they would value individual counselling. Much of what participants reported related to access to services on release, the lack of consistent links between community based and prison based services and the length of time it takes between identifying the need or request for a service and receiving same. In this study Prison staff were critical of each other’s ability and willingness to provide services. Some of this criticism was indicative of professional rivalry which can be beneficial in spurring staff on to greater achievements or more productivity. However there was little or no balance in these comments suggesting they contribute to the culture of blame and lassitude in relation to services for prisoners who abuse drugs. “They would usually be referred on to the psychologist who will never see them….You’re on a waiting list, that would be the typical type of story” (HCS). “No, its not there, no. We have AA on a Wednesday night but they’re, a lot of the time they’re held up at the gate, at security, they have to walk them across and they might not turn up to half past six in the evening, they could be out there since half past five. The whole system is totally in disarray” (MP). “There’s no work here for prisoners, you know when you wake every morning and you just see that yard out there you think I’m definitely getting drugs today” (MP). When prisoners did seek help they were frustrated at the lack of appropriate services and often had to wait months to be seen by a counsellor. “There is psychiatrists here, you can’t even see the psychiatrist here cause he’s up to his neck in reports for judges for the courts and that’s very unfortunate, psychologist the same. I’m an alcoholic and I find it very difficult to see even the counsellors, last time I saw a counsellor was a couple of months ago” (MP). “There was a meeting on here last night with counsellors and the officers wouldn’t let them through, he said tell them to fuck off, we’re having coffee” (MP) “There’s no support, you have to get sick on a Tuesday or a Thursday in the week before you see a doctor” (MP). “There’s no group support, there’s no solid unit there that would give any individual support, if you look for support you won’t get it” (MP). “Apart from the fact that the doctor is useless he thinks everyone who goes into him is going in to get stoned. You’re only able to see him on a Wednesday, or Tuesday, Wednesday and Friday so if you get sick on a Friday you’re suffering on till Tuesday morning” (MP). “A person doing a short sentence it would be very, very difficult for him to put their hand up and say, ‘look I need help’. A fella in there for a month, he’s not going to say, I need help” (FM). Prisoners had mixed reactions to the current services available with some reporting little or no faith in them. “No, it’s a talking shop really, we have a psychology service here but its just there for show” (MP). “My partner went into prison….., he used to phone me, ‘oh god the counsellor never came and they said there would be no one to bring him’, they were just giving him more tablets, he got addicted in prison to tablets” (FM) “The buck stops with the Minister and he’s a very far right Minister and he doesn’t care about addiction” (MP) “There’s 320 people in this prison, the school can only hold 25 people and each workshop, there’s only two workshops and they only hold 15 and the kitchen will only hold 15, so there’s at least 180 prisoners doing fuck all” (MP) 3.3 Staff skills All groups questioned the ability of staff to provide appropriate services. Some of this questioning was a reflection of a lack of knowledge about the remit of other staff or of their approach to intervening on a substance abuse problem. Belenko and Peugh (2005) found considerable variation in severity/recovery and use and health and social services. The findings suggest that inmates need a range of treatment modalities, and that the existing delivery of correctional treatment, especially residential, is highly inadequate relative to need. Only 24% of inmates reported receiving any type of drug treatment since admission (including non-clinical interventions such as self-help groups of drug education programs). Relatively few inmates with drug abuse problems receive clinical interventions while in prison. The study argues that available treatments are not matched with the individual needs of the prisoner. This finding indicates both a lack of appropriate services and/or a lack of skills on the part of staff in identifying prisoners at risk and matching them to appropriate interventions. In line with Belnko and Peugh’s (2005) findings this study found negative comments in relation to staff’s attitude towards prisoners and their families. Some prisoners and their families felt demeaned by the attitude of some members of Health Care Staff. This need to provide training in relation to attitudes was reflected in the language used by both prison officers and some Health Care Staff to describe prisoners. Most comments emphasised the need for appropriate staff education and training aimed at improving their understanding of prisoners who require help in relation to drug use. “Officers need to be trained….I heard someone say, ‘Oh that scumbag’. Now I know nothing is meant by it either, it’s only like a casual chat but it’s because people don’t know how to interact, the officers with the prison clients” (HCS). “I think they should train our staff up to a level too, because the staff have a fabulous relationship with a lot of the prisoners and they open up and they get to know them, they know their parents before them, with the little lads coming in on visits” (SPS). “There is definitely a lack of education and training and understanding which might be one of the bigger things” (FM) 3.4 Dual diagnosis: Co-morbidity of mental illness and addiction was identified as issues by prison and health care staff as well as prisoners. In some cases the link was viewed negatively and staff indicated that prisoners may use mental illness as a means to access services for addiction. Other participants felt that issues of dual diagnosis were inadequately addressed. The Expert Group on Mental Health (2006:146) stated that co-morbidity contributes to greater severity of addiction and mental disorder. Clinical implications include, worsening psychiatric symptoms, increased use of institutional services, poor medication adherence, homelessness, increased risk of HIV infection, poor social outcomes- including impact on carers and families and contact with the criminal justice system, (DoH 2002:8). “If you look at any prison population, one third of the population will have what you call a minor psychiatric morbidity; this means personality disorders, drug abuse disorders and so on. The major mental illness affects about twenty percent of any prison population” (HCS). “Where I’m coming from, there seems to be an attitude, it’s not dual diagnosis attitude, you’re either mentally ill or you’ve got addiction problems” (SESP). “Even now, when people are on drugs, mental illness shouldn’t be put down cause when you’re on drugs you are a small bit mental at the time” (FM) Drug related mental illness, what we call drug-induced psychosis, dual diagnosis, a major mental illness plus drug abuse, that is quite prevalent as well in Limerick” (HCS). Both prisoners and prison staff reported that there were inadequate services available to those with mental health and drug problems. “The medical profession has a funny way of operating the system, what I’ve seen, if you want to see a psychiatrist it would have to be ordered by the court or the doctor will give it the go ahead, we need to separate that, there is no psychiatric service as such” (PO) “There was one girl and she got a bad fit and they had to take her out of there and shifted her to, I think it was to Dundrum” (FP). “A lot of our clients would be dual diagnosis….I’ve tried to interact with the services here,…I wouldn’t be satisfied at all with that. The lack of liaising you know” (HCS). “There’s lots of people that come into the system here and it’s a disgrace, put into the holding cells or the isolation cells, its disgraceful, they shouldn’t be here without anyone looking after them properly” (PO). 3.5 Counselling approaches in Limerick Prison There are mixed reports about what kind of counselling services are available, on what days and times they are available and what services therapists provide. For example many staff and prisoners appeared to be unaware that during a crisis they could call a telephone help-line and / or that a phone hand set was available to make such a call from a prison cell. There appears to be no coordinated approach when it comes to counselling provision in the prison. There was a lot of mistrust among prisoners of counsellors delivering services. This confusion about who was providing services was also reflected by staff who sometimes professed to know little or nothing about each others skills or work practices and who openly commented that they could not get to meet other therapy providers even following direct requests for meetings. The research team also experienced difficulty in identifying the number and range of therapists engaged in working with prisoners who abuse substances. Service providers suggested that both abstinence and harm reduction were valid approaches. Integrative models of therapy, CBT and Psychoanalysis were preferenced as appropriate for use with the Limerick prison population. Group therapy was advocated but current service providers did not seem anxious to be involved in the provision of group work. Peer support was seen as appropriate by some prisoners but was less favored by staff. 12 step fellowship groups were considered useful by some service providers but prisoners complained of lack of access to same. Many staff are in agreement that motivational interviewing was helpful. The literature reviewed indicated that counselling and psychotherapy is helpful across a broad range of problems. The average treated person is better off than 80% of non treated people, (Dryden 2007). In an analysis of people who had experiences stress or other emotional problems at any time during the previous three years the Consumers Report (1995) found, treatment by a health professional usually worked, long term therapy produced more improvement than short term therapy, there was no difference between psychotherapy alone and psychotherapy and medication for any disorder and that no specific modality of psychotherapy did any better than any other for any problem. “..my experience in talking to counsellors in other countries is that group therapy is probably the best, its very time effective and cost effective,….fantastic if you can do one to one counselling, I doubt any counsellor can provide one to one counselling to all in a prison setting. So the best is group therapy” (HCS). “…it’s stage appropriate intervention, there’s a lot of people who aren’t motivated, they’re pre-contemplative,….I think a lot more could be done in terms of motivational work” (HCS) There were a wide range of responses to what would be an appropriate treatment option for drug use. “I think if you’re going to say anything within meetings in a group or whatever, say in groups like we’d have to get to know each other. …If you’re talking about trust, you know in meetings, you’re not gonna say stuff and then you have to see them outside” (MP). “I often think the common dominator with drug abuse anyway is physical or sexual abuse,….and if they really want to deal with their addiction problems you have to go back that far” (HCS) “You never have people in a group that are not going to talk about each other (in relation to group counselling) (MP) “Our background basically is twelve step, going for total abstinence, but unlike other centres we work with harm reduction and we work with motivational therapy…” (HSC) “Total abstinence is the goal….but they still need the help and support, our aim is towards abstinence, how we get there, that part can be very different from the regular treatment centres, …basically, we’re open to any model” (HCS) “You can’t trust them here,….you really need someone coming in with a blank pass, before you would start to trust them” (MP). “You have to understand that it has to be up to the individual, you can’t give people the counselling unless they really truly want to do it themselves, you know. You have to understand their age group, the sentence they’re doing, a lot of this stuff would go over their head you know” (MP) 3.6 Prisoner attitude to counselling services A variety of responses were expressed about the range of psychotherapeutic services in Limerick Prison. Some prisoners expressed a lack of faith in psychotherapeutic services which was attributed to having little faith in the skills and qualities of practitioners, disagreement with their philosophies of care, concerns over confidentiality and a sense of lack of engagement in any process of change. Prisoners who expressed positive responses to the current available psychotherapeutic services commented on three key aspects of the therapy process that they found positive; Confidentiality, Respect and Commitment to the therapy process. Many prisoners were very concerned about the lack of incentives, activities, education and work in Limerick prison. It was apparent that most prisoners met by the research team were at pre-contemplative or contemplative stages in relation to substance use and therefore would benefit from a psych-education approach as a first step towards engagement in therapy and a process of change. The literature review indicates that Motivational Interviewing is an effective strategy for engaging and treating substance abuse disorders. It is defined as a client-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Miller & Rollnick 2002). Interventions are designed to increase motivation among substance abusers such as motivational enhancement therapy may be helpful in reducing early drop out from treatment. “They’re nice people (counsellors) and all but most of the times they’re talking out their arses, they only tell you what they think you want to hear, they don’t really want to discuss the problems that you have on your mind” (MP) “And not filling me with all this AA crap, all this bullshit…maybe a psychoanalyst, or a proper fucking detox under medial supervision” (MP). “No matter what they bring in here, counselling or whatever, there’s always going to be drugs in this jail because you couldn’t go through your sentence without taking something in here anyway” (FP) “Like I think there is a difference between addiction counselling and bleeding counselling” (MP). “No, what good is the counselling if you’re still here, it’s the same thing day in and day out” (FP). 3.7 Harm reduction: A consistent harm reduction policy did not appear to be part of the current approach to treating substance abusers in Limerick prison. Thombs (1999) describes harm reduction programmes as tolerating some level of substance abuse’ and being ‘primarily concerned with extending help to high risk groups.’ Harm reduction programmes typically include a range of interventions, which, on a continuum, commences with communication with drug users and the general public and moves to the prescription of drug substitution treatment, (Moore et al 2004). There was no evidence that any drug taking paraphernalia is provided for harm reduction in Limerick Prison. Prison staff expressed few concerns about contact with drug taking paraphernalia. Prisoners who enter the prison with drug dependency can be prescribed a detoxification regime by the prison doctor. Prisoners are not maintained on methadone unless they have come directly from a methadone maintenance program outside the prison. Provision of a drug free wing in the prison was seen by family members, prisoners and staff as being beneficial to those who had a desire to change. Many staff commented that this was part of a previous plan for the prison that had not been fulfilled. Irish Prison policy aims at a total drug free environment in all prisons (IPS, 2006). There were a few minor concerns expressed in relation to feuds between prisoners and how this may impact on the creation of such a wing. However these comments were quickly dismissed by group members as over blown. Several staff members expressed hope that a new building due to be open later this year in the prison would improve the opportunities for treatment facilities and harm reduction approaches. “ Yea, it is real (the feuds) but it’s not that bad. I mean the people who wanted to be on a drug free wing wouldn’t be involved in those feuds, generally speaking.” (MP) “There should be more than just methadone; cause just giving people methadone is just like giving them heroin, it’s just a short-term solution. It’s not solving the problem; it’s just making it worse” (MP). “There is no coordinated approach, so really we’re just down to doing a slow detox but people are really just left to paddle their own canoe quite a bit” (HCS). “There is no particular catch all policy with the Irish Prison Service where drugs are concerned. It’s hit and miss” (SPS). “its ludicrous, it is ludicrous, we don’t actually have a policy, if we did have a policy that policy would have to be backed up by a range of other services that aren’t available to us” (SPS). “You probably would never get a better environment to keep people drug free than in prison” (HCS). While it was agreed by most that prison provides an excellent opportunity for people to address their drug use the reality and challenges of prison life makes this opportunity very difficult for some. “It would be virtually impossible here, prisons like here because we don’t know who’s going to appear at the main gate or in what quantity” (SPS) With the result that we ended up with this wing, the larger of the two white wings you see out there, this wing, originally intended to be a drug free unit is now a free drug unit. (SPS) “I think it’s essential that there is a drug free unit, but then you’d have a place that wouldn’t be drug free, a real dive, you’ve got to focus on that too, as well as an incentive from there to move into the drug free unit” (SESP) “People that go into drug free units in any other prisons in the country they would automatically benefit by going into an open centre and they’ve no incentive like that here. If there was I’m sure people would be queuing up to get in there but at the moment no” (MP) “Like, everything else is pointless unless you have a drug free environment, to get them off it, because its pointless people going in there willing to get off drugs and you go back up into a landing that’s full of drugs and it being thrown into his face so without a drug free environment everything else is pointless” (MP) Methadone or Detoxification: Access to detoxification and/or methadone treatment programmes remains a concern for prisoners. Currently there are fewer than 150 residential drug treatment beds in Dublin and approximately 5,000 drug users engaged in methadone treatment. The remaining 8,000 are receiving no treatment. (MQI, 2007) “That’s fair enough but for fella’s on heroin, ten, twelve years, its not right to be put on detox, I was clean for two or three weeks but there’s nothing in my head, nothing, hall, yard, cell, nothing else, no work, nothing” (MP) “Like methadone is like a legalised lobotomy, that’s all it is, cause you’re totally fucked cause methadone is a lot harder to come off than heroin” (MP) “There is a lot of controversy with methadone,….methadone creates a kind of sub-culture in the prison,…..I’m not very much in favour because it has got its own problems, they’re exchanging heroin for methadone, it’s just a different substance” (HCS). “They don’t want to be giving it out (methadone), they give you a detox, you get a detox out of them for about two weeks” (MP) “No point in going to the doctor for a detox, I just have to carry on cause I’m not going to get it” (MP) This chapter presented the main findings from the study by grouping them under the study aims outlined in chapter 1. Appropriate links have been made between the information generated by the literature review and the data collected during focus groups. Significantly the comments from all groups of participants were negative in relation to the range, quality and availability of services for prisoners who use drugs. The researchers repeatedly analysed the data in order to ensure the reduction of bias in relation to the presentation of data. Following careful revision of the data generated few positive comments about current services for drug users in Limerick Prison were discovered. However the findings of this study are broadly supported by information generated through the literature review. Evidently there is need for much change in the development and delivery of prison based counselling and addiction treatment for Limerick Prison. In the final chapter key recommendations and a model for service provision for Limerick prison is presented. Chapter 6 Conclusions and Recommendations ________________________________________ This chapter outlines the report recommendations and a description of an ideal drug treatment service for Limerick prison. There are a variety of recommendations some of which could be instituted in the short term and other which will require planning, resources and change on a longer term bases. At a contextual level data analysis indicted that both service providers and prisoners in Limerick believe that they are inadequately resourced and that in comparison to other prison in the state they had been neglected. Additionally the research team found that Limerick Prison has a significant number of resources in terms of education and health care services that could be put to more effect with some restructuring of management and timetabling systems. However, it is clear that there is no shared philosophy in Limerick Prison around drug use and drug treatment. This includes both the health providers employed by the IPS and those service providers that deliver in-reach services to the prison. This is a major stumbling block towards agreeing an integrative treatment plan for prisoners with problematic drug use issues. Study aims have been met in so far the available literature and data generated from the study allowed. A model for addiction treatment in Limerick Prison Planning the delivery of health care in any environment is a challenge. The challenge is more acute when it involves incorporating a new system or approach into current services. Limerick Prison is not a Greenfield site in terms of the management of prisoners who use drugs, before during and after imprisonment and developing an ideal service for Limerick prisoners and their families will be a challenge to prisoners, the prison and local health care providers. However it is imperative that the ideal is presented and that work commences towards making the ideal a reality. In effect Limerick prison and associated service providers have an opportunity to develop a model of best practice for prisoners who use drugs that other prison services could adopt. The Bedford Row Project, the IPS and the HSE (Mid-Western Region) are faced with the task of utilising the material identified in this report to make the study aims, outlined below, a reality for Limerick prisoners and their families. To estimate the extent of addiction treatment needs within the Limerick Prison population. 2. To estimate the extent of the affected population likely to respond to, and participate in, treatment and assistance that may be made available in relation to substance use. 3. To establish what constitutes best practice in relation to the type of counselling services that might support and integrate well with existing health-related assistance to the affected population such as methadone maintenance and detoxification. 4. To assist the HSE the IPS and other relevant agencies in a collaborative planning process for the provision of appropriate drug treatment interventions in the HSE Mid-Western Region. Limerick Prison counselling and prison based addiction treatment model The list below outlines the constituents of an ideal drug treatment service for Limerick prison. There is also a flow chart provided below which outlines how this model will appear in practice. The data generated in this study indicated that the affected population is likely to respond to, and participate in, treatment and assistance when it is made available and easily accessible on a fair and equitable base in relation to substance use. Development of a drug court system in the Limerick and Cork regions that would enable some offenders access to treatment services as an alternative to prison A comprehensive assessment for all prisoners at the point of entry to the prison to assess them for drug use / abuse / dependency A strict transparent detoxification protocol available for all prisoners who wish to engage in a drug free lifestyle Access to a drug free wing which includes active therapy inputs from a team with a shared philosophy of care for all prisoners who wish to avail of a drug treatment programme staffed with experienced qualified personnel A contract system for prisoners to engage in treatment with incentives for those who abstain from illicit drug use Harm reduction services available in all prison wings A drug education programme and social skills training programme available on an on-going bases for all prisoners Flexible arrangements for counselling and psychotherapy appointments Structured engagement of concerned persons in the treatment process, e.g. partners, family members, friends or employers A broad team of heath professionals which may include, Outreach Workers, Nurses, Doctors, Social Workers, Educators, Psychologists, Pharmacists, Probation and Welfare officers, Addiction Counsellors and Psychotherapists Flexible approaches to treatment including individual, couple and group options Encouragement and access to engage in peer support and 12 step fellowships Quick and easy access to relapse prevention Planned and prearranged access to treatment centers and aftercare support groups on release Planned and prearranged access to social and housing supports on release Commitment to research, training and development   Counselling and Prison Based Addiction Treatment Model for Limerick Prison Prison Drugs Policy Working Party Assessment Psychiatric Medical Psychoeducational Services Intervention  The Ideal Prison based addiction counselling and treatment programme The flow chart above outlines in diagrammatic form the overall structure required of a model for counselling and prison based addiction treatment for Limerick Prison. Outlined below is a breakdown of that model and recommendations about it how the model can be applied to individual prisoners following assessment of their needs. An ideal prison based addiction counselling and treatment programme would commenced with all prisoner being comprehensively assessed, on incarceration, by the prison health service providers to ensure that base line information is collected and that prisoners can access appropriate interventions. A comprehensive assessment would allow for prison service providers to make appropriate decisions at the point of entry in relation to streaming prisoners with a history of drug use into appropriate service provision frameworks. A comprehensive assessment, as well as identifying current levels of drug use, should identify the individual’s position in relation to change and the extent of their current motivation. Initial assessment is critical. Ongoing assessment and formal reassessment at appropriate intervals during a prisoner’s sentence would provide a useful link between, prison, probation and welfare, and health care staff in making recommendations for prisoner management. This report has identified that drug use can be broadly categorised under three headings; Drug Use Drug Abuse Dependence Outlined below are four frameworks for treatment, one relating to each level of drug use, and one that relates to dual diagnosis, that could then be utilised in the process of collaborative health care planning to ensure that all prisoners, following initial assessment would be in a position to receive appropriate interventions. Each level one through to level four should be seen as an opportunity to motivate prisoners to change, making an incentive based approach a workable model for the prison staff to institute. Each level of intervention, (1, 2, 3 and 4), have psychoeducation, work/activity programmes and drug free environments as fundamental supports. Prisoners with more complex needs, i.e. those assessed for level two, three and four interventions need more intensive interventions. The research generated in this study indicates that Limerick prisoners are currently insufficiently prepared and supported to engage effectively in psychotherapeutic interventions, in other words counselling alone would only be effective for a minority group of highly motivated prisoners. Psychoeducation, meaningful work/activity programmes and drug free environments will be essential to enable prisoners to reach a level at which psychotherapeutic interventions will become meaningful and desirable. Interventions Level 1 - for Drug Use As outlined in the chart above prisoners who present on assessment as being engaged in drug use should receive interventions at level 1. This should not preclude them form accessing counselling for other issues that they have encountered in their lives however the scarce resource of addiction counselling should not be required. Intervention Level 2 - for Drug Abuse Level 2 interventions for drug abuse requires a more intensive input on behalf of prison based addiction services. Prisoners at this level need input to enable them to make informed decisions about their drug use which should include the decision to reduce, control or stop using drugs. All prisoners in this group should have access to psychoeducation programmes on the harmful effects of drug use. Psychoeducation programmes should be delivered to groups of inmates to facilitate peer learning and should incorporate opportunities for group discussion. When possible these interventions should include inputs from peer advocates. The emphasis at this level of treatment should be mindful of providing motivation to stop engaging in drug taking and encouragement to become involved in alternative lifestyles. It would be essential that prisoners at this level of use are incentivised and encouraged to engage in education and work skill programmes. Opportunities should exist in the prison for prisoners at this level to be accommodated in drug free environments. Prisoners who opt to stop using should have the option to avail of individual, group and peer support services. Medical intervention for detox may be required. Appropriate contract arrangements for ongoing random drug testing and incentives for remaining drug free should be considered. Intervention Level 3 - for Drug Dependence Prisoners identified as being drug dependant require careful medical assessment and need to be engaged in collaborative care planning in relation to their lifestyle choices. Drug dependant prisoners, regardless of their treatment plan prior to incarceration, should be considered for maintaince programmes as a first step towards a drug free lifestyle. This group of prisoners should also be carefully assessed for appropriate psychotherapy inputs and may require specialist intervention in the areas of Psychoanalytic, CBT, Humanistic, Systemic or Integrative therapy. Every effort should be made to ensure that prisoners identified as requiring interventions at Level 3 are actively involved in planning for release and that they are carefully matched to community services to ensure continuity of care. Intervention Level 4 - Dual Diagnosis Level 4 interventions apply specifically to prisoners identified as having a dual diagnosis. In this case having a co-morbid mental health treatment requirement should not exclude an individual from accessing addiction interventions as outlined in level 1-3. However health care providers should be mindful to provide a timely appropriate assessment and treatment package for addressing the mental health needs of the prisoner. Prison staff may also need to be mindful that individuals with identified mental health treatment needs may need additional consideration in terms of accommodation within the prison system. It would also be essential that they provider of mental health services within the prison is linked appropriately with external service providers to ensure continuity of care on release. Recommended steps towards making the ideal model the real model The next and final section of this report considers the steps that need to take place on phased bases to make Limerick prison a place where prisoners who use drugs are afforded every possible opportunity to engage with meaningful therapeutic supports that will enable them to address their drug taking behaviors. The recommendations have been structured under the following headings; Drug use in Limerick Prison Treatment Options Communication Facilities. It is acknowledged that changes under these headings need to be implemented on a phased base and that they involve consideration from philosophical, social, physical and financial perspectives. The recommendations are challenging for service providers and will require cooperation across disciplines and organisations but have been constructed to address the welfare of both the individual prisoner and the broader community. Drug use in Limerick Prison In order to address the extent of addiction treatment needs within the Limerick prison population there is a need to shift from a reporting system that relies on staff and prisoner beliefs and attitudes towards drug use towards a system based on accurate information gathering and clear accessible record keeping. Coupled with this there is a clear and present need to provide on-going staff education about the impact of drug use that tackles knowledge of and attitude toward substance use. Six recommendation are given below which should be addressed immediately. Development and implementation of clear written policy on the management of drug service in Limerick prison The appointment of a coordinator who would have responsibility for implementation of the drugs policy and the coordination of drug services provision The prison services should have a clear mechanism for recording and collating information on drug use in the prison A consistent approach to reducing the illicit drug supply in the prison On-going staff education for all grades of staff on the harmful effects and methods of administration of all illicit drugs aimed at improving knowledge and attitudes towards illicit drug use Education to equip staff to distinguish between drug use, abuse and dependence Treatment options Outlined below are seventeen recommendations designed to assist the HSE, the IPS and other relevant agencies in a collaborative planning process for the provision of appropriate drug treatment interventions in the HSE Mid-Western Region. These recommendations require consideration and should be introduced on planned phased bases over a period of 12 months. While it would be ideal that they could be immediately implemented it is recommended that the Limerick prison service in conjunction with its health care partners put in place a working group charged with implementing these goals. The working group should be required to abide by specified timescale for the introduction of these recommendations and should be answerable to the current MDT. The working group should be chaired by the coordinator as outlined in the recommendations above. A comprehensive assessment package that includes an appropriate assessment for all individuals on detention to Limerick prison is required for baseline assessment Assessment should distinguish whether an individuals current drug use is classified as use, abuse or dependence As a pre-contemplative and contemplative approach to the provision of treatment psycho-education programmes should be developed and delivered on an on-going bases to all prisoners on the harmful effects of illicit drug use All staff need skills development in motivational interviewing Personal development groups on communication, social skills and anger management should be provided on an on-going bases for all prisoners Detoxification and medical support for withdrawal from a substance of abuse should be conducted under a strict protocol which is transparent and is available to all prisoners with a history of dependence regardless of their residential address prior to imprisonment MMT needs to be carefully monitored to ensure that they are not being used by prisoners to tide them over when illicit drugs are not available Access to and the frequency of 12-step group meetings needs to be increased particularly for narcotic drug use and gambling Providers of Counselling and Psychotherapy should provide group as well as individual therapy in order to maximise the use of limited resources and to enable peer learning Greater emphasis should be given to regular access to addiction counselling and CBT Prisoners need to be made aware of current crisis intervention services such as access to telephone help-line counselling services Efforts should be made to engage concerned person and family members in treatment programmes Signed contracts with prisoners should be introduced as a engagement tool in treatment regimes Compliance with treatment programmes should be rewarded with privileges and better conditions In order to maintain motivation in prisoners a comprehensive review of the limited skills training and education services needs to undertaken, this is particularly significant for services available to female prisoners Services to prisoners need to be more evenly distributed, for example all prisoners should have equal access to outdoor recreation, computer skills training and gym facilities The current delivery of Psychology services needs to be reviewed in order to redress the balance between the percentage of psychologist time spent with male and female prisoners Communication The data generated in this study indicated there is a lack in communication between service providers consequently both staff and prisoners claimed to be unaware of the variety of services that are currently available in the prison. This level of information sharing and communication issues needs to be addressed immediately. Outlined below are eight recommendations that could be addressed over a six month period and that require minimal investment in terms of new resources. The MDT need to agree a philosophy of care in relation to substance abuse The MDT should reconsider when it schedules its meetings to ensure that all team members participate on a regular basis The MDT meeting should be a forum in which therapists clearly identify which prisoners they are working with Health Care providers and Counselling and Psychotherapy staff need to set aside 1-2 training days each year when the can meet and share information in order to improve their working relationships and to develop shared goals A database of counsellors and psychotherapists working in the prison needs to be developed and maintained by the drug service coordinator. It should be available to all staff and list all of the counsellors and psychotherapists, the hours they are available, their registration details, qualifications, supervision arrangements and a brief outline of their approach to the treatment of substance abuse There should be an agreed defined and written statement of who is allowed to deliver counselling and psychotherapy to prisoners. This should include an arrangement to include therapists in training The establish of a biannual prisoner / staff forum where verbal feedback on the range and quality of services available can be evaluated should be given immediate consideration Formal systems need to be develop to ensure that prisoners are linked to substance abuse services on their release from prison for prisoners normally resident in Limerick and other geographic locations Facilities Part of the establishment of best practice in relation to the type of counselling services that might support and integrate well with existing health-related assistance to the affected population such as MMT and detoxification involves examining basic facilities which are current incompatible with the provision of a therapy service for prisoners who use drugs. Three recommendations are made in relation to the provision of a prison environment that would enable prisoners to make and sustain changes in relation to their drug use. These recommendations require a physical, psychological and philosophical shift on the part of all grades of prison staff. Much preparatory work is required in order for these recommendations to be successful. The coordinator of the drug services for the prison will need to work closely with prison management and the working group to plan and implement these changes. Changes of this nature should not be introduced prior to the establishment of the recommendations outlined above. However there is a requirement that planning for these changes should commence immediately with a view towards their introduction over an 18 – 24 month period. Prison management in conjunction with the MDT should review current arrangements for the placing of prisoners in different wings. It is desirable that all prison wings should be drug free, however the reality of the endemic substance abuse requires a pragmatic harm reduction orientated approach that facilitates prisoners with a genuine desire to change Drug free environments should be managed appropriately and should include access to a comprehensive treatment programme commencing with detoxification, progressing through the provision of individual and group psychotherapy towards community links with are gained through successful engagement in treatment The issue of overcrowding in the prison needs to be addressed. This is particularly obvious in the female wing This chapter has outlined the main and significant finding of the study. Recommendations are made for transformation of the prison based counselling and treatment services. An outline of a treatment model for Limerick prison is given. The recommendations have specific suggested time lines, which are essential to consider in the context of following the report recommendations. Finally the study has found that those who occupy and work in Limerick Prison have much work to do to address the current relatively high rate of substance use. There are significant resources available in terms of prison, health care and voluntary staff however the lack of a shared philosophy towards substance use in the prison is a hindrance to the development of services. Not least in the available resources are the prisoners themselves more than 300 men and women who are confined on a daily bases within the wall of Limerick prison, there is real potential and opportunity to enable this group of people to change and progress, provided fundamental work in terms respect for the individual and motivation to change can be instituted. Epilogue ------------------------------------------------------------------------- Appendix A Plan for Staff/Prisoner Focus Group Opening the Group Introduction and welcome, name all staff, acknowledge use of name tags State purpose of research, to make recommendations about the most suitable type of counselling that could be offered to prisoners in Limerick Prison. Note that we are researchers from DCU but have been financed by Bedford Row to conduct this research State limit of confidentiality; check that everyone has signed consent form. Note that the group is confidential and that we will not be identifying peoples names in the research report they will be replaced with staff participant/prisoner participant Explain how session will be conducted, length of session, recording, note taking. Everyone will be encouraged to participate but only has to say as much as they feel comfortable with. The facilitators will keep the discussion on track and may ask people to elaborate or explain a point. Thank everyone for agreeing to participate Themes to be explored with Staff: What they think is the extent of drug use in the prison, type of drugs? Personal health and safety of staff when dealing with prisoners who use drugs. Main areas of concern? What type of treatments are they aware of on offer in prison/ not on offer? Specific training in drugs education? What staff? Long term/short term prisoners, Male/Female Responsibility of staff towards prisoners? Themes to be explored with Prisoners: Extent of drug use/ types of drugs used, most common etc. What are current treatment options available? Are they working? Types of treatment they would like to see: drug free units, detox, methadone maintenance, needle exchange/ counselling ect…. Why avail of treatment? Benefits: Positive/Negative Outcomes (how this affects status in relation to other prisoners/staff) Relationship with prison staff Continuing drug treatment in prison/outside prison: What services needed Individual/Group counselling Short term/long term: Specific challenges? Closing the Group Note taker should comment on time when we are about 10 minutes from end so that group are aware that a finish is eminent. Facilitator should request people to make final comments that the feel the researchers should be aware of in relation to the counselling needs of prisoners who use drugs before / after or while in prison. Again note the confidential nature of the research, it is sponsored by Bedford Row and a fully report is expected to be available in March of 2007. Bring our contact details and those of Bedford Row to group’s attention in case anyone wants to get back to researchers about issues that may have impacted on them by participating in the research. Thank everyone for coming. Appendix B Self Report Form Thank you for taking the time to complete this Self Report Form in relation to the provision of prison based counselling services for prisoners with a history of Addiction. Please fill in all the questions and feel free to give your opinion about prison-based addiction counselling services. All information in the form will be treated confidentially. Information gathered will be used as part of a final report on Prison Based Addiction Services, which has been sponsored by the Bedford Row service in conjunction with the Irish Prison Services. Biographical details are only required for the duration of the study as the researcher may need to contact some participants to clarify information or to participate in an interview process. Biographical Information Name _______________________________________________________________ Address_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Phone _______________________________________________________________ Email _______________________________________________________________ Name of Organisation __________________________________________________ Job Title ____________________________________________________________ 1. Brief Outline of your role and responsibilities in relation to prisoners with a history of illicit drug use ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Current Services 2. List current services that you are aware of for prisoners with a history of illicit drug use in Limerick Prison. Please include services based within the prison and those that link in with the prison. Please include both statutory and voluntary groups, (for example, health services, homeless services, drug services, education and training and family support) --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 2.1 Do you network/have links with any other group/organisation that provide services to drug users inside or on release from prison? If so, please list them. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. Please list the types of professionals and voluntary workers that you are currently aware of who offer support, counselling and / or psychotherapy to Prisoners in Limerick Prison who have a history of illicit drug use. (E.g. social workers, Chaplin, psychologist, counsellor, health care personnel) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Potential Counselling and Psychotherapy Services 4. Please tick the types of counselling for drug treatment intervention that you would consider most appropriate for prisoners who abuse illicit drugs. Use the additional space to add counselling and psychotherapy supports not listed. Alcoholics Anonymous Gamblers Anonymous Narcotics Anonymous ALANON ALATEEN Psycho Education Relapse Prevention Drug Awareness Education Harm Reduction: Detox Unit Segregation Unit / Drug Free Unit Methadone Maintenance Needle Exchange Programme Family Interventions Life Skills Training Anger Management Humanistic Counselling Cognitive Behaviour Therapy Family Therapy Psychoanalytic Approaches _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please tick the social care interventions you believe would be appropriate to have available to prisoners on release who use illicit drugs Hostel Halfway House Support with Housing Employment Assistant Programme Education Services Community Based Drug Treatment Unit Residential Drug Treatment Unit Please answer the following questions by ticking the box provided 6.1 There are sufficient counselling and psychotherapy services for illicit drug users in Limerick prison. 6.2 Counselling would be best provided by trained professional’s 6.3 Current staff should receive education and training in: Understanding Addiction Treating Addiction Counselling Skills 6.4 A Drug Free Unit in prison would be an appropriate idea 6.5 Prisoners found to be using illicit drugs should loose privileges 6.6 All Prisoners should be screened for drug use 6.7 It should be mandatory for all prisoners with a history of drug use to attend available drug treatment programmes. If you have any further comments on the treatment and counselling needs of prisoners who use or have a history of illicit drug use please use the following space: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Thank you for your cooperation. Please return this form using the return stamped addressed envelop Appendix C CONSENT FORM FOR STUDY OF COUNSELLING AND PRISON BASED ADDICTION TREATMENT IN LIMERICK PRISON Thank you for participating in this research study, which is being carried out by the School of Nursing at Dublin City University and is funded by the Bedford Row Project. Please take the time to read this consent form carefully before signing below. If you have any questions please do not hesitate to discuss them with a member of the research team: Gerry Moore Ph: 01 7005340 Email: gerry.moore@dcu.ie Muriel Redmond Ph:01 7007923 Email: muriel.redmond@dcu.ie I confirm that I have received a copy of the information sheet. I have read it/it has been read to me and I fully understand it. I have been given all the information regarding the nature, purpose and potential risks, which may be involved in taking part in this study. I have been given enough time to consider whether or not I should take part in this study. 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Drugs Services Co-ordinator Prison Staff Prisoner Prison Health Service Providers Drug Education Security Safe Drug Free Environment Motivated to Engage Information re: Services Work/ Activity Programme Harm Reduction Drug Free Unit / Wing Cognitive Behavioural Therapy Motivational Interviewing Dual Methadone/ Diagnosis Detox Humanistic/Psychoanalytic 12 Step Programmes Systemic/Integrative Psychotherapy Addiction Counselling Community Services Assessment Drug Use Psychoeducation Work /Activity Programme Drug Free environment Assessment Drug Abuse Psychoeducation Motivational Interviewing Work / Activity Programme Link to outside agency for reintegration into community services Harm Reduction Medical Assessment and detox (if required) Addiction counselling Drug Free environment Assessment Dependence Psychoeducation Motivational Interviewing Work / Activity Programme Link to outside agency for reintegration into community services Harm Reduction Detox Programme Maintaince Programme Appropriate Psychotherapy Intervention Addiction Counselling 12 Step Programme Drug Free environment Assessment Dual Diagnosis Psychoeducation Motivational Interviewing Referral to Mental Health Team for appropriate intervention Harm Reduction/Drug Free environment & Access to appropriate Level 1-3 interventions Harm Reduction/Drug Free environment & Access to appropriate Level 1-3 interventions Referral to Mental Health Team for appropriate intervention Psychoeducation Motivational Interviewing Assessment Dual Diagnosis Harm Reduction Detox Programme Maintaince Programme Appropriate Psychotherapy Intervention Addiction Counselling 12 Step Programme Drug Free environment Work / Activity Programme Link to outside agency for reintegration into community services Psychoeducation Motivational Interviewing Assessment Dependence Harm Reduction Medical Assessment and detox (if required) Addiction counselling Drug Free environment Work / Activity Programme Link to outside agency for reintegration into community services Psychoeducation Motivational Interviewing Assessment Drug Abuse Drug Free environment Work /Activity Programme Psychoeducation Assessment Drug Use Community Services Humanistic/Psychoanalytic 12 Step Programmes Systemic/Integrative Psychotherapy Addiction Counselling Motivational Interviewing Cognitive Behavioural Therapy Dual Methadone/ Diagnosis Detox Drug Free Unit / Wing Harm Reduction Drug Education Security Safe Drug Free Environment Motivated to Engage Information re: Services Work/ Activity Programme Prison Health Service Providers Prisoner Prison Staff Drugs Services Co-ordinator Contemplation Preparation Maintenance Action Pre -Contemplation