1. Page 1 Treating drug users in prison Dr Sanja Stojadinovic Special Prison Hospital Belgrade

2. Page 2 Drug use and crime  Individuals who use illicit drugs are more likely to commit crimes.  Drug use amongst offenders entering prison is on the increase, mirroring the rising levels of drug use generally in the community.

3. Page 3 Breaking the cycle  Treatment is the most effective course for interrupting the drug use/criminal justice cycle for offenders with drug use problems.  Forced abstinence is not treatment, and it does not cure addiction.

4. Page 4 Learning new skills  Abstinent individuals must still learn how to avoid relapse, including those who may have been abstinent for a long period of time while incarcerated.

5. Page 5 Therapeutic process change  To alter attitudes, beliefs, and behaviors that support drug use, the drug user must engage in a therapeutic change process, which may include medications to help prevent relapse.

6. Page 6 Why should drug use treatment be provided to offenders?  Effective treatment decreases future drug use and drug-related criminal behavior, can improve the individual’s relationships with his or her family, and may improve prospects for employment.  In addition, it can save lives.

7. Page 7 Why should drug use treatment be provided to offenders? (2)  Also, drug use treatment is cost effective, it reduces costs associated with low productivity, crime and incarceration.  The largest economic benefit of treatment is seen in avoided costs of crime (incarceration and victimization costs).

8. Page 8 V oluntary or mandatory treatment ?  Most studies suggest that outcomes for those who are legally pressured to enter treatment are as good as or better than outcomes for those who entered treatment without legal pressure.

9. Page 9 Voluntary or mandatory treatment ? (2)  Individuals under legal pressure also tend to have higher attendance rates and remain in treatment for longer periods, which can also have a positive impact on treatment outcomes.

10. Page 10 Evidence based interventions in drug use treatment  Evidence-based interventions include:  cognitive-behavioral therapy to help participants learn positive social and coping skills,  contingency management approaches to reinforce positive behavioral change, and  motivational enhancement to increase treatment engagement and retention.

11. Page 11 Phases of treatment  Early phases of treatment help the participant stop using drugs and begin a therapeutic process of change.  Later stages address other problems related to drug use and, importantly, help the individual learn how to self- manage the drug problem.

12. Page 12 “What works?” principles  Interventions should address:  Risk: the ‘intensity’ of the intervention should be matched to the risk of re- offending. Therefore prisoners assessed as having a higher risk of re-offending should receive the most intensive interventions and vice versa.

13. Page 13 “What works?” principles (2)  Need: interventions should be targeted at risk factors for re-offending (also known as criminogenic needs). These risk factors, when targeted effectively, can be reduced thus reducing the risk of recidivism.

14. Page 14 “What works?” principles (3)  Responsivity: this requires that interventions are matched to an offender’s learning style and personality characteristics and the characteristics of the therapist/ counselor.

15. Page 15 SPECIAL PRISON HOSPITAL BELGRADE

16. Page 16 Special prison Hospital in Belgrade  Special Prison Hospital is specialized for treatment of offenders with drug and alcohol use problems and mental disorders referred to mandatory treatment by a court decision.

17. Page 17 Psychosocial treatment of drug users  Treatment involve different psychosocial interventions:  structured group work,  counseling and psychotherapy (cognitive-behavioral, gestalt, client- oriented),  Drug free unit.

18. Page 18 Structured groupwork  Interventions include:  Motivational enhancement: delivered via motivational interviewing;  Relapse prevention (training drug users to develop a range of skills to identify, anticipate, avoid and/or cope with high risk situations and triggers for relapse);  Prerelease: planning and preparation for release.

19. Page 19 Counseling and psychotherapy  Based on cognitive-behavioral strategies includes relapse prevention strategies (identifying triggers, high- risk situations, strategies to cope with craving) and identifying dysfunctional patterns of thinking, emotions and dealing with problems.

20. Page 20 Counseling and psychotherapy (2)  Components include managing cravings, preventing a “lapse” becoming a “relapse”, rehearsing skills and developing relapse prevention/management plans, identifying and beginning positive fulfilling alternative activities, coping with stress and instilling a belief in the drug user’s own self efficacy.

21. Page 21 More on psychotherapy – Creating bonds  One of the major goals of psychotherapy is connecting to external world by developing adequate relationships with therapists, family and social network outside the closed universe of addiction.

22. Page 22 Creating bonds  In order to maintain abstinence and accomplish better therapy outcome, client and therapist need to establish meaningful relationship or positive therapeutic alliance.

23. Page 23 Relational approach Relational approach in psychotherapy puts emphasis on creating deep, independent attachment to new life style and to people sharing that new life style.

24. Page 24 The dark side of addiction  “I came from the dark side, tied up by the barriers that other posed and that I posed by myself, bounded by fear. My life was just a simulation, filled with substitutions of life.  Now, I am the person striving to conquer my fears, anger and guilt by positive thinking. I am learning to deal with everyday problems and frustrations, I am learning to communicate freely and to exchange my emotions with others.  I am learning to be free, in order to learn who I am”. (Patient in Special Prison Hospital)

25. Page 25 Drug free unit  In Special prison hospital since 2007, as a result of cooperation with OSCE mission to Serbia.  Up to 17 prisoners from Drug addiction department.  Besides enhanced conditions, it offers more intense psychosocial treatment.

26. Page 26 SERBIAN PRISON REFORM

27. Page 27 Serbian prison reform  Goals of Serbian prison reform are  implementing evidence based approach to offenders, introducing risk assessment tools and  treating criminogenic needs of offenders in order to decrease the rate of re- offending.

28. Page 28 Treatment in Serbian prisons  Since 2010 OASys (Offenders Assessment System) has been applied in risk assessment for offenders with prison sentences over 3 years.

29. Page 29 Drug using inmates in Serbian prisons in 2012.

30. Page 30 Treatment in Serbian prisons  Serbian prisons until now offered no integrated, specialized treatment for drug using inmates.  Concerning the number of drug using inmates and high rates of re- offending, the necessity for systematic addressing the problem emerged.

31. Page 31 Treatment in Serbian prisons (2)  Second phase of reform of the Treatment service in Serbian prisons is directed to introducing specialized programs targeting criminogenic needs (dynamic risk factors in which it is possible to intervene) of offenders.  One of them will offer psychosocial treatment for drug users in all Serbian prisons.

32. Page 32 Treatment in Serbian prisons (3)  Program for drug users is based on UNODC recommendations for effective drug users treatment and will include structured group work, cognitive-behavioral strategies and relapse prevention strategies (modeled according to program in Special prison hospital).

33. Page 33 Specialized program for drug users  Interventions include:  Motivational enhancement: delivered via motivational interviewing in order to build motivation for change, compliance for treatment and provide remaining in treatment for sufficient time;

34. Page 34 Specialized program for drug users (2)  Relapse prevention (training drug users to develop a range of skills to identify, anticipate, avoid and/or cope with high risk situations and triggers for relapse);  Prerelease: planning and preparation for release.

35. Page 35 Thank you for your attention!