“Give them a chance!” The social representation of the counsellor’s institutional role in prison-based drug treatment programmes in Finland.

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Imprisonment, community sanctions and mortality by cause of death among patients with substance use disorder – a 28-year follow-up using Finnish register data

Background The first few weeks’ post-imprisonment are associated with high mortality, particularly among individuals with a history of substance use. Excess risk may vary by societal context due to a range of penal systems and substance use patterns. Using data on Finnish individuals who had sought treatment for substance use, we studied the association between criminal sanctions with cause-specific mortality. Methods The database contained 10887 individuals who had sought treatment between 1990 and 2009. Their treatment data were combined with register data on imprisonments and community sanctions and weekly mortality between 1992 and 2015. Mortality was analysed using discrete-time survival models. We controlled for age and sociodemographic factors, and analysed whether education, type of substance used and the type of latest sentence modified the associations. Findings Mortality was high in the first two weeks after sanctions (all-cause odds ratio [OR] 2.61, 95% confidence interval [CI] 1.67-4.07; drug-related deaths OR 8.52, 95% CI 4.64-15.7). Excess risk declined over time (OR after 12 weeks: 1.19, 95% CI 1.07-1.31). Most of the excess risk was attributable to external causes. Mortality was low during imprisonment, but not during community sanctions. The patterns were similar by level of education, substance use and the type of latest sentence. Conclusions Community sanctions were not associated with mortality among people with substance use disorders. Mortality was low during imprisonment, but high post-release. Criminal sanctions should be better utilised as intervention touchpoints and follow-up resources should target prisoners with substance use treatment history to reduce post-release mortality.Peer reviewe

Nuorten mielenterveyden tukeminen sosiaalihuollossa ja matalan kynnyksen toiminnassa : Työntekijöiden ja nuorten näkemyksiä tarpeista ja toimintatavoista

Nuorten mielenterveyspalvelujen kasvanut kysyntä sekä nuorten päihdekuolemien lisääntyminen nostavat esiin kysymyksen sosiaalihuollon mahdollisuuksista ja kyvyistä toimia nuorten tukena. Sosiaalihuollossa on käytössä useita hyväksi koettuja menetelmiä, joiden keskiössä on kohtaaminen nuoren kanssa. Onnistunut kohtaaminen koostuu kuulluksi ja ymmärretyksi tulemisesta, kyvystä vaikuttaa saadun tuen muotoihin ja mahdollisuudesta saada uusia näkökulmia vaikeisiin tilanteisiin. Sosiaalihuollon työmenetelmien käyttö on kuitenkin osin sattumanvaraista ja epäjohdonmukaista. Sopivien menetelmien valintaa, käyttöönottoa, ylläpitoa ja vaikuttavaa hyödyntämistä helpottaisi valtakunnallinen koordinaatio. Nuorten kohtaaminen kokonaisvaltaisesti ja erilaisten yhteen kietoutuvien ongelmien käsittely edellyttävät sosiaalihuollon sisäisen yhteistyön parantamista esimerkiksi tuomalla palveluja fyysisesti yhteen. Kuntien ja järjestöjen tarjoamat palvelut voivat muodostaa toimivan työnjaon nuoren auttamisessa. Yhteistyössä sosiaali- ja terveydenhuollon välillä on merkittäviä puutteita, joita voidaan korjata muun muassa perustamalla suoria yhteydenottolinjoja ja parantamalla verkostoyhteistyön koordinaatiota sekä fyysisissä että digitaalisissa ympäristöissä. Nuorten palveluissa on huomioitava myös matala kynnys, joka tulee ymmärtää laajasti ja arvioida palvelukohtaisesti.Tämä julkaisu on toteutettu osana valtioneuvoston selvitys- ja tutkimussuunnitelman toimeenpanoa.(tietokayttoon.fi) Julkaisun sisällöstä vastaavat tiedon tuottajat, eikä tekstisisältö välttämättä edusta valtioneuvoston näkemystä

Understanding the impact of brain disorders: Towards a 'horizontal epidemiology' of psychosocial difficulties and their determinants

Objective To test the hypothesis of ‘horizontal epidemiology’, i.e. that psychosocial difficulties (PSDs), such as sleep disturbances, emotional instability and difficulties in personal interactions, and their environmental determinants are experienced in common across neurological and psychiatric disorders, together called brain disorders. Study Design A multi-method study involving systematic literature reviews, content analysis of patientreported outcomes and outcome instruments, clinical input and a qualitative study was carried out to generate a pool of PSD and environmental determinants relevant for nine different brain disorders, namely epilepsy, migraine, multiple sclerosis, Parkinson’s disease, stroke, dementia, depression, schizophrenia and substance dependency. Information from these sources was harmonized and compiled, and after feedback from external experts, a data collection protocol including PSD and determinants common across these nine disorders was developed. This protocol was implemented as an interview in a cross-sectional Objective To test the hypothesis of ‘horizontal epidemiology’, i.e. that psychosocial difficulties (PSDs), such as sleep disturbances, emotional instability and difficulties in personal interactions, and their environmental determinants are experienced in common across neurological and psychiatric disorders, together called brain disorders. Study Design A multi-method study involving systematic literature reviews, content analysis of patientreported outcomes and outcome instruments, clinical input and a qualitative study was carried out to generate a pool of PSD and environmental determinants relevant for nine different brain disorders, namely epilepsy, migraine, multiple sclerosis, Parkinson’s disease, stroke, dementia, depression, schizophrenia and substance dependency. Information from these sources was harmonized and compiled, and after feedback from external experts, a data collection protocol including PSD and determinants common across these nine disorders was developed. This protocol was implemented as an interview in a cross-sectionalThe PARADISE project is supported by the Coordination Theme 1 (Health) of the European Community’s FP7, Grant Agreement No. HEALTHF2- 2009-241572

Päihdehoidon ja vankeuden yhteenkietoutuminen käytännön tasolla 2000-luvun Suomessa

Finland faced two major changes after the early 1990s that had an impact on both substance use treatment and prison institutions. The first major change was the normalization of drug use, in which previously low levels of drug use and related problems increased rapidly in the 1990s and have since stabilized to an average European level. Another major change was a paradigm shift concerning rehabilitation in prisons. There was a move toward penal welfarism from the earlier neoclassical penal policy, in which punitive and rehabilitative institutions were strictly separated. The number of inmates with substance use—and especially drug use—problems increased, and prison-based drug treatment (PBDT) programs were developed. The aim of this dissertation is to explore how these two major changes changed the institutional logics of prison and substance use treatment institutions at a practical level. This aim is divided into two questions. First, this dissertation analyzes how inmates participating in the PBDT programs and the counselors running them adopted changes in their actions and thinking. Second, this dissertation analyzes associations between imprisonment and substance use treatment in the life courses of persons with substance use problems (PWSUPs). The dissertation approaches these questions by using two different datasets that complement each other. The ethnographic data consist of observations of the programs and interviews with counselors and participating inmates in three different PBDT programs in Finland. The follow-up data combine data from different official registers, including information on prison sentences and crimes that led to imprisonment and data on the treatment records of clients who received substance use treatment between 1990 and 2009. The PBDT programs have been normalized as part of the everyday life of prison institutions. The features of penal welfarism can be found on the practical level of the prison institution; however, rehabilitation was subsidiary to the dominant punitive logic of the prison institution. The existence of rehabilitation was viewed pragmatically by inmates and counselors: inmates could participate in PBDT programs to gain benefits to improve their time in prison but simultaneously to handle their substance use problems. Inmates made a hard distinction between prison guards and counselors, even though—in contrast to many other countries—they were both employed by the prison services. In addition to tasks related to the PBDT programs, inmates were eager to handle prison practicalities via counselors instead of guards. Both inmates and prison officials sometimes acted in hybrid roles, following both rehabilitative and punitive logics in their everyday life in prison. The flexibility between the roles of counselor and guard seemed to ease the divide between different occupational groups in prison. The two major changes have also had an impact on the profile of substance use treatment clients: imprisonment became a significant issue in the lives of PWSUPs. The client had a prison or community service background in every fourth inpatient period in the studied hospital specializing in substance use treatment. Earlier imprisonments increased the likelihood of committing crimes, including those leading to imprisonment. Additionally, the discontinuation of substance use treatment during the inpatient period was found to be associated with an increased risk of committing a crime leading to imprisonment. Other risk factors for criminality, such as male gender, younger age, problems with substances other than alcohol, lack of secondary education and unemployment confirmed the results of earlier studies. If a PWSUP had a prison record, the differences between men and women in the risk of committing a crime evened out and the differences in the risk for property crimes disappeared. This dissertation uses interesting datasets, and hopefully these experiences in data collection and analysis will assist researchers in the future. The use of registers that were not originally designed for research purposes was time-consuming; however, the combination of multiple registers offers possibilities for interesting research designs. The involvement of researchers in the development of treatment record systems and equivalent practical data systems would ease the postprocessing of the data for research and monitoring. The ethnographic data comprised part of an international joint project. That project, involving multiple researchers in different countries, offered knowledge and insight that supported national data collection and analysis. As ethnographic research is often conducted in isolation, such support should be encouraged more. In conclusion, prison and substance use treatment institutions have been closely intertwined. Drug rehabilitation has been normalized as part of prison institutions. A history of imprisonment and a high risk for imprisonment are common features among clients in substance use treatment. The step out of the backdoor of both institutions is a crucial moment, and ways to support clients immediately after release should be developed and encouraged. As serious substance use problems (SUPs) tend to relate more often to illegal drugs instead of alcohol, and as punishments for drug-related crimes have increased in severity rather than eased, imprisonment is more directly and more often connected to substance use problems. For the prison institution, this has resulted in the normalization of substance use treatment. It is not as clear, however, how substance use treatment institutions have responded to the increasing role of imprisonment in the life courses of their clients; therefore, this should be discussed in the future. One possibility could be staff education on the methods to support crime desistance and to identify groups with a high risk for criminality.Kaksi suurta 1990-luvulla tapahtunutta muutosta vaikutti merkittävästi sekä päihdehoito- että vankilainstituutioihin. Ensimmäinen muutos oli se, että huumeiden käyttö normalisoitui osaksi suomalaista yhteiskuntaa. Tämä näkyi huumeiden käytön yleistymisenä, jonka seurauksena myös huumeisiin liittyvät ongelmat kasvoivat merkittävästi. Vankiloissa huumeita ongelmallisesti käyttävien vankien määrä kasvoi. Samanaikaisesti vankilainstituution suhtautuminen kuntoutukseen muuttui. Toinen muutos olikin Suomen kriminaalipolitiikan liikkuminen kohti kuntoutusajattelullista kriminaalipolitiikkaa aiemmasta rankaisemisen ja kuntoutuksen tiukasti erottaneesta uusklassisesta kriminaalipolitiikasta. Tämän myötä vankiloissa kehitettiin ja otettiin käyttöön päihdekuntoutusohjelmia. Väitöskirjassa tarkastellaan sitä, kuinka nämä kaksi suurta muutosta ovat muuttaneet vankila- ja päihdehoitolaitosten institutionaalista logiikkaa käytännön tasolla. Tutkimus pohjautuu kahteen laajaan aineistoon. Ensinnäkin aihetta on lähestytty analysoimalla laadullisin menetelmin aineistoa, joka kerättiin havainnoimalla vankiloiden päihdekuntoutusohjelmia sekä haastattelemalla ohjelmien ohjaajia ja osallistuvia vankeja. Toiseksi analysoitiin päihdehoidon asiakastietoja ja eri viranomaisrekistereitä yhdistelevän laajan rekisteriaineiston avulla eri taustamuuttujien yhteyksiä päihdehoidon asiakkaina olleiden ihmisten rikosriskiin. Väitöskirjan tulokset voi tiivistää siihen, että vankila- ja päihdehoitoinstituutiot ovat 2000-luvulla kietoutuneet aiempaa tiukemmin yhteen myös käytännön tasolla. Päihdekuntoutus on normalisoitunut osaksi vankilainstituutiota. Vankeustausta sekä korkea vankeusriski ovat tyypillisiä piirteitä päihdehoidon asiakkaiden keskuudessa. Vankilainstituution sisällä sekä henkilökunnalle että vangeille on muodostunut niin sanottuja hybridirooleja, joissa he toimivat samanaikaisesti rankaisemisen ja kuntoutuksen logiikan mukaisesti. Molemmissa instituutioissa asiakkaan askel takaisin arkeen on kriittinen hetki, joten on tärkeä kehittää ja ottaa käyttöön uusia tapoja, joilla asiakasta voidaan tukea tässä riskialttiissa siirtymävaiheessa. Erityisesti päihdehoitoinstituution sisällä vankeustausta ja korkea vankeusriski tulisi ottaa entistä systemaattisemmin huomioon