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Article Excerpt
This study analyzes how social workers describe case-management after clients' discharge from initial compulsory treatment according to the Act on Care of Addicts in Certain Cases (LVM). Officially, it is often acknowledged that coercing substance abusers to treatment means violating their civil rights and personal autonomy, and that the ethical legitimacy of Swedish coercive care relies on its ability to produce positive outcomes (e.g. SOU 1987:22; SOU 2004:3). Yet, follow-up studies demonstrate that previously coerced substance abusers seldom experience improved living conditions (e.g. Larsson & Ollus 1999; Yohanis, Angelin, Giertz & Sward 2002) or participate in aftercare (e.g. Bergmark 2004; Gerdner 2004; Larsson-Kronberg, Ojehagen & Berglund 2005). LVM-referrals and other forms of civil commitments may be characterized as a severe type of institutionalized pressure for abusers to enter treatment, compared to for example referrals from the criminal justice system or the workplace (Grichting, Uchtenhagen & Rehm 2002). The LVM act has been typified as paternalistic (Lehto, 1994).
Sweden's history of coercing alcohol abusers to treatment dates back to 1913 with the Alcoholics Act (Rosenqvist & Takala 1987). Since 1989, the LVM regulates compulsory treatment of persons with ongoing abuse of alcohol, drugs or volatile solvents (Kinnunen 1994). In short, the LVM states that a substance abuser who endangers his/her own or others' health or risks damaging his/her own life, and who does not enter treatment by his/her own decision shall be court ordered to treatment for a maximum period of six months (cf. Larsson-Kronberg et al. 2005; Palm & Stenius 2002). The aim of the incarceration at specialized LVM-institutions is to interrupt substance abuse, motivate to further voluntary treatment and promote long-term rehabilitation (SOU 1987:22). Swedish compulsorily treated substance abusers have in general deficient living conditions and acute physical/psychosocial health problems (Gerdner 1998; Sallmen 1999). The municipal social welfare boards select cases to be tried in county administrative courts, pay for treatment expenses and have a statutory responsibility to actively promote the client's "acquisition of housing and work or education after discharge and see to that he or she acquires personal support or treatment in order to lastingly exit from substance abuse" ([section] 30 in LVM).
The outcomes of compulsory treatment have generally been considered unsatisfactory and the social services' accomplishments in the domain of aftercare have been questioned (SOU 2004:3; SOU 2005:82). In an effort to solve such problems, the Swedish government invested approximately 30,000,000 Euros during 2005-2007 on strengthening compulsory substance abuse treatment and aftercare (http://www.regeringen.se). This emphasis on what happens with clients after discharge from coercive care has, for instance, resulted in a nation-wide project called "Contract for life", where municipal treatment costs are reduced if the client, the LVM-institution and the case-managing social worker reach an agreement on what aftercare to opt for (www.stat-inst.se). However, the Swedish state does not regulate the form or the content of post-treatment interventions delivered by the municipal social welfare boards, and it is largely unknown how aftercare is organized in practice.
According to the international literature, the claimed significance of aftercare in successful treatment processes is based on findings showing that length of stay in substance abuse treatment is positively associated with treatment effectiveness (e.g. Ouimette, Moos & Finney 1998; Simpson, Joe, Broome, Hiller, Knight & Rowan-Szal 1997) and that treatment retention therefore may be perceived as a positive outcome in its own right (Carroll 1997). Research on aftercare covers for instance predictors of adherence (e.g. McKay, McLellan, Alterman, Cacciola, Rutherford & O'Brien 1998; Lash & Blosser 1999) and outcome differences between various types and formats of post treatment interventions (e.g. Brown, Seraganian, Tremblay & Annis 2002; Fiorentine 1999; Irvin, Bowers, Dunn & Wang, 1999; Ouimette, Moos & Finney 1998; Sannibale, Hurkett, Van de Bussche, O'Connor, Zador, Capus, Gregory & McKenzie 2003). Nevertheless, it has been argued that the impact of aftercare on outcomes is understudied (cf. Brown et al. 2002) and that there is a lack of strong evidence for its clinical effectiveness (Donovan 1998; McKay 2001). In this literature, the concept of aftercare often signifies low intensity outpatient programs with weekly sessions during the months following initial treatment. Such services presuppose that clients are sufficiently stable in their recovery (Blume 2005) and that initial treatment goals have been met (National Institute on Drug Abuse 1993). Still, it has been suggested that services delivered after treatment discharge should be regarded less as strictly relapse-preventive and optional add-ons, and more as central elements of the care continuum "that may be used intermittently across time for supportive purposes" (Donovan 1998:318).
These brief portrayals of Swedish compulsory substance abuse treatment and the international aftercare discourse highlight the perplexity of the social services' task in coercive care cases. A key aim of the LVM is to motivate substance abusers to engage in additional treatment after discharge, which implies that social workers are to satisfy clients' novel demand for further voluntary care. Nonetheless, help interventions offered after discharge from compulsory treatment are referred to as aftercare in the official discourse, which implies that the social services are to assist clients in maintaining improvements achieved during initial care. Adding to this ambiguity is that official reports (see e.g. Riksdagens Revisorer 2002) raise doubts about whether the coercive care at present actually contributes to long-term improvement in substance abusers' status of abuse, living conditions and motivation for lifestyle change. In this respect, the social services may be characterized as a professional context short of concrete guidelines on how to model aftercare interventions in harmony with previously coerced clients' needs. The aim of the present study is to analyze how a sample of social workers define the current situation and describe case-management related to compulsory treatment aftercare. Special focus will be put on how the somewhat unclear official ideology, as illustrated above, translates into the social workers' constructions of aftercare practice, treatment goals and client characteristics.
Material and methods
Twenty social workers employed by the social services were selected randomly from a list of 38 individuals who had administered at least one compulsory substance abuse treatment case according to LVM during 2004-2005 in the Stockholm region or in Vastmanland (a mid-Sweden county). The criterion of recent experience of case-management was to augment interviewees' interest in and understanding of research questions and objectives, and was thus a means to increase the validity of the study. The social workers in the sample were approached with written and verbal information about the research project and were asked to participate in interviews carried out in their offices. Five persons declined participation and were replaced with new randomly selected subjects from the list. In all, 14 different municipalities/town districts were represented in the sample. The interviews were carried out during March to May 2006. Sixteen out of 20 interviewees were female.
A research assistant conducted the...
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