Women and men in alcohol and drug treatment:

An overview of a Stockholm County study

Robin Room, Jessica Palm, Anders Romelsjö,
Kerstin Stenius Jessica Storbjörk

The Swedish alkohol and drug treatment system:
A brief history

Treatment centers specifically for alcohol problems first appeared in Sweden on a small scale in 1885 and the years following. In 1916 the Alcoholics Act came into force, placing the main responsibility for alcoholism treatment within the frame of the poor law administration. The core of the treatment was compulsory treatment for anyone who due to excessive drinking was a danger to his/her own or others' safety or life, failed to provide for his/her family, or was a burden to the poor-relief system (Blomqvist, 1998). These criteria were successively broadened in 1922, 1931 and 1938, but the number of beds for compulsory treatment in the whole of Sweden remained at around or below 1,000 until 1955, and there was little voluntary inpatient treatment. The number of beds for involuntary treatment continued to grow until the mid-1960s, after which they have gradually diminished. The growth of voluntary inpatient beds, on the other hand, was dramatic from the mid-1950s until around 1990, after which a certain decline has happened (Blomqvist, 1998). Outpatient care grew gradually from the mid 1950s. There has been very scarce statistics about outpatient treatment until recently. Its role has however been emphasized in policy-documents, particularly during the last 20 years.

Drug cases had been a negligible part of the system until 1970, but thereafter rose steadily. The drug treatment system was initially separate from the alcohol treatment system, and was part of the health system until 1982, when responsibility was transferred to the social welfare system. By the beginning of the 1990s, the systems were largely combined (Bergmark, 1998).

These days, the separate state-run compulsory treatment system is only a small part of the total system (804 cases in the year 2000; Palm Stenius, 2002). Except for this compulsory treatment system, responsibility for alcohol and drug treatment is hared between the county, with the health based addiction treatment, responsible for detoxification and treatment of medical complications, and the social welfare system at the municipal level. The system is dense and well developed, by international standards. In a comparison of 16 countries, Sweden appeared to be near the top in the 1980s in its provision of treatment per head of population (Takala et al., 1992), and it probably retains such a position today.

Swedish doctors took a leading role from the beginning in public discussions about the nature and handling of alcohol problems (Rosenqvist, 1986). Nevertheless, alcohol problems -- and drug problems also, when they emerged -- have always been defined more as a social problem than as a health problem (Abrahamson 1989; Rosenqvist Kurube, 1992; Bergmark, 1998). Until the 1970s, specialized lay boards at the local levels, called "temperance boards", were the main drivers of the alcohol treatment system. After the dissolution of the temperance boards in the 1970s, their functions became part of the generalized responsibilities of municipal social welfare departments, with general-purpose lay boards still playing a role in decisions on social handling but in a gradually, albeit slowly, professionalised system.

The health system, run at the county level, has become more involved in the provision of alcohol and drug treatment services in recent years. As Rosenqvist and Kurube noted concerning the early 1990s,

In principle there is a clear division of labor between the medical and the social services in regard to alcohol problems. The medical sector is responsible for detoxification and acute medical and psychiatric care, and the social sector for rehabilitation.

But "in practice this division is by no means clear", they continued, and the division has become further blurred in the years since then, despite efforts to clarify the division with policy statements. A study in the 1960s found that about one-third of the treatment for alcohol and drug problems was being provided by medical institutions, most of it in psychiatric hospitals. In the 1980s, another study found about one-quarter of the outpatient treatment in a community outside Stockholm was being provided in health system outpatient clinics (Rosenqvist and Kurube, 1992:82). Roughly speaking, it seems that today about 40 % of the persons in treatment specifically for alcohol and drug problems in Sweden on any given day can be found in the health system, and about 60 % in the social welfare system (Insatser och klienter… 2002).

Studying the treatment system

Treatment for alcohol and drug problems can be studied from a number of perspectives. A major strand of the research literature today is what might be called "treatment modality" studies, studies of particular treatment models and practices. Prominent among these, of course, are treatment outcome studies - studies of the effectiveness, or preferably of the relative effectiveness, of the modality. A landmark in this literature in Sweden was a recent 900-page review of the treatment outcome literature by an authoritative medical committee (SBU, 2001). Another strand of the literature, less well developed, studies the process of treatment itself: what the treatment provider intends, how the recipient experiences treatment, what happens in the therapeutic interaction.

A third strand, which has developed particularly in the last decade, is the tradition of treatment system studies, often also referred to as "health services research". One aspect of this tradition studies the operations and interactions of different elements in the service system - for instance, in an American context, how "managed care" practices impact on the provision of alcohol and drug services. Another aspect, more developed in Sweden, studies the composition of the client loads of different agencies and systems, typically using health and other recording-system data, and sometimes matching files to study interactions in the broader system.

Our primary interest in the study described in this paper, however, is in a third aspect of the treatment systems studies tradition -- what has been described as the "social ecology" of alcohol and drug treatment in Sweden (Weisner, 1986). As Weisner explained,

By "social ecology" is meant the social environment of and processes surrounding treatment,… however carried out. The term calls attention to the general patterns of problems-handling and service provision in the community - how cases come into the systems and the interaction and referral processes between different community systems.… The term refers also to the interaction between formal treatment represented by agencies and the informal processes that take place in the everyday life of the community. (Weisner, 1986:204)

The present study was conceived with this perspective in mind. As it was stated in the original proposal for the study:

The project aims to study the functioning of Swedish alcohol and drug treatment at the level of treatment systems, using services in Stockholm county as its study site…. The project has a dual focus both at the level of agencies and systems and at the level of individual clients. At the agency and system level, the project studies the organization and functioning of services for alcohol and drug problems in the social service and the health systems, and the articulation between the two systems. At the client level, the project studies [the characteristics of] those receiving social services and health services, … and their referral and treatment histories. The social context of alcohol and drug treatment will be studied through comparisons of client samples with those having a recent history of problematic drinking or drug use in a general population sample.

In terms of the functioning of the treatment systems, we were interested in other distinctions as well as the major one between the social welfare-based and the health-based system. At the time the study was initiated, the health-based system was organized into two separate entities, Beroende Centrum Nord and Syd (Dependence Centre North and South), with rather different organization and philosophies of treatment. The northern system was moving toward a more decentralized and outpatient-oriented system, setting up outpatient facilities in the community in conjunction with the welfare systems' offices, while the southern system remained more hospital-based and oriented, at large multifunction teaching hospitals, even in its outpatient clinics. As we noted in the proposal, "the divergence in mode of organization offers an unusual opportunity to study the effects of differences in the organization of treatment at the system level."

Treatment services in Stockholm County

The study is being carried out in Stockholm County, the most populous county in Sweden. While Stockholm City is the largest municipality in the county, there are altogether 26 municipalities, and a total population of about 1,833,000. The local treatment system varies somewhat in different parts of Sweden, so the further characteristics described below apply only to the Stockholm county region.

In 1997, the alcohol and drug treatment services in the health system became separated from the psychiatric services. Prior to that, the services had been primarily hospital-based, whether provided on an inpatient or outpatient basis. With the change, the services in Stockholm county were combined into two services, one (Beroende Centrum Nord, BCN) serving the northern half of the county, and the other (Beroende Centrum South) the southern half. The division was not complete, however: for instance, BCN had responsibility for methadone maintenance in the county.

On 1 September, 2001, near the end of our initial interviews with clients in the systems, the two systems were merged into a single Beroende Centrum system, managed by the leaders of the former northern service and moving towards its treatment model. However, the biggest addiction hospital in the south, Maria Hospital, chose to become privatized and thus evaded the merger (Stenius Storbjörk, 2003).

As noted above, while health services are organized and financed at the county level, it is the municipal level which is responsible for social welfare services. While the services are centralized in smaller municipalities, in some larger municipalities, and notably in Stockholm City, the system has been decentralized, with separate welfare offices and boards in different neighborhoods. Altogether, Stockholm City has 18 geographically-defined welfare districts, plus an extra office for the homeless.

Welfare services provide a variety of services to a diversity of clients. The primary aim of services to clients of working age is to restore and reintegrate the case to his or her full functions in work, family and social life. One task for social workers thus is to identify what aspects of the client's situation or functioning are potential impediments to this aim, and to make a plan for removing the impediment. Alcohol and drug "misuse" are thus of interest to the welfare system primarily in terms of being potential impediments to these functions, and from a systemic perspective the aim of treatment for alcohol and drug problems is to remove the impediment.

A social worker can decide that treatment for alcohol or drug misuse is needed for a particular client, or can request an assessment from a specialized unit if the situation is unclear. Some alcohol or drug treatment is offered as part of general services by generalist social workers, but most treatment is offered by specialized services. Depending on the municipality and the nature of the problems, the treatment can be offered by social work staff within the social welfare office itself, or it can be performed on contract for the welfare department by private treatment centers, on either an inpatient or an outpatient basis. There has always been a large proportion of non-publicly produced treatment in Sweden, but the purchaser-provider models and market-like contracting out has brought about a new kind of privatization. (Stenius, 1999).

Sampling treatment systems:Agency and client levels

Our aim was to study the treatment system both at the level of the agencies which composed it and at the levels of clients coming into it (see Fig. 1 for overview of datasets). Given the number of treatment agencies and services in the county, it was clear that it was impractical to study every treatment service, and particularly to interview a sample of cases from every service. We needed to draw a sample of treatment services that could stand in for the system as a whole.

Agency-level information. At the level of the treatment agencies, we have collected some information on every treatment service in the health-based system, with a special focus on the 18 services from which clients were interviewed. In the welfare-based system, we focused on collecting information on the treatment services in four districts of Stockholm, as well as the service for the homeless, and in 6 suburban municipalities (Botkyrka, Huddinge, Järfälla, Solna, Sollentuna and Täby), chosen to reflect a diversity in demographic composition.

Information on the treatment services has been collected by observation, by key informant interviews and from published material.

Staff questionnaires. We also distributed questionnaires to staff of the Beroende Centrum treatment services, and in the case of social services to staff specializing in alcohol or drug cases in the municipalities included in our client study (including all districts of Stockholm City). We received 344 responses from health system staff, a response rate of about 56% (Storbjörk, 2003), and a total of 569 responses from social welfare system staff, a response rate of about 58% (Palm, 2003).

Table 1 shows in summary form the topical areas covered in the staff questionnaire. Staff were asked about their priorities in client groups, and their own attitudes to their workplace and its treatment program. We also asked staff about their perceptions of client characteristics and expectations, and what clients wanted from treatment. In part, in their responses staff were acting as informants about their daily work. But they were also communicating attitudes about clients and the daily flow of interactions, attitudes which can then be compared with the attitudes of the clients themselves. In this line, too, we asked staff for their opinions on how alcohol and drug problems should be defined and treated, and on different aims and modes of treatment. Staff views in these areas are interesting to analyze in their own right. It will also be interesting to compare them with the views of the clients they serve, and with views in the county's general population.

Initial client interviews. Our aim was to collect samples of clients as they entered treatment in each of the two systems, health-based and welfare-based, so that we would be able to construct a representative sample of the population entering treatment for alcohol and drug problems in Stockholm County. Because of our focus on the social ecology of treatment, we were interesting in interviewing cases as they came into treatment, rather than in a cross-section of those in treatment at a particular time. Interviewing at treatment entry also gave an additional dimension to the research, since the follow-up interview then constitutes data on treatment outcome from the "index treatment episode" by which a case was defined into our sample.

On the other hand, we wanted our sample to represent the full range of cases coming into treatment, and not only those, for instance, entering treatment for the first time ever. As with all such studies, we were therefore faced with defining what constituted "treatment entry" for our purposes. We adopted the same definition used by the health-based system for a new treatment episode: that the case had not come to that same treatment service in the previous 3 months.

In the health-based system, we excluded the "acute" hospital services (alcohol/drug emergency wards) from our locations for sampling cases. Clients typically spend less than 24 hours in these services before leaving or being transferred to "detox" services. While the decision to exclude these services can be justified by the short duration of stays there, the decision was primarily taken on logistical and ethical grounds; cases in "acute" services are often there for a very short time and are typically not in shape to be interviewed.

There were altogether 9 inpatient units in the health-based system from which clients were interviewed: detoxification wards for alcohol and drugs, and treatment wards for medication dependence, methadone and infections. Typically, client stays in most of these inpatient services are fairly short - one or two weeks.

Interviews were also conducted with clients from 11 outpatient services, as a sampling of the full list of outpatient services in the health-based system. These included both specialized hospital outpatient services (for medication dependence, and for women), and general alcohol and drug outpatient treatment services, both hospital-based (in the south) and in the community (in the north).

Staff in the units from which we were sampling were asked to keep a log of cases entering treatment during the period in which we were interviewing cases in that unit. This would allow us to determine the flow of new clients, and rates of clients being approached for interview and agreeing to be interviewed. On this basis, it is possible to weight the actually interviewed client sample to be representative of the client flow in the treatment system as a whole. In practice, it proved difficult to get complete logs throughout the system, and the data from the logs must be supplemented with analyses of electronic client data records kept by the treatment system itself.

In a 12-month fieldwork period, a total of 942 clients were interviewed in the health-based system. In the social welfare-based system, over a 12-month fieldwork period, 833 initial interviews were conducted of clients in six suburban municipalities and four districts (plus the homeless service) of Stockholm, as noted above. With 103 additional initial interviews conducted in four municipalities in northwest Stockholm County, in a study directed by Kaisa Billinger, the total sample of social welfare clients is 936 cases.

In the context of the social welfare system, the question of what constituted a "new case" took on a somewhat different form. We contemplated initially collecting sample of persons coming into the social welfare system as a whole. However, the great majority of these cases would not have turned out to be "alcohol or drug" cases, and our sample of such cases would have been too small for a full comparative analysis. While the issue of how a case becomes identified as an "alcohol or drug case" in the social welfare system is important to the study, it seemed that client interviews conducted at the beginning of the client's interaction with the social welfare system was not a good way to get at this issue. Rather, this issue could better be tackled with key informant interviews or observational studies in the system.

The criterion for a case being included in our interview sample, then, was that a new insats concerning alcohol/drug treatment or assessment was filled out by a social worker, with the services provided under the insats to be paid for by the social services (thus excluding cases referred to the health system). The insats might be a referral to an in-house assessment unit for an assessment on alcohol and drug problems, it might be a referral to an outside contract agency for treatment, or it might simply record that the social worker filling out the form intends to offer the case advice and counseling concerning alcohol or drug use. The case for which there is a new insats might be new to the social welfare system, or may be a continuing client who has been getting other services. Cases who had received the same insats in that unit in the past 3 months were excluded from the sample. Again, an effort was made to get the social work services included in the sampling to fill out logs of cases for which a new alcohol- or drug-related insats has been filled out.

The topical areas covered in the client intake interview are listed in Table 1. A good deal of space in the interview, as might be expected, was taken up with questions on the respondent's status with respect to alcohol and drug use and problems, and with respect to general areas of life functioning. The latter areas were covered by the items from the summary scores of the Addiction Severity Index (ASI) (McLellan et al., 1992). A shortened version of the UCLA Social Support Index (Dunkel-Schetter, 1984) was also asked of the welfare system clients. Current and recent drug use is covered by a summary version of the ASI items, and alcohol use by a short Graduated Frequency measure (Greenfield, 2001). Clients are also asked which is the main drug (or drugs) for which they are coming to treatment. Problems from alcohol and from drug use in the last 12 months are covered separately, in several different ways: with 10-item measures of ICD-10 dependence on alcohol and on the respondent's main drug other than alcohol (Janca et al., 1994); with 5-item measures of life-area problems from alcohol and from all other drugs together; and with 8 items on adverse social and health events connected with drinking or drug use.

Respondents are asked a series of questions about their entry to treatment: perceived barriers to treatment, reasons for coming to treatment, who suggested treatment to them, and their expectations, wants and initial impressions of treatment. Their alcohol and drug treatment history, particularly in the last 12 months, is ascertained. And, like the staff, the clients are asked for their opinions on how alcohol and drug problems should be defined and treated, and on different aims and modes of treatment.

Client follow-up interviews. All clients interviewed in both the health-based and the welfare-based systems are being approached for reinterview approximately 12 months after the initial interview. The follow-up interview is done by telephone if that is possible, or otherwise in person. As shown in Table 1, the reinterview schedule repeats the measures of the respondent's status with respect to alcohol and drug use and problems, and with respect to general areas of life functioning, including the items for the ASI summary scores, for dependence, and for alcohol- or drug-related life-area problems. Otherwise, the emphasis in the follow-up interview is on the respondent's experience with and views of the index treatment episode, and of subsequent treatment experience and efforts to control or quit drinking or drug use.

The general-population sample

A crucial issue in the social ecology of the treatment system is the question of who volunteers or gets chosen for treatment, and under what circumstances. This question cannot be approached only with data from those who are already clients in the treatment system, or even from the system's staff. One important way of approaching the question is from the perspective of the general adult population - with particular attention to relatively heavy alcohol or drug users in the general population. Comparing such a general-population-based sample with clinical samples, we can address the question, what differentiates heavy users who are not in treatment from those who are?

In fall, 2002, Statistics Sweden (SCB) conducted a telephone survey of the general adult population of Stockholm County for SoRAD. Starting from a random listing from the population register of 6000 persons, screening interviews identified 384 respondents with heavier drinking or drug use. These respondents were asked a series of further questions, matching those asked of the treatment intake samples: ASI summary score items, alcohol and drug dependence, drug life-area problems, and drinking or drug-related recent adverse events (see last column of Table 1). Those with past experience of treatment were asked the questions on perceived barriers, who suggested treatment, and what treatment was received, as for the client samples.

A further 800 cases were randomly chosen from those who were screened out, and both they and those screened in were asked the opinion questions on how alcohol and drug problems should be defined and treated, and on different aims and modes of treatment, as well as a short series on which kinds of treatment they thought would help those with problems. With appropriate weighting, these answers give a representative sample of general population opinions, which can be analyzed in comparison with the opinions of clients and of treatment system staffs.

We hope to follow up the 384 "screened-in" cases after 12 months, since this will allow for measuring the extent and nature of "natural remission" in an untreated sample, an important topic for analysis in its own right, as well as in comparison with the treatment outcomes in the clinical samples.

Future directions

A number of other studies are being carried out in association with the study of "Women and Men in Swedish Alcohol Drug Treatment", which has thus become the keystone of a growing field of work on addiction treatment system research in the Stockholm area. In future work, it is hoped to extend data collection to other community service systems. Building on the data already in hand or projected for collection, the work can be seen as developing into an analogue of the Berkeley model of the "community epidemiology laboratory" (Weisner Schmidt, 1995).

The project also provides a good platform for comparative studies, both between different metropolitan areas in Sweden, and cross-nationally. Treatment systems are complex and historically rooted phenomena, relating to and reflecting many specific cultural and institutional aspects of their society. So deeply rooted are they in their particular sociocultural frame that their specific arrangements are often taken by those in the society as natural and necessary, or at least optimal. In this circumstance, a comparative perspective which combines client-level and agency-level data, and which is also anchored in comparable general-population data, can be especially productive in offering new perspectives and insights on determinants and characteristics of the societal handling of alcohol and drug problems.

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