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Existing treatments in Sweden
In Sweden 12-step treatments are used for drug related problems and they are based off of the Alcoholics Anonymous [AA] and Narcotics Anonymous [NA] treatment programs (Socialstyrelsen, 2017a). The aim of the treatment is to give insight into the negative consequences that come from a drug and alcohol use. Detoxification is supposed to be included in the treatment according to the basic concept but it differs from treatment to treatment (Socialstyrelsen, 2017a). The treatment is mostly done in group with a drug and alcohol therapist. There is also outpatient care offered, for example through Sundsvall county, Sundsvalls Behandlingscentrum [SBC] which is Sundsvall´s treatment center and offers 12-step treatment, and work rehabilitation (Sundsvall kommun, 2017). An inpatient treatment last for about six weeks and contain daily group therapy and is followed by after treatment for about a year, in the participant’s hometown (Socialstyrelsen, 2017a). When it comes to relapse when in group treatment facilities where participant live and go to treatment together, the person that relapses might need to terminate the treatment and come back later (Riksförbundet för rättigheter, frigörelse, hälsa och likabehandling [RFHL], 2008). In Sweden addiction care is primarily voluntary, but compulsory care can be put in place in certain cases (SFS 1988:870).
Substitution treatment is also an option, but only for opioid users (Socialstyrelsen, 2015a). Through substitution treatment, in Sweden called läkemedelsassisterad rehabilitering vid opiatberoende [LARO], people with opioid addiction receives methadone or other medicine approved for opioid treatment to be able to manage their addiction. Substitution treatment is prescribed together with psychosocial treatment (Socialstyrelsen, 2015a). Sweden also offers cognitive behaviour therapy [CBT] and psychotherapy in different forms, like recidivism prevention which is based of off CBT, and psychodynamic therapy (Carlsson & Fahlke, 2012; Socialstyrelsen, 2017b, 2017c). CBT is therapy based in people’s feelings, thoughts and behaviours and how they affect them. Certain types of CBT, like dialectal behaviour therapy, have shown to work well with co-morbidity, for example addiction in combination with some personality disorders, but there is very little support for this in research (Balldin & Berggren, 2012; Socialstyrelsen, 2017b, 2017d). In Sweden drug abuse treatment is paid for by Socialtjänsten, so money is not a restriction for participating in drug treatment (SFS 2001:453).
Social bonds theory
Social bonds theory is a criminological theory by Travis Hirschi (2009) that focus on four kinds of bonds a person has to society (Hirschi 2009; Sarnecki, 2009). The first bonds is called attachment which is the connection a person has to conventional people or activities, such as school, friends, family and alike (Hirschi 2009; Sarnecki, 2009). The Commitment bond is about the connection a person has to the conventional social order, such as education or employment. Involvement is the third bond to conventional activities, engagement to school or association activities (Hirschi 2009; Sarnecki, 2009). The last bond is belief, which is positive or negative attitude towards the law enforcement agencies, legislation and also towards addiction (Hirschi 2009; Sarnecki, 2009). If a person has all four bonds, according to social bonds theory, they will abstain from any criminal activity such as illicit drug use. Relationships to people who differ from society, can increase the risk for the person themselves to also deviate from society, as for example through drug use.
Strain theory and general strain theory
Robert K. Merton (1938) developed the theory called Strain theory. Strain theory is based on the notion that society puts people under pressure to reach goals accepted by the society (Merton, 1938; Sarnecki, 2009). If the person lacks the means to reach these goals this might cause strain, which can lead a person to commit crimes. Strain theory focuses both on a structural and a individual level (Merton, 1938; Sarnecki, 2009). Structurally, strain refers to the society’s effect on the individual’s perception of his or her needs. Individually the strain refers to the individual’s attempt to reach his or her needs, and the friction it may cause. Merton elaborated on the theory by expressing that when an individual is faced by obstacles on their way to their goals strain occurs. When this happens, adaption can come about in five ways, conformity, innovation, ritualism, retreatism and rebellion (Merton, 1938; Sarnecki, 2009).
1. Conformity, when a person tries to reach their goals by means accepted by society.
2. Innovation, when a person uses unapproved means to reach their goals, for example dealing drugs.
3. Ritualism, using approved means to reach more humble goals.
4. Retreatism, when a person rejects the society’s goals and the means to reach them, for example through addiction.
5. Rebellion, when a person rejects both goals and the means, and then work towards replacing them.
General strain theory is a development of the strain theory by the criminologist Robert Agnew (1985). The general strain theory aims at expanding the focus that strain theory has, to include all types of negative relationship between both individuals and others. General strain theory also aimed at explaining why some people under strain do not turn to delinquency (Agnew, 1985; Agnew, 1992).
General strain theory brought up three categories of strain, the first category being the actual or expected failure to achieve goals (Agnew, 1985; Agnew, 1992). The second being, the actual or expected removal of positive stimuli (Agnew, 1985; Agnew, 1992). This might cause a person to commit some kind of delinquency as a mean to stop this loss from happening, to find a substitute stimuli or to seek revenge on those who caused the loss or to manage this loss by using drugs. The third category being, actual or expected presentation of negative stimuli (Agnew, 1985; Agnew, 1992). Negative stimuli may lead a person to commit some kind of delinquency. The negative stimuli that has occurred or is expected might lead a person to escape or avoid it, terminate it seek revenge at the cause of the negative stimuli or to manage it by using drugs. As there are different types of sources of strain that may cause a person to expect or actually fail at reaching their goals it is unclear which of these strains that lead to delinquency, which might mean that all types of strain might be relevant for this (Agnew, 1985; Agnew, 1992).
The study aimed at understanding why some heavy users were not in treatment. Through interviews their perceptions and attitudes towards drug treatment were raised to create that understanding. Three objectives for the study was formed, objective 1 what are the heavy users perception of treatment programs, objective 2, what do they want from treatment and objective 3 life-areas requiring care attention. To answer the aim this thesis also found out the characteristics treatment programs should have in order to have successful results from the participants perspective.
Method
Participants
The participants in this study were people with a current pattern of heavy drug use. That meant that the participants who state that they had used some kind of narcotics recently or had used for a longer time were included in the study. Narcotics includes substances such as amphetamine, opioids, benzodiazepines, and alike. Since previous research has shown that people not in treatment tend to underreport, people who stated that they had not used much narcotics are still included in the study (Morral et al., 2000). The people were contacted through Slink In personnel at first but after the first two interviews people who visited Slink In and did seem to have a drug use were asked if they wanted to participate. The heavy drug use was checked through verbal self reported drug use during the interviews.
The participants were both male and female with a heavy drug use. People who did not disclose any usage of narcotics were excluded. Those who voluntarily decided to participate were users of drugs such as amphetamine, heroin, cocaine, alcohol etcetera. The study consists of interviews with ten people who frequent Slink In in Sundsvall. The participant are between the ages of 21 and 40. Four females and six males participated. Other people were interviewed, but were excluded later on because they did not meet the inclusion criteria.
Design
For this study a qualitative design was used. Information was collected cross-sectionally to give a description of the circumstances at the moment of the performed study (Flick, 2014). The information was collected through semi-structured interviews and the questions were carefully chosen and written to an interview guide (see appendix A). By choosing the semi-structured interviews it was possible to ask questions during the interviews that was suitable and met the topics defined on the interview guide (Braun & Clarke, 2013).
Sampling method
Since the study had a qualitative design the concern of sampling was related with having people of different ages and gender that could have different perceptions and attitudes towards treatment. This was made through purposive sampling (Flick, 2014). Therefore potential participants were chosen through convenience with a primary selection with people who could answer the questions with knowledge about the area in question (Flick, 2014). The participants were chosen through help from personnel at Slink In, but also by asking if people at Slink In wanted to participate.
Procedure
The interviews were held in a meeting room at Slink In, where the participants felt comfortable. The participants were informed about all the ethical aspects the study entailed before the interviews were held and an information sheet with the same information was given to them. The information sheet also contained contact information in case they would want to withdraw their participation or had any further questions. Since not everyone wants to participate in a study like this, finding people willing to participate was not the easiest. This is also why the study was later expanded to include the EFS church in Sundsvall. One interview was held there one wednesday since they serve free lunches for people in need. The amount of time spent on waiting and searching for people who were willing to participate took about ten hours per week the first two weeks and the last two weeks about twenty hours per week. This time was spent at Slink In trying to meet people willing to participate.
Table of contents :
Introduction
Previous research on drug users and treatment
Previous research from Sweden
Existing treatments in Sweden
Social bonds theory
Strain theory and general strain theory
Method
Participants
Design
Sampling method
Procedure
Data collection
Ethical concerns
Data analysis – Content analysis
Results
Descriptives
Participant 1
Participant 2
Participant 3
Participant 4
Participant 5
Participant 6
Participant 7
Participant 8
Participant 9
Participant 10
Objective 1. What are the heavy users perception of treatment programs?
12-step treatment
Positive aspects of 12-step treatment
Negative aspects of 12-step treatment
Summarization of 12-step treatment
Substitution treatment for opioid users
Positive aspects of substitution treatment
Negative aspects of substitution treatment
Summarization of substitution treatment
Cognitive Behaviour Treatment
Other information about treatment in general
Interviews with heavy drug users about drug treatment
Motivation for treatment
After treatment care
Objective 2. What do they want from treatment
Combination of treatment
Participants in treatment
Objective 3. Life-areas requiring care attention
Living and work situation
Diagnostics and psychological, physical issues and self medication.
Discussion
Objective 1. What are the heavy users perception of treatment programs?
Objective 2. What do they want from treatment?
Objective 3. Life-areas requiring care attention
Conclusion
Limitations
Strengths
Future research
References
Appendices
