Swedish drug treatment and the political use of conceptual innovation 1882-1982.
This article was first presented in 2011 at the Contemporary Drug Problems Conference in Prato, Italy. An overarching theme of the conference was the connections between the formulation of (drug) problems and the suggested solutions. These are processes where concepts play a central part. The naming and framing of drug-related phenomena lies at the very core of understanding, politicizing, and reforming state responses to drug consumption.
This article investigates the historical background to the concepts applied to drug use and drug users in current Swedish legislation on drug treatment. When the Social Services Act of 1982 came into force, it was the first piece of concerted legislation in Sweden to seek a solution to the problem of drug consumption. But the "drug abuser" of the social services act was not a sick person. The problem was rather described in terms of a lack of resources, and drug consumption was seen as a symptom of social and economic disadvantage. It was also a reaction against how the problem had been described in the 1960s, when it was to some extent articulated as a medicalized and individualized problem.
Now, 30 years later, the concepts are once again being challenged. The Swedish government recently received a public report (Statens offentliga utredningar [SOU], 2011:35) on the present state and possible future of drug treatment in Sweden. In what amounts to almost 1,000 pages, the report covers several aspects, analyses, and suggestions on the treatment of alcohol and other drug abuse. If they were put in place, the report's proposals would add up to the most dramatic organizational change to drug treatment since its introduction in the late 1960s, in shifting the chief responsibility from social to medical services.
The report carries the notion, both explicitly and implicitly, that substantial drug consumption is to be regarded as a state of illness. And even if the investigation does not fully elaborate on the diagnosis of this disease, the very thought of an illness allows suggestions for rather radical changes in the organization of drug treatment and the preferred methods. Drug treatment is expected to become more like other treatment areas, with emphasis on diagnoses and methods borrowed from the field of psychiatry.
The proposals put forward in the report require a new description of drug consumption and the drug consumers. To fully grasp the extent of how innovative the investigation is, we must examine the older (and to a large extent the present) use of concepts in this area. This is what I intend to do in this article.
The concepts used to describe drug consumption and drug consumers do not denote an uncomplicated progression of how these phenomena should be regarded, whether they should be seen, for example, as a disease, a vice, or an unfortunate consequence of unjust societal conditions. Several questions need to be answered to bring some clarity to the issue, including how the use of narcotics and the users have been labeled during the years 1882-1982, what the notions imply, and how they connect to more comprehensive concepts as a "problem" or a "disease." What is the role of the formulation and reformulation of concepts in drug politics and drug treatment solutions?
In the next section, I outline theoretical writings on the subject of concepts, conceptual change and politics, moving on to present the empirical investigation under three separate period headings. The article concludes with a short summarizing analysis.
Conceptual and methodological considerations
My theoretical focus is concepts and their meaning and function in a political context. Drug consumption is surrounded by concepts that facilitate, necessitate, or preclude certain political actions, legislation, and public measures. The political activities examined here also have repercussions for the concepts, their range of meanings, and relations in larger systems of concepts.
Concepts are political tools, and working with concepts is political work. British historian Quentin Skinner describes this as strategic work on conceptual shifts of signification where the innovative ideologist has to connect to concepts and moral connotations generally agreed on, after which a "redescription" or a "reinterpretation" of concepts could introduce a new meaning (Palonen, 1999, p. 48, Aarnio & Pekonen, 1999, p. 181). These formative moments, when concepts are reformulated or when new concepts are launched, can often be traced to conceptual or logical contradictions. Such contradictions often have their origin in an argumentative inconsistency, or in conflicts between ideology and perceived practice. But, as pointed out by political scientist Robert Martin (1997), it is also worth paying attention to when obvious contradictions do not lead to any conceptual reformulation. This could be the case because of active attempts to naturalize a state of things, because concepts are claimed to cover incompatible assertions and problem formulations, or when there is an unwillingness to acknowledge the political and temporary nature of concepts (Room, 1978; Edman, 2009b; Edman, 2012).
The concepts used to make sense of our social reality are always potentially challenging and contestable; that is, they are political. The connection between conceptual history and political history is central to the work of political scientist and conceptual historian Karl Palonen (2005a, p. 36), who claims that "there cannot be any serious study of politics [...] without the presence of at least a minimal element of conceptual history," but who also argues that "conceptual history [can]not be understood without its political dimension." Palonen (2005b, 2006) has frequently criticized practitioners of conceptual history for their lack of interest in scrutinizing parliamentary discussions. These discussions are a treasure trove of open controversies and attempts to reinterpret central concepts. In this context, politicians are described as "the foremost conceptual innovators in the use of political concepts" for reasons highly relevant to my analysis: "politicians act in acute conflict situations, where one alternative is to change the concepts, i.e. the vocabulary, the meaning, the range of the concept or its normative color" (Palonen, 2005a, p. 42).
Parliamentary discussions are not covered in this study, but I have instead chosen to analyze a number of public reports. Their political tendencies are evident because, first, they are the result of political initiatives and, second, they have often laid the foundations for further political discussion. But the reports can also be seen as political manifestations in themselves; as a forum for negotiations, the published reports show all signs of both joint government and corporativist considerations (Claesson, 1972; Back, & Larsson, 2006). Therefore, there is every reason to expect quite explicit political work on concepts in this material.
The drug problem made itself known in Sweden in the 1960s, but it took until 1982 for Sweden to pass any specific treatment legislation. In order to understand this development, I read several public reports on different problem areas that might touch upon the conceptual understanding of the drug problem: eight reports on vagrancy from the years 1882 until 1962; 19 reports on the alcohol problem from the years 1911 until 1968; and nine reports on mental health treatment from the years 1923 until 1964. Reports that explicitly deal with the drug problem have been read more selectively. These include four reports from the late 1960s, when the problem was being articulated more clearly, and three reports from the 1970s and early 1980s when the problem was conceptually reformulated.
I detect three separate periods in these reports. The first period, 1882-1962, comes under "silence and free formulations," because the problem was rarely discussed and when it was discussed there seems little need for strict definitions. However, the choice not to conceptualize and politicize the drug question, even though drugs were being consumed, is in itself an interesting result and serves as a historical background to the intense political work with concepts in the later periods. During the second period, labelled as "specification and manipulation" (1964-1969), the political need for certain concepts was more clearly evident. During these years, the mentally ill drug user--the "narcomaniac"--was first seen as an object for compulsory treatment and later transformed into a part of a broadening concept of drug users. I also deal with a third period, "retreat and reformulation" (1974-1981), leading up to the treatment legislation of the 1980s, when one finds evidence of a reformulation of concepts. Here, we can see a different process, taking us away from specific concepts of drug users in terms of sickness, and creating the political means for bringing alcohol and other drug users under joint treatment legislation.
Silence and free formulations (1882-1962)
As has been shown by Swedish sociologist Borje Olsson (1994), drugs and drug problems were already being discussed with some intensity by the medical profession in Sweden in the mid-19th Century. However, this did not mean that the drug problem was constituted as a political issue. Accordingly, there was little need for conceptual specification, and public reports on vagrancy or alcohol abuse treated the questions in a rather impressionistic manner.
That is, if drugs were discussed at all. Reading the eight reports on vagrancy and vagrancy treatment published in 1882-1962, there are only casual remarks on drug abuse, most often as incidental descriptions of the clientele's characteristics. In six of these reports, the drug problem is not discussed at all (Underdanigt forslag, 1882; SOU, 1923:2; SOU, 1926:9; SOU, 1929:9; SOU, 1949:4; SOU, 1962:22). Drug consumption is mentioned as a problem in only one report from the late 1930s and in another from the early 1950s. The concepts are rather vague. In 1939, the generic term for alcohol and other drug abuse is "poison abuse" (SOU, 1939:25; App. C, p. 133). * Drug abusers were described as "narcomaniacs" and their action or condition as "narcomania" (SOU, 1939:25, App. F, p. 106). In 1952, narcotics were treated as a generic term, which also included alcohol, but narcomania was also a condition related to a psychologically burdened clientele (SOU, 1952:46). The concepts were not elaborated or defined.
The drug issue was far from an integrated or elaborated part of the vagrancy problem. But in reports discussing alcohol abuse, it is ever present from the early 20th Century onwards. In 1911, we can see the problem of drug consumption already emerging as a question of whether a proposed law on compulsory treatment of alcohol abusers should also cover the abuse of narcotics. "Narcotics" was considered a generic term for intoxicating substances, alcohol among them. But even if drugs were seen as potentially more damaging to the individual than alcohol, the Committee (Fattigvardslagstiftningskommitten I, 1911) concluded that drug use did not lead to the kind of social harm that the law aimed to prevent. A complementary investigation by the Medical Committee (Bratt, Gahn, Key-Aberg, Kjellberg, & Petren, 1912, p. 192) suggested that the law would indeed also apply to "persons who, by use of narcotic substances other than alcohol, put themselves in a condition that causes the same effects." However, when the Alcoholics Act came into force in 1916, it made no reference to drug users.
By the late 1920s, three more investigations had been published on the topic without any considerations of the status of drug use (Betankande, 1914; Nykterhetskommittoon, 1921; SOU, 1926:17). The issue of the applicability of compulsory treatment laws to drug consumers was raised again in the 1929 investigation. The National Board of Health presented its views in an appendix, referring to "such narcotics which were not attributable to alcohol" (SOU, 1929:29, p. 120), narcotics again being a main category. References were made to "the cocaine habit's development with some younger people, who, possibly after some malicious attempts, caught a taste for this luxurious toxic" (SOU, 1929:29, p.122). The treatment could be limited to "weaning and correcting moral treatment" (SOU, 1929:29, p. 122). "Weaning" implies a kind of dependence, although the emphasis is on the moral value of the action. The state of dependence is also implied by the suggested treatment, "abstinence treatment at a mental institution" (SOU, 1929:29, p. 122).
But there was no discussion of narcomania. The chosen word is "abuse," even if the terms "morphinist" and "cocainist" (the latter compared to the "alcoholic") also appeared. A qualitative difference is emphasized in assuming that people seldom become "boozers" by drinking moderately, while the corresponding dose of morphine "makes the person a helpless slave to the need" (SOU, 1929:29, p. 122). A long-standing description of narcotics emerged: these were substances that promoted "habituation" and increased "tolerance" (SOU, 1929:29, p. 122).
Two value systems were able to coexist here. First, we have the description of an imperative hunger for poison, a necessity that individuals at this stage do not seem able to avoid. At the same time, this poison hunger is demoralizing, affecting the character traits that the individual is assumed to possess. When this process has reached the point where the morphinist is suffering from withdrawal symptoms, he/she may also be considered "in the narrower sense insane" (SOU, 1929:29, p. 123). Similar characteristics and effects were attributed to the cocaine "abuser." However, the National Board of Health could not recommend compulsory treatment for drug abusers. Drug abusers were generally described as different from alcohol abusers, as coming from a more affluent social stratum and thus not posing such a threat to society that the Alcoholic Act was intended to prevent.
Eight reports investigating the alcohol question in the 1940s and 1950s ignored the drug issue (SOU, 1944:3; SOU, 1948:23; SOU, 1951:43; SOU, 1952:12; SOU, 1952:52; SOU, 1952:53; SOU, 1952:54; SOU, 1952:55). In 1951, however, one public report devoted several pages to the issue when discussing phenomena such as vanjning and tillvanjning. The former was translated as "habituation" and defined as "the changed reaction of the organism to a substance, if supplied regularly over a long period" (SOU, 1951:44, p. 25). The effect was described as at times euphoric and as an increased tolerance to higher doses. This condition was to be separated from tillvanjning (translated as "addiction" by the Committee), seen as synonymous with narcomania. Here, the increased tolerance signified an unwillingness to give up the supplied substance as well as severe withdrawal symptoms. The substances capable of inducing narcomania included alcohol, opium, morphine, heroin, and hashish, all named by the Committee as "addiction promoting" substances (SOU, 1951:44, p. 26).
Drugs are more or less absent in three of the four public reports investigating the alcohol problem in the 1960s (SOU, 1961:58; SOU, 1967:36; SOU, 1967:37). A public report from 1968 brought life to the WHO definition from 1952, characterizing "the actual narcotic substances" (opium, morphine, and heroin) as highly addictive (SOU, 1968:55, p. 207). Dependence on "anesthetic narcotics" was called "narcomania," a condition regarded as pathological (SOU, 1968:55, p. 208). Alcoholism was described as a similar condition, and thus also as "a special form of narcomania" (SOU, 1968:55, p. 208).
Specification and manipulation (1964-1969)
So far, the public reports had been quite modest in their attempts to specify the drug problem. Drug consumption was not a social issue; it was hardly noticeable in the public environment and, as stated by several of the investigations, it could not be attributed to any socially troublesome groups. Therefore, there was no obvious political need for a specific conceptual framework, and the concepts surrounding this problem remained consistently vague. This all changed in the 1960s.
Mental health treatment and the division of concepts
Between 1923-1964, nine publications discuss the treatment of mental disorders. Seven of these reports, published between 1923-1958, do not deal with the drug issue (SOU, 1923:74; SOU, 1927:10; SOU, 1928:18; SOU, 1948:37; SOU, 1957:40; SOU, 1958:20; SOU, 1958:39). In a 1958 report by the Mental Health Delegation, the subject was quickly exhausted. The Delegation established that an overdose of toxins such as alcohol or sleeping pills could cause psychosis. But "the chronic abuse of alcohol, morphine and related drugs, sleeping pills, etc." was also regarded as a form of psychosis (SOU, 1958:38, p. 54).
The political conceptualization of the modern drug problem originates from the 1964 report by the Mental Health Legislation Committee. This investigation eventually resulted in a new psychiatric compulsory treatment law that came into force in 1967 (Svensk forfattningssamling [SFS], 1966:293). After a revision in 1969 (SFS, 1969:212), the law was clearly defined as applicable to drug abusers (Edman, 2009a; Edman, 2009b; Edman, 2011). This required substantial work with concepts and definitions. The Committee separated narcomania from alcoholism; narcomania was no longer seen as the main category. Narcomania was characterized partly by "toxicomania" ("abuse of toxic substances") and partly by "euphomania" ("substances with a mood boosting (euphoric) effect") (SOU, 1964:40, p. 126). But the salient feature of narcomania was that it would lead to "addiction" (SOU, 1964:40, p. 126). Addiction, and by this token narcomania, was primarily characterized by the development of dependence.
The Mental Health Legislation Committee initiated work on the conceptual definitions that would have a direct impact on drug policy and drug treatment. Drug consumption was no longer seen as a marginal curiosity that one could choose to discuss or not. Here was a problem in the making, a problem that required a conceptual framework for political action. In order to establish this, the Committee constructed a distinction between narcomania (narkomani) and drug abuse (narkotikamissbruk), a distinction not made in previous public reports. According to the Committee, "manifested narcomania" was to be considered a mental illness, but it was highly uncertain whether drug abuse could be considered as such (SOU, 1964:40, p. 228).
The Committee was quite aware of its role in the political process. The issue of drug abusers' treatment had been initiated in parliamentary discussions in 1960 and 1962, and the solution had been to refer this question to the Mental Health Legislation Committee. It was described as "important that a new law on care in psychiatric hospitals does not stand in the way of a development of care and treatment of narcomaniacs and drug abusers within health care" (SOU, 1964:40, p. 229). One could therefore expect that the Committee had every reason to carefully consider how to describe such conditions.
Under the heading "the concept of narcomania," the Committee made a serious attempt to deal with the question. Narcomania ("in the medical sense") was defined as "medical conditions where people have become mentally or physically dependent on drugs or substances with similar effects" (SOU, 1964:40, p. 230). The Mental Health Legislation Committee experimented with habituation and dependence as interchangeable concepts, or possibly so that habituation was a process whereby increased tolerance and dose increase manifested as both cause and effect in a state of dependence. Psychological dependence was supposed to present itself before physical dependence. In addition to dependence, the consequences of narcomania included "physical and mental degradation" (SOU, 1964:40, p. 230). The Committee also speculated that certain personality traits--such as weakness and an inability to cope with the pressures of life--could count as predisposing factors for drug consumption.
The Committee was not satisfied with the legal definition of narcotics as a collective name for substances included in international and national conventions. They rather sought to create a functional definition, and they chose "psychological or physical dependence" of certain "pharmaceuticals and stimulants" (SOU, 1964:40, p. 232). But narcomania was already claimed as a legal concept, which made the Committee opt for another designation for dependence, which was equivalent to the English "addiction," the German sucht or the French toxicomanie (SOU, 1964:40, p. 232). The World Health Organization (WHO) definition of 1957 seemed accurate, although it was limited to pharmaceuticals (and did not include non-medical stimulant use).
Compared to the legal definition, the functional demarcation was considerably broader. This had a direct impact on the practicalities of problem management, since the broader definition was expected to lead to more confirmed cases of narcomania in society. It also contributed to structuring the extent of the solution, as "the treatment of narcomania in many cases must take place in a mental hospital" (SOU, 1964:40, p. 235). The work with definitions was undoubtedly political in "trying to achieve legislation which allows admission and treatment of narcomaniacs in mental hospitals" (SOU, 1964:40, p. 235). The question was whether narcomania had to appear explicitly in the law, or whether one could settle for allowing measures targeting the psychological condition characterized by narcomania.
It had previously been understood that narcomania was tantamount to insanity. Now, the Committee suggested that "insanity" could be replaced by "mentally ill to such an extent" (SOU, 1964:40, p. 238) as required treatment in mental hospitals. Such a formulation, it was argued, would include narcomaniacs. Narcomania could be seen as a psychosis, and it was therefore straightforward to equate it with mental illness. Drug abuse was defined in relation to narcomania as an "illegitimate consumption of non-recurring or repetitive or routine nature, where the typical changes of narcomania [...] have not occurred" (SOU, 1964:40, p. 233). The drug abuser was, unlike the narcomaniac, not seen as mentally ill. Compulsory treatment in mental hospitals was therefore not needed.
A proposal never realized
The Swedish drug policy was hatched in the 1968 drug policy program. The key elements--measures against smuggling and selling drugs, as well as treatment of drug abusers--can also be found in older programs. However, these were more general efforts against the smuggling of goods, prosecution of violations against medicine and drug regulations, and the psychiatric care of some drug abusers. The 1968 drug policy program was different, an attempt at massive mobilization of efforts against a drug problem that, in the 1960s, took shape as one of the most serious contemporary issues. The drug problem was no longer seen as a marginal matter for a well-established clientele; instead, it was formulated as a serious threat to society, the nation, and the youth of the nation (Edman, 2012). Actions against the manufacture, smuggling, and sale of drugs were therefore assembled in a new law. Beds at various treatment centers were created, stimulated by government subsidies.
It also became more important than ever to clarify the nature of the problem, to conceptually define what was meant by drug abuse and narcomania. As the question had already been treated in some detail by the Mental Health Legislation Committee, it is fair to say that the committee appointed to investigate the new field of activity--the Drug Rehabilitation Committee--also inherited some conceptual definitions. This came to influence the political room for maneuver and promoted some explicitly politicized positions.
The Drug Rehabilitation Committee published four reports during the years 1967-1969, examining the drug problem from several angles. The Committee's conceptual determination helped to structure the Swedish drug rehabilitation services from 1968 to 1981, before the Social Services Act came into force in 1982. The Committee's work on the definitions therefore warrant a thorough investigation. To achieve precision in the analysis of its concepts, however, I begin by presenting an alternative conceptual apparatus, which appeared in an appendix to the report.
Appendix four in the Committee's first report was authored by the deputy secretary of the Committee. Entitled On narcomania definitions, the appendix can be described as an ambitious attempt to create an adequate conceptual framework for this new field. The appendix is interesting mainly because these are definitions that had not occurred in any legislation or other normatively structuring text. The Committee's decision to override this proposal hence clarifies their preferences regarding conceptual determination.
According to the deputy secretary, a basic problem was that definitional relations were seldom differentiated from empirical relations, which gave rise to tautological reasoning and theories that would be hard to disprove. The discussions on measures to combat drug abuse thus suffered when someone could propose measures against drug abuse based on notions of what the concept meant in terms of causes and effects, while someone else treated the causes and consequences as empirical questions. Another complication was the tendency to "prematurely bind the definitions to a specific frame of reference, and then disseminate this definition as the definition above others" (SOU, 1967:25, p. 208). A further issue was that sociopolitical values were built into the definitions, as exemplified by WHO's definitions, which clearly showed that "the scientific problems are discovered and formulated by a particular culture's position or from the perspective of a particular standard-setting group within a culture" (SOU, 1967:25, p. 209).
As the appendix's proposed definitions did not translate into the Committee's official definitions and as they did not find their way into structuring legislation and public policy, I do not intend to treat them extensively. It can be briefly noted that "drug user" was suggested as a main category of sorts under which the sub-categories narcotic (narkotiker) and narcomaniac (narkoman) were listed in different varieties. What is really interesting is the justification for these linguistic maneuvers, first and foremost that they would not "connote illness, harmfulness or necessity of public intervention" (SOU, 1967:25, p. 211). Nor were the definitions locked in a specific scientific frame of reference. Overall, this pointed to a desire to politicize the issue, to keep the concepts from being a decisive argument in themselves for a certain kind of action. The defined terms would make discussions on the drug issue empirically based and politically alive, and nobody would be allowed to hide behind a self-referential terminology. However, this was not how it turned out.
Medicalization as political solution
The Mental Health Legislation Committee dealt with the drug problem somewhat prematurely. When the report was published in 1964, there were few visible drug problems in Sweden. But the investigation led to a government bill and legislation before the Drug Rehabilitation Committee had even published their first report in 1967. This meant that the Mental Health Legislation Committee had managed to establish a conceptual framework to relate to, and also that they had proposed a solution within the borders of mental and physical health care.
The Drug Rehabilitation Committee accepted the suggested solution. They did not aim to create a new treatment area nor incorporate the care of drug users within existing treatment of alcohol abusers. This meant that psychiatric treatment was suggested as the main treatment for drug abusers, which could pass as a relatively undramatic choice of measures for drug users agreeing to voluntary treatment. It was a far more delicate matter to opt for psychiatric treatment as involuntary treatment, since it meant that the Committee gave up the social argument for compulsory treatment. This argument had been valid in the compulsory care of alcohol abusers ever since the 1910s. The decision also meant parallel systems in which alcohol abusers could be coercively treated mainly when they posed a danger to or burden on relatives or the local community, whereas the circumstances in which drug abusers could be forced into care were left unspecified.
This was something of a key issue in the Drug Rehabilitation Committee's first report and a prime mover in the very active political work with concepts. The Committee conducted a thorough investigation, starting with the Greek origins of the concept of narcomania. The Committee adopted a legal approach where narcotics (narkotika) referred to those substances defined as narcotics in the relevant laws, regulations and inventories. Drug abuse (narkotikamissbruk) designated "all non-medical use of narcotics," and narcomania (narkomani) was defined as "an imperative need to continue the abuse of narcotic substances" (SOU, 1967:25, p. 22). In a more elaborate description of the consequences of drug abuse, dependence was referred to as "the most direct consequence of the abuse" (SOU, 1967:25, p. 27).
Such definitions gave no political guidance, however, and things came to a head when the issue of compulsory treatment of drug abusers was discussed. The Mental Health Legislation Committee had kept drug abuse and narcomania apart: only the latter was regarded as a disease to be cared for with or against the will of the patient. After the circulation of the draft for comment, the Minister of Health and Social Affairs corrected the Committee on this point in the hope of avoiding a "strict separation between narcomania and drug abuse" (Government bill, 1966:53, p. 166). The Drug Rehabilitation Committee agreed with the minister's conceptual innovation completely, signalling that the question of who was mentally ill or not depended on political rather than medical considerations:
Drawing on the statement of the head of the ministry on the new law's fundamental applicability also to the category which the Mental Health Legislation Committee called drug abusers, it is the Drug Rehabilitation Committee's opinion that the law provides sufficient opportunities to detain such abusers for whom care at a hospital is urgently called for. (SOU, 1967:25, p.161)
The Drug Rehabilitation Committee helped to transform the meaning of drug abuse into something quite new and--in view of forthcoming legislation--much more useful. Narcomania had been paired with dependence, which legitimized compulsory care. This now applied also to drug abuse. Dependence was a central ingredient, and in the next report by the Drug Rehabilitation Committee, drugs were mainly characterized by their addictive qualities (SOU, 1967:41).
The Narcotics Criminal Code came into force in 1968 after the Committee had published their first two reports. Drug treatment facilities were now established, and contrary to what the Committee had planned, to a great extent outside the health care system. The Committee's reports from 1969 also noted that the coming together of psychiatry and drug abusers had been a mutual disappointment. Drug abusers were treated badly, while the health care sector could not solve the basic problem.
In its final reports, the Drug Rehabilitation Committee was already moving away from the medicine-centered preconception that had distinguished the concepts and proposed solutions of 1967. The overall description of drug abuse as a disease was of no use if the problem could not be treated within the health care sector. This made dependence not so much a consequence of abuse as the ultimate "symptom" (SOU, 1969:52, p. 338) of an underlying problem. In some formulations, dependence was also both intentional and rational: "Dependence often represents an attempt to find a way out of psychic conflicts and anxiety" (SOU, 1969:52, p. 339).
Indeed, the Drug Rehabilitation Committee testified that they used exactly the same concepts and definitions as in 1967, but it is clear that something had changed in the 1969 formulations. The Committee dissociated itself from a terminology that had not been widely approved. This became particularly clear in the Committee's final report in which a number of researchers published their studies of different aspects of the drug problem. Here, the terminology appeared to be free and inquiring. One study spoke simply of "drug consumption" with no descriptions of psychological or physical dependence (SOU, 1969:53, p. 13). Another study referred to "drug use" and "drug users" without any further attempt to define the concepts, whereas a third discussed "drug abuse" and "toxicomania" without defining the terms (SOU, 1969:53, p. 43; SOU, 1969:53, p. 68).
The terminology went into free fall. Without offering any definitions, study after study discussed narcotics abuse, abuse of narcotics, drug abusers, abusus alii, medicine abuse, narcotics use, limited abuse, advanced abuse, severe abuse, narcomaniacs, uninterrupted narcotics use, or simply just abuse (SOU, 1969:53). Drug policies and drug rehabilitation programs had already been launched, together with supplementary compulsory psychiatric care of drug consumers of an unknown quality. The Committee's final examinations showed no obvious need for a rigorous conceptual apparatus.
Retreat and reformulation (1974-1981)
Taken together, the Drug Rehabilitation Committee's reports contained a great deal of variation in their conceptual precision. At decisive moments, the Committee nevertheless delivered what was politically demanded: a definition of narcomania which was primarily characterized by the drugs' addictive features and which could be equated with an illness to be cared for--with or without the patient's will--in psychiatry. Added to this concept of the dependent and care-needing drug consumer was yet another category, that of drug abusers. And once drug abuse had been defined as all non-medical use of drugs, political conceptual work made alternative interpretations more or less impossible.
Away from medicine
The first report of the Social Inquiry was published as early as 1974. The Inquiry's task was to replace the patchwork of social legislation that had been in the making since the 1950s. Preventive and curative measures against alcohol and other drug abuse now found a place within the same legislation. This was rather a challenge, since the compulsory care of alcohol and other drug users was based on radically different problem descriptions, which was also reflected in the treatment programs' use of concepts. Against the socially troublesome alcohol abuser stood the sick drug abuser. These two were now expected to share the same legislation.
We can detect a clear structuring factor for the Social Inquiry's ability to conceptualize drug abuse, a theoretical pre-understanding that had been suggested already in the texts of the Drug Rehabilitation Committee. The Inquiry's analysis stemmed from "a desire to avoid a symptom-oriented description" (SOU, 1974:39, p. 293). Together with other antisocial behavior, drug use was considered a symptom of social or psychological background factors, and it was these factors that really should be the focus of social work. The Social Inquiry therefore almost apologized for even discussing "drug abuse," which was only done because "from experience, abuse of such substances often creates special problems that are worth some further elucidation" (SOU, 1974:39, p. 293).
The Inquiry settled for "dependence-producing substances" (SOU, 1974:39, p. 293) as a main category, including such substances as alcohol, other drugs and various technical preparations (for example, thinners and solvents). However, faithful to the ambition to create a law for both alcohol and other drug abusers, the Inquiry did not separate the possible problems or suitable solutions for different substances. They were rather forced to discuss drug users separately, because the existing measures and statistics had been based on a symptom-split problem. This construction they could deal with only at arm's length:
An abuser of narcotics generally refers to a person who for a purpose other than legal medical ends uses narcotic substances. This definition appears to be based on the fact that the possession and use of narcotics which do not constitute medical treatment, is in principle prohibited in Swedish law (SOU, 1974:39, p. 294).
But the Inquiry would rather not use the terms "narcomaniac" and "narcomania." These were medical concepts whereas the new legislation was aimed at social measures. Nor did the Social Inquiry immerse itself in the question of what constituted "abuse," other than when this allowed coercive measures (see below). Also, the definition of drugs was plainly legal, emanating from the substances that could be found in the national laws and regulations and in international conventions.
The investigation acknowledged that there were different degrees of abuse, but the reluctance to use medical terminology led to occasional users of cannabis coexisting with injecting drug users under the same label ("abusers"). Abuse was defined primarily as a social phenomenon in terms of the consequences for individuals, families, or society. The individual could incur physical or psychological damage, be pacified, or dramatically impair relations with those nearest to him/her. This could result in ever-increasing abuse, locking the person--frequently described as "the dependent"--in a vicious cycle (SOU, 1974:39, p. 301).
Dependence remained a central characteristic of the problem description. Even if individual treatment aimed at a resolution of medical, psychological, social, and economic problems, the goal remained that the individual would "liberate himself from his dependence on alcohol or drugs" (SOU, 1974:39, p.307). The Social Inquiry's definition of abuse related to dependency but the definition was never particularly concrete, not even in discussions about compulsory care. The Inquiry agreed on a paternalistic legal basis for compulsory care but was less keen on the prevailing coercive psychiatric drug rehabilitation care. While the first Social Inquiry report did not deliver a proposal of its own in 1974, the second, published in 1977, led to two competing proposals.
Two competing proposals
The Social Inquiry's second report is a good example of how politics has the upper hand in the investigation system and how the work with concepts reflects political ambitions. The first report became the subject of a massive referral procedure, setting off a comprehensive debate on the goals and means of social welfare. The Inquiry also acknowledged that such factors influenced the proposals in the final report.
After the Social Inquiry's first report was published in 1974, the election of 1976 led to a change of government after more than 40 years of social democratic governments in Sweden. A bourgeois coalition government took office, which affected the investigative mission of the Social Inquiry. They now had the task of designing two proposals for compulsory care: one without compulsory treatment enshrined in the new social legislation but with maintained psychiatric coercion (even for alcohol abusers) and another with compulsory care as an essential part of the new social legislation.
Most of the Inquiry members advocated psychiatric coercion. In light of the social debate in which the social coercion of alcohol abusers was often condemned as repressive class legislation, psychiatric coercion was sometimes called the "voluntary solution." This must be regarded as a fairly innovative linguistic choice. The report and the planned legislative reform were permeated by a spirit of solidarity, democracy and free will. The question of compulsory care was hard to handle, and there is evidence that not even psychiatric compulsory care would be a straightforward solution. Also, there are few traces of any articulated discussions about alcohol and other drug abusers' status within a psychiatric compulsory treatment law. The clients are frequently described as "abusers," but never as "alcoholics" or "narcomaniacs." While there are some notions of "narcotics abusers," there is a clear unwillingness to classify clients in terms of the substances they consume. In line with this, the Social Inquiry also predicted a move towards treating alcohol and other drug abusers in the same institutions. This trend had already started, and the Inquiry could report that several institutions called themselves "treatment homes or collectives for drug abusers" (SOU, 1977:40, p. 233).
In order to be treated within the framework of compulsory psychiatric care legislation, one would have to be ill in some way. The law allowed caring for the "alcohol or drug sick" (SOU, 1977:40, p. 536) against their will, given that they were considered to be suffering from mental illness. "Client" could also refer to a person "who abuses dependence-producing substances" (SOU, 1977:40, p. 537). In the alternative proposal, where compulsory care remained within the remit of social legislation, there was no use for a terminology of disease. Instead, coercive measures could be legitimated by several complex factors: abuse, need for treatment, inability to understand one's need for treatment, and an assumption that the loss of care could be expected to result in serious danger for the abuser's life or health or serious social harm to him or her. The need for treatment was central. The potential client's status--whether he/she was a drug abuser, dependent, sick, and so forth--was considered secondary and therefore ignored.
Socially defined abuse once again
Developing the precise terminology to describe drug consumption and drug users was not a relevant task for the Social Inquiry. Treatment measures were not discussed at any detailed level or on the basis that this would play a major role in treatment. The existing social compulsory treatment law against extensive alcohol abuse, the Temperance Care Act, was extremely unpopular and was often presented as a direct heir to predemocratic and repressive class laws from the early 1900s. Therefore, in the bill that followed the Social Inquiry's reports, the right-of-center minority government suggested continued psychiatric compulsory care, which became a new kind of coercive treatment for alcohol abusers. The government was once again forced to argue that drug users and alcohol abusers were to a great extent sick people in need of compulsory psychiatric treatment. But this was not an undisputed treatment form in the late 1970s, either. When the Minister of Health and Social Affairs then also sought to broaden the treatment criteria to cover drug abusers in need of treatment but not necessarily mentally ill, he met with serious resistance from the Council on Legislation, the standing committee on social questions and the Parliament. The proposal became law--the Social Services Act--in the summer of 1980 and was expected to come into force on January 1, 1982. However, the law was eventually stripped of its coercive elements. These were to be examined by yet another investigation, the Social Drafting Committee (Edman, 2009a; Edman, 2011).
At the very outset, in describing its mission, the Social Drafting Committee revealed the direction it would take. There was talk of "alcohol and drug abusers," rather than "sick" people (SOU, 1981:7, p. 3). Compulsory care was needed in situations with "a compelling need for care that is not possible to satisfy by actions under the Social Services Act or other law" (SOU, 1981:7, p. 7). The proposed legislation suggested compulsory care in order to "get away from abuse of alcohol or other dependence-producing substances" (SOU, 1981:7, p. 11). Dependence or disease-like conditions were not mentioned, but there was talk about an "urgent need of care due to ongoing abuse of alcohol or drugs" in situations when the "measures under the Social Services Act or other laws [were] insufficient to meet care needs" (SOU, 1981:7, p. 11).
After a meandering tour through health care and psychiatry in the 1970s, it was now time to reclaim abuse as a social and a political problem. Ever since the first Alcoholic Act was introduced in 1916, local politicians had made the final decisions on measures targeting abusers. The Social Drafting Committee did not wish to see a professionalization of this social complex of problems, and it was emphasized that the boards of the treatment institutions should continue to be composed of politicians.
The new compulsory treatment law aimed at motivating the clients for further voluntary care, and a reasonable basic assumption should therefore have been that motivation was necessary and that the client's unwillingness to undergo treatment showed that he or she was unmotivated. However, this criterion was never developed in terms of dependence. The Committee was careful to point out that treatment also sought to provide care recipients with resources other than motivation, such as help to organize personal finances, and find accommodation and employment.
In light of the heavy criticism leveled against political attempts to expand psychiatric compulsory care, the Committee distanced itself from medical-psychiatric descriptions of abuse. They discussed the need for care as a criterion for intervention, a need which resulted from relatively regular consumption. But there was no discussion on how prolonged or advanced this alcohol or other drug consumption had to be. Nor did the Committee speculate whether any kind of dependence existed. This demarcation of abuse was more or less treated as mysticism:
The advantage of linking to the abuser's current condition or situation (caused by abuse) is, amongst other things, that specific conditions are easier to test than the subjectively coloured concepts by which we otherwise have to classify abuse. This is important for the legal rights of the individual. (SOU, 1981:7, p. 37)
Dependence was classified as one of those "hard-to-define abstract concepts" that explained less and confused more (SOU, 1981:7, p. 38). It could also be assumed to have completely different meanings in everyday language and in law. By refraining from elaborating on the dependent criterion, one could possibly also enable earlier interventions in some cases, when dependence could not yet be discovered.
The Social Services Act was passed in the summer of 1980 and the new compulsory treatment law--LVM--in December the following year. Both laws came into force on January 1, 1982, representing the legal regulation of the care of both alcohol and other drug abusers. The Social Services Act regulated a variety of social measures. Substance abuse treatment was just a small part of the legislation. The treatment was briefly discussed in paragraph 11, which stated that the social welfare board had to "work to prevent and combat abuse of alcohol and other dependence-producing substances" (SFS, 1980:620, [section] 11). This could sometimes be achieved by care interventions.
LVM, however, focused completely on the compulsory care of alcohol and other drug abusers. As already suggested by the Social Drafting Committee, legislation made no mention of disease-like conditions. Terms such as "dependence," "tolerance increase," and narcomania did not feature. The clients abused alcohol or other drugs, and care was the answer to an urgent need for care. This need could either manifest itself when the abuser put "his physical or mental health in grave danger," or when he or she "as a result of abuse was likely to come to seriously harm himself [or herself] or those nearest to him [or her]" (SFS, 1981:1243, [section] 3). Reasonably, both alcohol and other drug abusers could be found guilty of this, which is why one did not have to speculate about which disease-like state might pertain to the abuse. The reformulated concepts thus came to fill the political purpose, which was necessary when, at the eleventh hour, a new piece of treatment legislation encompassing both alcohol and other drug abusers was finally put in place.
Conceptual change is an important part of politics. The conceptual formulations and reformulations leading to the legislation investigated in this study tell us a great deal about how the problem of drug use and drug users was politically perceived and handled. The intensity of the conceptual work also matters, the dedication which innovative ideologists give to concepts in order to make them applicable for the purposes of common politics. In times of great and rapid change, such as the mid-1960s, when the concept of drug abuse was wholly redefined in just a few years, one can also assume a political turn of events which would not have been possible without extensive conceptual work.
From the reading of the 43 public reports discussed above, I have been able to construct three separate periods. The first period, from 1882 to 1962, is a time without any specific political need or the presence of conceptual clarity. There are some general yet vague tendencies, such as the widening of the concept of narcotics away from the classical Greek definition of a sedative. Narcotics, narcomania and narcomaniacs become the main categories also for alcohol, alcoholism and alcoholics. A budding idea on dependence as a core definition of narcomania can be found, but the legislative focus was social harm. Drug users were not seen as socially harmful, and there was, therefore, no political need for conceptual clarification.
What happened in the 1960s was in stark opposition to the previous years. A key goal was to enable and widen the coercive treatment of drug abusers. Initial work was carried out by the Mental Health Legislation Committee, which in 1964 agreed on a definition of narcomania applicable to psychiatric compulsory care. However, the Committee insisted that there were drug consumers to whom this definition should not be applied. This became politically troublesome since the political opposition, amongst others, claimed that such action would leave those drug users unwilling to undergo treatment without care. In the government bill for new psychiatric legislation, the Minister of Health and Social Affairs therefore argued that there should be no strict conceptual separation between narcomaniacs and drug abusers. The definition was later confirmed by the Drug Rehabilitation Committee in 1967 and in a revised Mental Health Act in 1969.
The process towards psychiatric compulsory care as the solution for some drug abusers is further accentuated when viewed against one of the conceptual innovations never put into practice, the concepts proposed by the Committee's deputy secretary. This proposal reflected an articulated will to use concepts that would have necessitated a politicization of the problem area. But the Committee opted for the opposite in using self-referential concepts that necessitated actions without political interference.
This process also made it possible to do without specific treatment legislation for drug users, and compulsory treatment could be carried out within psychiatry. At the same time, Sweden had coercive treatment for alcohol abusers on social grounds, and public, political and professional discussions on the topic often departed from an anti-psychiatric and symptom- theoretical point of view highlighting the social and psychological circumstances around a drug. Altogether this called for a political retreat from the disease model. In the public reports leading up to the legislation of 1982 and in the legislation itself, the drugs and the individual predisposition to take drugs are no longer important. As a consequence, the drug user was no longer considered (mentally) sick. On the surface, it may look like the late 1970s development, a kind of deconceptualization of key terms, was the exact opposite of the conceptual work of the 1960s. But the process filled the same role in enabling a policy that could hardly have been realized with the older concepts.
To summarize, what we have is an intriguing and useful political endeavour with concepts. The 1960s was characterized by a two-step process in which the mentally ill drug user, the narcomaniac, is first seen as an object for compulsory treatment and is then made part of a broadening concept of drug users. In the mid-1970s and early 1980s, there is a different process, taking us away from the specific concepts of drug users in terms of sickness and creating political means of bringing alcohol and other drug users under joint treatment legislation. While this is still the treatment legislation in effect in Sweden (with minor revisions), a new public report has made a concerted attempt in the autumn of 2011 to re-medicalize the question and to make both alcohol and other drug users objects of health care and psychiatric care. It has been suggested that this proposal is not based on a convincing argument of abuse as akin to a disease or that adequate treatment should to a greater extent be located in psychiatric and somatic care (Bergmark, 2011). The proposed reform must therefore be regarded as an impressive political act of will, making it all the more fascinating to follow the future conceptual efforts in the process.
AUTHOR'S NOTE: For additional information about this article contact Johan Edman, SORAD, Stockholm University, SE-10691 Stockholm, Sweden. E-mail: email@example.com.
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* Translations of key concepts are a delicate matter in studies of conceptual history that are written in a language other than that of the source materials. The most important single concepts used in the analysis are: beroende (dependence); beroendeframkallande (dependence-producing); drogmissbrukare/narkotikamissbrukare (drug abuser); eufomani (euphomania); giftmissbruk (poison abuse); missbruk (abuse); narkoman (narcomaniac); narkomani (narcomania); narkotika (narcotics/drugs); narkotikabruk (drug use); narkotikabrukare (drug user); narkotikakonsumtion (drug consumption); narkotikamissbruk (drug abuse); narkotikasjuk (drug sick); narkotiska amnen/medel (narcotic substances); narkotiker (narcotic); supare (boozers); tillvanjning (addiction); tillvanjningsbefordrande (addiction promoting), toxicomani (toxicomania); and vanjning habituation).
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|Title Annotation:||Beyond the Buzzword: Problematising "Drugs"|
|Publication:||Contemporary Drug Problems|
|Date:||Sep 22, 2012|
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