Active Drug Users
Transcription
Active Drug Users
Introduction Jørgen Anker, Vibeke Asmussen, Petra Kouvonen & Dolf Tops We are people from around the world who use drugs. We are people who have been marginalized and discriminated against; we have been killed, harmed unnecessarily, put in jail, depicted as evil, and stereotyped as dangerous and disposable. Now it is time to raise our voices as citizens, establish our rights and reclaim the right to be our own spokespersons striving for self-representation and self-empowerment. (Statement by The International Activists who use drugs 30 April 2006, Vancouver, Canada) In our society it is very rarely that people who use opiates, cocaine and amphetamine or any combination of these and other substances are invited to speak up and play an active role in the formulation of policies and practices in the drug field. On the contrary, drug users are often treated as second-rate citizens; not as subjects with rights, a voice and an identity, but rather as passive recipients or objects of help or measures of control, punishment and discipline. This publication aims to generate greater interest in and increase awareness and knowledge about the existence of drug users as a group with an active voice. It explores the spaces where such voices are given an opportunity to evolve with a minimum of legitimacy and recognition. Through its various articles, therefore, this publication seeks to provide an improved understanding of the possibilities, limitations, advantages and dilemmas of user participation and user organisation. Drug users obviously do not speak with one voice. In fact, they are a very diverse group of people who are defined by one shared practice: their use of substances, which are currently defined as illegal and dangerous. Apart from being involved in a practice that is illegal, drug users vary in terms of age, sex, class, ethnic origin, place of residence, source of income, etc. Obviously, there are also characteristics that users share in common – the most basic of these being that drug users by definition are regarded as criminals because they use illegal substances. But many drug users also share the common fate of a rather miserable life on the margins of society. On the other hand there are also many users who do not live in misery, but who have permanent housing and a steady job. The group of people concerned are described using a number of different terms: drug addicts, drug abusers, problem drug users, users of hard drugs, recreational drug users, active drug users, people who use illegal drugs, etc. These terms also carry with them different kinds of moral judgements, ranging from the derogative drug addict or junkie at one extreme of the continuum to ‘people who 5 use illegal drugs’, at the other. The latter is the term that is currently preferred by activists in the field. We will return to these discursive dimensions and questions of framing below. Here it suffices to note that this publication first of all focuses on associations and specific practices or initiatives in the field that seek to encourage the participation of people who are presently using so-called hard drugs (e.g. heroine, cocaine, amphetamine), including opiate users in substitution treatment. Organisations for active drug user are not, however, the only actor on the drug policy scene to speak up for drug users. Several of the articles in this publication focus not only on organisations for and by active drug users, but also on organisations run by former drug users, by drug users in substitution treatment or by drug users’ relatives. In their contribution Brandsberg Willersrud & Olsen show how these different kinds of organisations differ in their views on drugs and drug users and how they struggle in public debates to gain the status of the legitimate voice of drug users. Many of the contributions trace the historical development of different organisations, explore their relationship with the authorities, as well as the relationship between different but interrelated organisations in the field. A further important aspect covered in this publication is the involvement of drug users in different kinds of social services, which offers interesting insight into drug users’ interaction with the official system. The articles look at user participation both from the point of view of user consultation, where users are asked their opinion and where they respond to the demands expressed, and from the point of view of direct action, without any clear demands on the part of the system. In the Nordic countries, the first organisations for active drug users were formed during the 1990s in Denmark and Norway, and in Sweden in the early 2000s. In Finland, the first user-driven organisation was established in 2004 (see the contribution by Tammi). These drug user organisations have been founded by heroin users, they are run by heroin users and users in maintenance treatment, and they also cater for active drug users, mainly heroin users. Representing active drug users, the aim of these organisations is to raise issues where the situation of drug users is considered unacceptable in relation to treatment systems, control policies or the criminal justice system, for example. In this sense the organisations serve as interest organisations and a mouthpiece for active drug users. This publication aims to provide a deeper understanding of the background for the emergence of these organisations, what they mean in a broader sense, and how they help and empower drug users. It is a guiding assumption in this publication that user organisations and the patterns of participation they provide for have to be understood and studied in close relation to the social, cultural and political context in which they emerge. An important aim of this publication is hence to draw attention to some aspects of drug policy and some trends in drug use in different national contexts that 6 enable the emergence and continuity of drug user organisations. Examples are included from Denmark, Finland, Norway and Sweden. To sharpen the comparative focus, a contribution is also included on drug user organisations in the Netherlands, where the first drug user organisations emerged much earlier than in the Nordic countries. Drug User Organisations: A Social Movement in Formation? Many of the contributions in this publication deal with associations and organisations that are rather difficult to define and categorise: some of the terms used to describe them include user organisations, client organisations, self-help organisations, patient groups, interest organisations, voluntary organisations, and social movement organisations. Indeed this field is characterised by great diversity. At the same time, though, the wide range of terms also indicates that a number of different analytical approaches are possible. We suggest that many of the organisations described here indeed have a certain family resemblance (Wittgenstein 1953) with phenomena that often are referred to as social movements (calling attention to groups, questions, values and rights of minorities that are often ignored or repressed by society). At the same time, however, the concept of social movement may be misleading if it is used in its traditional sense, i.e. as broad collective action that challenges existing relations of power – which is how the concept has been used in the empirical analysis of peace movements, labour unions, women’s rights movements, or civil rights movements. The organisations described here are often much more introvert, defensive and vulnerable than the powerful collective actors that are traditionally described as social movements. Nonetheless they may still be important to the participants themselves, to policy makers, and to the general development of drug policies and drug users’ living conditions in the future. Indeed the associations discussed and described here, seen individually as single cases in their respective national political contexts, appear weak, fragmented and marginalised. However the picture is very different if we look at them not as separate and isolated national phenomena, but rather as part of a broader transnational current. The idea of movement becomes more relevant when the minor associations are considered as part of a more widespread trend that seeks to address, question and even challenge the conditions and policies that define and structure drug users’ lives. In this way, some of the associations in this publication may be seen as being related to and stimulated by the emergence of an international harm reduction movement that challenges the hegemony of the discourse of a drug-free society (Bluthental 1998; Wieloch 2002; Tammi 2005). 7 One argument for this unified view on drug user organisations is that they tend to copy ‘repertoires of contention’ (Tilly 2002), applying similar forms of action to gain attention to their problems. For instance, drug user organisations in the Netherlands, Denmark, Norway and Sweden have copied the idea of awarding a prize to someone who has made a particular effort to help drug users in the field (see Tops, Anker in this publication). The different organisations also tend to support one another, and the Danish Drug Users’ Union has directly supported the formation of drug user associations of similar ideological persuasion in both Norway and Sweden. Furthermore, there have been serious attempts to form and strengthen international networks and cooperation between associations of active drug users. Thus, at the annual International Conference on Drug Related Harms in Vancouver on April 30 – May 4, 2006, representatives of user organisations from all over the world gathered in a special session to agree on a common statement and to discuss ways of stepping up their collaboration. Finally, some of the organisations are members of international networks and organisations that are committed to promoting harm reduction measures or the downgrading of control policies. While we must not overestimate the extent and weight of this cooperation, and indeed activists themselves tend to look upon their organisations primarily as national or local efforts, it is interesting that the phenomenon definitely is in evidence in many countries around the world, and that in many others it is only just beginning to unfold. All social movements develop through certain phases: they usually start as minor, more or less invisible units or networks, and gradually gather momentum. This was also true in the case of the movements mentioned above (Calhoun 1993). Our argument is not that these groups and associations are social movements proper; we acknowledge and emphasise that individual organisations should not be misinterpreted as social movements (Eyerman & Jamison 1991). Nevertheless many of the articles in this publication are inspired by social movement theory, which is also applicable when exploring the character and processes of other, smaller phenomena than the more powerful and well-known collective actors. We find, in other words, that each organisation may be analysed through the lens of social movement theory, and to underline this, we suggest that drug users’ associations can be seen as ‘social movement organisations’ (Zald & McCarthy 1987). Social movement organisations are singular organisations that form part of a broader social movement. The purpose of applying this term is to signal that the associations concerned are basically ‘just’ normal interest organisations when studied individually. At the same time, though, they appear to form part of something bigger, and they address a specific conflict in society. They strive to gain recognition for the rights of a particular group of people and to gain influence over and to change current drug policies. In other words, even though they each apply rather pragmatic and non-confrontational strategies (with the exception of the Dutch organisation), their broader and collective aim is to change existing power relations and structures – and in this sense they may be seen as social movements in formation. We therefore use the concept of social 8 movement organisations to describe these associations that are aimed at changing local or national drug policies and that are – or claim to be – either organised by or work for their constituency. Understanding User Organisations and User Participation The articles in this publication focus primarily on the particular forms of user participation and associations that are found in the respective national contexts. It follows that they are rather different in nature and deal with the issue of user participation and association from various different angles. However, these differences in themselves contain an important message in that they provide very useful and important insights into the various dominant perceptions of user participation and user association in the different national contexts. Even though the organisations share many similarities in common, the articles clearly reveal how sharply the ideas of drug user organisation differ in Sweden and Norway from those in Denmark and the Netherlands, and that in Finland drug user organisation is still very much in its infancy. But how should these differences be interpreted? Is it possible to explain why user participation and association assume so very different forms in countries that in cultural, social and political terms are so closely connected? Based on a careful reading of the articles in this publication, and inspired by social movement theory, the following sections aim to provide a provisional outline of some of the features that appear to influence the landscape, opportunities and constraints of drug user organisations and participation. This, we hope, will help to pave the way to new and more focused comparative studies of user organisation and participation in which the relationship to national and international drug policies can be explored in more depth. Theories of social movements are generally concerned to understand and explain why movements emerge and how they are organised, how they interact with other actors in their respective field and why some movements succeed while others fail. One line of social movement theory points at the importance of the resources of social movement organisations (Zald & McCarthy 1987), other theories emphasise the significance of political opportunities and political processes (Tarrow 1994; McAdam, McCarthy & Zald 1996), others still emphasise the processes of forming collective identities and the discursive struggles in which movements are engaged (Melucci 1996; Johnston & Noakes 2005). These different theoretical leanings each contain important analytical clues as to how the differences between drug users organisations in the countries included here are understood. We do not propose to offer a full-blown theoretical argument that gives full credit to the different theoretical stances. 9 Instead, on a very eclectic and provisional basis, we present the dimensions that appear to be important in the case of drug user organisations. In other words, drawing on the thinking of social movement theory, we are aware of the importance of resources, opportunities, openings and constraints and we seek to take both institutional and discursive elements into consideration. The field in which the organisations and opportunities for participation are located, is absolutely crucial to the type of organisation and the kind of action that is possible. Moreover, it influences the type of collective unity and selfunderstanding that is created among drug users. In the same way as the organisation of labour structures the self-understanding, the action repertoire, and the fate of the labour movement, the trends of drug use, the organisation of services for drug users, and spaces of interaction among drug users are extremely important to drug user organisations and to drug users’ participation. Following from this, Rucht (1996) applies the concept of context structure to the analysis of social movements. Context structure includes ecological elements, i.e. conditions external to a given movement. The most crucial contextual dimensions are the cultural, social and political. Seeking to translate these dimensions into more specific empirical categories, we suggest that the three main aspects that should be taken into consideration when examining and explaining drug users’ struggles for legitimacy are the dominant ideological and moral perceptions of drug use, the institutional contexts and patterns of drug use. We elaborate on these dimensions below. Institutional Patterns: Inclusive Welfare States – Excluding Practices Drug user organisation and drug user participation in the Nordic welfare state is characterised by a number of odd constellations and contradictions. On the one hand, a number of institutional and cultural practices provide opportunities for drug users. On the other hand, specific institutional practices and some overarching ideological and moral schemes tend to limit or remove the legitimacy of drug user organisation and participation. Moreover, the situation varies in the different countries, as will be discussed in more detail further on. First, a few comments are in order on the nature of the welfare system. From an international perspective it is important to emphasise that the Nordic welfare states as well as the Netherlands both provide a minimum level of social security to all their citizens. Even so, users of illegal substances often live a miserable life in poor conditions. However the existence of a public social safety net means that drug users, at least in principle, are guaranteed the satisfaction of their most basic human needs. 10 An illustrative example of the welfare system’s role as a source of income is that many activists in the Danish Drug Users’ Union receive early retirement benefits rather than social benefits. As their primary material needs are met, this provides, at least in theory, an opportunity for them to engage in organisational activities, such as in user organisations. The existence of a social security system in other words ensures that the energies of drug users may be channelled into activities that are not entirely a matter of physical survival. A number of specific restrictions are occasionally applied to the group of drug users, however. In Sweden, for example, there are requirements of remaining drug free for a certain period of time in order to qualify for different kinds of assistance (e.g. housing benefits). Differences of this kind between the countries are related to the moral and ideological regimes, which dominate drug policies. Moreover, they may also either facilitate or hamper drug users’ organisation and participation. The Nordic welfare state system leans heavily on Social Democratic ideologies. However, welfare states today are exposed to mounting pressures as a result of the challenges of globalisation, new demographic patterns, and growing neoliberal ideologies. These trends are also felt in the field of drug user organisation and participation, where practices of social work as well as client categories are gradually changing. Stenius (2006), who has studied the citizenship and rights of substance users in Finland and Sweden, asks how two countries with extensive treatment systems for alcohol and drug problems both continue to have a group of substance users that is socially marginalised, in terms of weak social networks, poor housing and exclusion from the workforce? She concludes that both countries have changed into a society that no longer is able to provide work for all its citizens. Instead, a minimum normative goal is to produce independent consumers of goods and services, whose incomes also may derive from the welfare system. In practice, however, several aspects, such as legislation and the role assumed by the state, impacts the extent to which basic human needs are met. As an illustrative example Laanemets refers in her article to how different changes influence the field of drug treatment in Sweden, where there are signs of a growing focus on decentralisation, market-related solutions and a gradual withdrawal of the central state. One important aspect that needs to be addressed when discussing drug users’ spaces for legitimate action is the shift in social political concepts from ‘client’ to ‘consumer’ (or ‘user’, as is the English translation of the Danish ‘bruger’, the Swedish ‘brukar’, and Norwegian ‘bruker’, Finnish ‘asiakas’). Welfare policies in general and social policies in particular have been influenced since the 1990s by neo-liberal currents, new public management schemes and ideas of empowerment, which also lie behind the new understanding of citizens as ‘users’ (in the sense of consumers) of welfare institutions such as treatment systems, social security, hospitals, etc. (Asmussen 2003; Asmussen & Jöhncke 2004; Bjerge 2005). In short, this social policy discourse is based on ideas of user ‘empowerment’ and active ‘participation’. In this understanding, citizens are 11 offered a greater degree of freedom, but also expected to assume greater responsibility for managing their own life. The state, in this model, is responsible for providing efficient and targeted services for users, and user participation is one of the means for improving the effectiveness and efficiency of services. In other words the Nordic social policy context – somehow through the back door – advocates ideas and a rhetorical frame that enable drug users legitimately to promote their wishes and to claim their right to substitution treatment, for example. The social policy context has so to speak invited drug users into an exchange on the question of how to deal with drugs in society. In Denmark, the Ministry of Social Affairs has consistently provided economic support for organisations for drug users and homeless people since the mid-1990s. Nonetheless there are still critical voices which suggest that user participation can also be seen as a particular form of control. Brandsberg Willersrud & Olsen discuss this issue in their article, while Asmussen in her contribution deals with some of the dilemmas of user participation. The Nordic welfare states and the Netherlands have long traditions of involving organised interests in the drafting of legislation and major reforms. Corporatism was gradually established in the 20th century, enabling labour market organisations to gain significant influence in the development of the welfare state. Voluntary organisations have also traditionally held a relatively strong position and degree of legitimacy in the Nordic countries, where they serve as claims makers and service providers in specific areas of the social welfare system, especially in the alcohol and treatment system (Stenius 1999). Compared to the Netherlands, however, voluntary organisations here play a minor role in the central fields of the social welfare system. In the Netherlands, with its strong liberal tradition, drug treatment facilities are almost entirely provided by NGOs. In the Nordic countries the main responsibilty for the provision of medical treatment rests with the public authorities at central government, county or municipal level. Nonetheless NGOs and private foundations are still important suppliers of other forms of treatment. Even though these organisations are not officially part of the state apparatus, they work closely with the public system and depend heavily on public funding. As far as drug user organisations are concerned, this is something of a dilemma because these organisations are dependent on the authorities, which at once constitute a target for the organisations’ actions. This implies a difficult balancing act and the organisations risk becoming co-opted by and adapted to the political structures to such a degree that they eventually lose their room for manoeuvre. In their contributions Laanemets and Tops both draw attention to some of the dilemmas and limitations faced by organisations when they enter into close cooperation with the authorities or when they become heavily dependent on public funding. However, even though the tradition of corporatism has been said to clearly favour a particular kind of interests (Hernes 1987), it also gives rise to a particular administrative and democratic practice in which organised interests 12 are given a legitimate right to have a say in public inquiries. This is an issue that Johnson addresses in his article with reference to particular interest organisations’ influence on decision-making processes in Swedish drug policy. He concludes that drug user organisations have in fact had only very limited influence on Swedish drug policy, a trend that has continued (or worsened) with the further reinforcement of control policies. In his opinion, the emergence of the Swedish Users’ Union is not an outcome of increased openness or better opportunities for participation, but rather of neglect and limited opportunities for interest representation. National Patterns of Drug Use Another feature that influences drug users’ opportunities for organisation and participation apart from the dominant ideological and moral perceptions of drug use and the institutional contexts, is the pattern of drug use. Specific practices and traditions of drug use – which are obviously linked to the nature of drug policies – provide the basic condition for users to identify shared interests related to drug use and representation in relation to the authorities and the surrounding society. The countries described in this publication all represent different trends and histories with respect to drug use and perceptions of drug use. These trends are crucial to understanding the emergence of user organisations and the specific demands placed on the services provided for drug users. The lack of organisations for active drug users may for instance in the case of Finland be explained by the absence of a ‘tradition’ of heroin use. It seems that the presence of particular treatment facilities can often support and promote the establishment of drug user organisations. The following outlines some of the recent trends in drug use and drug policy in Denmark, Finland, Norway, Sweden, and the Netherlands. Together with the rest of Europe, the Nordic countries saw increased levels of drug use in the 1990s (EMCDDA 2005, 11–12). In all countries the fastest growing category seems to be represented by poly drug use, but some substance specific comments can nonetheless be made. In Denmark heroin is reported to be the primary drug for about 60 per cent of those seeking treatment (National Report to the EMCDDA, Denmark 2004). Injecting heroin use has been going on in Denmark for several decades, and even though this is still the most prevalent form of use, smoking heroin has become increasingly common among those entering treatment. In Norway, too, drug users who seek treatment are primarily intravenous heroin users (National Report to the EMCDDA, Norway 2005), and again injecting heroin use has been going on for decades. In Finland and Sweden there is a long tradition of intravenous amphetamine use. Until the 1990s opioid 13 use was virtually non-existent in Finland. Recent estimates of problem drug use around the turn of the century put the proportion of amphetamine users at around 70–75 per cent (Partanen et al. 2001). Among those seeking treatment for injecting opioid use in 2004, 27 per cent sought treatment for buphrenorphine use, and only 3 per cent for heroin use (Clients in Substance Abuse Treatment/Stakes, 2004). In Sweden large numbers of users who seek treatment are on amphetamines, but the figure for those using heroin is rising and is now at almost the same level as amphetamine use (National Report to the EMCDDA, Sweden 2003–2004). In the Netherlands, heroin has been regarded as the most problematic drug ever since its introduction on the black market in 1972, although since 1990 it has been accompanied by cocaine. In 2003, the number of heroin clients registered in ambulatory treatment showed a tendency to decrease, while the number of cocaine clients was on the increase. The proportion of amphetamine clients remained steady (VWS 2005). There are organisations for active drug users, mainly heroin users, in the Netherlands, Denmark, Norway and Sweden. Finland has organisations that are run by relatives of drug users, but none run by active users themselves. In the past year or so, however, small groups of users have been forming. Against the background of the different drug trends and traditions in the Nordic countries it is hardly surprising that Finland did not have any such organisations until 2006. As Tammi explains, it takes time for the necessary critical mass to form, and since it was not until the late 1990s that hard drug use really began to expand in Finland this is still a novel phenomenon. Furthermore, the mean age of drug users in Finland is lower than in the other countries concerned. Young people with a relatively short ‘drug user career’ can therefore hardly be expected to have gained sufficient experience and political awareness of the drug field to perceive a need for collective action. Yet if we want to gain a more in-depth understanding of what facilitates or obstructs the emergence of drug user organisations, we cannot simply explore trends of drug use in isolation from the ideological and moral perceptions of drug use, which are largely reflected in national drug policies. Moreover, it appears that drug user organisations often tend to emerge in the wake of developments in the treatment system. The services and intentions of the treatment system tie in closely with the ideological and moral principles that lie behind national drug policies. In the next section, we first provide a short overview of the most salient features of national drug policies, and then return to the question of how the treatment system is connected to drug user organisations and participation. 14 National Drug Policies, Harm Reduction and Substitution Treatment The Nordic countries are often said to represent a particular type of welfare state model (Esping-Andersen 1990). However, as far as drug and control policies as well as drug users’ opportunities for legitimate action and participation are concerned, there are certainly many differences between these countries (Hakkarainen, Laursen & Tigerstedt 1996; Christie & Bruun 1985). Drug policies consist of different domains (control, treatment and prevention) that often contradict one another, mainly since they are often based on different – and often contradictory – drug policy ideologies. Basically, a restrictive control policy is typically associated with ideas of abstinence and a drug-free society in the realms of treatment and prevention. A liberal control policy, on the other hand, fits more easily with ideas of harm reduction. Norway and Sweden have traditionally had the most restrictive drug policies in the Nordic countries, pursuing ideas of a ‘drug-free society’. Harm reducing initiatives, then, have been virtually non-existent, at least until recently. Denmark, on the other hand, has until today had the most liberal drug policy, both with respect to its control policy and the existence of harm reducing initiatives alongside drug-free treatment. Finland differs from the rest of the field in the sense that up to the 1990s, it had only minor drug problems. Officially, the goal was to prevent drug use and minimise the supply of drugs. The country’s drug policy was mainly control-oriented. Minimal attention was given to the treatment of drug abuse (Hakkarainen & Tigerstedt 2005). The Netherlands has no mechanisms in place to try and eliminate drug use, and the official policy for almost 20 years has been one of harm reduction. Instead, the main focus has been on the (wholesale) trade of hard drugs and cannabis (Tops 2001). In the 1990s all the Nordic countries (and indeed northern Europe more generally) saw changes in patterns of drug use as well as an increased public awareness of the serious consequences of problematic drug use. This prompted new responses to drug use and new directions in drug policy. Still, the main strategies vary according to the ideological climates and the political compromises reached in the respective countries. Today, drug policies seems to be moving towards an increased focus on substitution treatment or ‘medicalisation’ even in those countries that traditionally have had a restrictive drug policy (Skretting 2006). At the same time, however, there are no signs in the Nordic countries of their intending to downgrade the control against drug users. In Finland, for instance, the policy has moved forward on a dual track of both increased control and increased harm reducing measures (Hakkarainen & Tigerstedt 2005). In the past 3–4 years Danish drug laws have also become more restrictive. At the same time there is a strong tradition of methadone maintenance treatment. Recently a three-year 15 methadone trial with extended psychosocial support was initiated as an alternative to a heroin trial. An important part of this trial was to integrate user participation in treatment facilities in order to empower drug users and encourage them to take part in their own treatment. In this publication Asmussen discusses the different forms of user participation implemented in the trial and addresses the question as to how far these initiatives provide opportunities for drug user participation in their interaction with the treatment system. Norway has continued to pursue a restrictive drug policy and it is now moving towards a more lenient criminal policy. As Brandsberg Willersrud & Olsen point out in their article, however, the increasing number of drug-related deaths in the 1990s meant that the country began to lean more towards a harm reducing drug policy. Substitution treatment is today an integral part of the treatment offered to drug users in Norway. Even Sweden, which has taken the most restrictive stance on medically-assisted treatment, introduced substitution treatment with buprenorphine in 1999. The articles by Anker, Brandsberg Willersrud & Olsen, Palm and Tammi all show that the first initiatives to establish drug user organisations or organisations that speak up for active drug users often takes place within or in close connection with substitution treatment facilities. The organisations raise critical questions with respect to the treatment provided, for example the availability of substitution treatment in general, the control of supplementary use of illegal drugs, as well as other forms of control measures practised by the treatment institutions. In Norway the first user organisation MIG-96 started up in connection with the country’s first methadone trial, with the aim of improving the quality and availability of methadone treatment in general (Brandsberg Willersrud & Olsen). In Denmark, the Danish Drug Users’ Union (DDUU) was established in 1993 following the closure of a popular activity centre for methadone users (Anker). In Finland, the Association for Support of People with Opiate Addiction (ORT) campaigned between 1997 and 2003 to increase the availability of treatment for opiate addicts and generally to improve the quality of treatment. The first user-driven organisation, Support for Substitution Treatment Association (KT), consisting of four clients of a substitution treatment clinic in Southern Helsinki, was established in 2004 (Tammi). The Swedish Drug Users’ Union was set up in 2002, and one of its main criticisms has been against the strict formula for substitution treatment in Sweden (Palm). The first organisation for drug users in the Netherlands was established in Amsterdam in 1975. In its first year the organisation advocated an alternative ‘user-friendly’ treatment approach. Soon, however, it shifted its attention to campaigning for a change in the national drug policy on hard drugs, which was seen as the main cause for the problems encountered by drug users (Tops). Apparently, there is some kind of connection between the establishment of substitution treatment programmes and the emergence of drug user organisations; but how can this connection be explained? We suggest that the 16 introduction of harm reduction initiatives in general, and substitution treatment programmes in particular, open up opportunities for organisation and user participation among drug users. First, in a situation where the aim of a drug-free society dominates and rules out any other pragmatic options, there is very little tolerance for and acceptance of alternative voices. In a context of control, repression and zero tolerance, drug users will have only very limited room to manoeuvre as long as they continue using drugs. This situation seems to have prevailed in Sweden for many years, and the only legitimate and visible mouthpiece for drug users have been organisations of former drug users or associations of relatives. There must be a certain acceptance of harm reduction initiatives in order for drug user organisations to emerge. In both Denmark and Finland, relatives of drug users and medical doctors have been important advocates for harm reduction initiatives and substitution treatment programmes. They have sought to document the need for substitution treatment, they have highlighted the right of drug users to receive treatment, and they have occasionally sought to change practices themselves, for example by providing methadone to drug users through acts of civil disobedience (see Tammi and Anker in this publication). These groups are important allies to drug user organisations, and they often appear to be important because of their ability to mobilise and channel resources (economic, skills, strategic considerations, influence, etc.) to groups of drug users, thus enabling the subsequent formation of organisations. Moreover, once established, substitution treatment programmes create a closer and more formalised relationship of interaction between ‘the system’ (authorities) and drug users. A number of other user organisations that have emerged in relation to the social welfare system, are based on categories that from the outset were defined and invented by the system. These categories (e.g. psychiatric patients, the disabled, the elderly), after being subjected to the development of specific policies and services, have then slowly come to form the basis for acts of resistance and the formation of collective identities (Williams 1999). In other words, these categories – and the subsequent collective actors – are to a great extent created and structured by the system. Gubrium and Holstein (2001) have called the identities institutional selves. This, we contend, is also the case with drug user organisations. Most drug user organisations are directed towards different levels of authorities in the drug policy field, they define themselves and their actions in relation to the authorities, and it is also from the system that they seek recognition and legitimacy as collective actors. This process is enabled by the creation of substitution treatment programmes. Substitution treatment programmes create a shared space and a shared point of reference where drug users are expected to conform to the previously defined 17 rules and requirements. Whereas life as a drug user, without any formal relationship to the system, does not necessarily bring drug users together, the rules, physical space and interaction with health and social workers involved in a substitution treatment programme become a shared experience and an opportunity to interact as a group with particular characteristics. In this way drug users feel they are confronting the same opponent, and thus also have an identifiable target for their claims. Finally, substitution treatment programmes draw the drug issue closer to the medical discipline, converting as they do the drug use into a matter of illness rather than just a moral issue. In other words, substitution treatment programmes also help to afford the drug user the status (and rights) of a patient who is entitled to claim his or her rights, proper treatment, and recognition and respect as a human being. Drug users may still object to this perception of drug use as an illness, but our point is that the hegemony of moral judgements loose strength when drug users become more closely connected to the health system, as patients rather than as social outcasts. Struggling for Legitimacy in a Climate of Ideological and Moral Condemnation People addicted to drugs are a small minority, and the majority of people in society do not share their experiences. However the ‘drug issue’ has been regarded as a very serious social problem for many decades now, and in that respect it has been of great interest to society. For drug user organisations, the challenge is to frame the problems of their constituencies in such a way that they resonate with cultural patterns in the population and are easy to recognize. The way that drugs and drug problems are conceptualised in national drug policies depends closely on the choice of language in describing these problems. An example is provided the Danish government’s use of language in the recent publication The Fight against Drugs - action plan against drug abuse (2003). The use of ‘fight’ here resembles the American drug rhetoric of ‘war on drugs’. The choice of ‘drug abuse’, then, implies a particular moral attitude towards drug use, including a sense of ‘irresponsibility’, ‘weak personality’, ‘lack of selfdiscipline’, ‘lack of motivation’, etc. Decades of liberal Danish drug policy have now given way to a more repressive policy – and at the same time to rhetoric traditionally used in connection with repressive drug policies. Drug use in general is constructed and perceived as something negative and dangerous, not only to the individual concerned but also to society at large, and it seems extremely difficult to shrug off the negative image of drug user that follows from this understanding (Christie & Bruun 1985; Gossop 2000/1982, 18 Reinarman & Levine 1997). Drugs have become a powerful metaphor with (extremely) negative connotations. Drug addiction, drug abuse and even drug use are blamed for the worsening of – or even seen as synonymous with – different traits such as criminality, instability, untrustworthiness, violence, mendacity, a weak personality, bad temper, irresponsibility, etc. Such is the power of the metaphor that drug users are identified by society as people with particular traits, regardless of whether or not this is the case. It is important to underline that drugs and drug use may have devastating, even fatal consequences. People get into serious problems by using drugs, and some drug users can in certain situations be identified with the traits described above. However it is important to recognize that the general perception of drug use is so pervaded by moral and ideological judgements that other perceptions of drug use have great difficulties gaining legitimacy. As is shown by the articles in this publication, these negative and moralising attitudes may also hinder drug user participation. In an environment of control and moral condemnation, drug users will often hesitate to openly admit they are drug users. They therefore often lack spaces of legitimacy where they could take their first steps of organisation. Palm discusses constructions of the ‘user’ by the Swedish User Organisation (SBF) in relation to the limited space and possibilities to act in the name of active drug users. One of the aims of organisations for active drug users is to try and change the existing, denigrating perceptions. Stigmatisation and marginalisation are among the key issues addressed by these organisations. In this publication Anker, Palm and Brandsberg Willersrud & Olsen discuss the different strategies applied by drug user organisations to fight stigmatisation and marginalisation. One of those strategies is to use concepts that avoid negative connotations. Therefore, rather than talking about ‘drug abusers’, ‘drug addicts’ or ‘junkies’ (Denmark & Norway: ‘narkoman’, Sweden: ‘knarkare’, Finland: ‘narkkari’), which all carry the negative associations described above, most drug user organisations prefer the more neutral term ‘drug user’. Their rationale is that a change in language in the long run will bring about a change in meaning and hence a change in perceptions of drugs as well as drug use. Besides strategies to overcome stigmatisation, another probably more immediate effort to alter the negative perceptions of drug users is by demonstrating their ability to run or participate in running an organisation, to take part in meetings, keep agreements, etc. A related question is whether drug user organisations should be organisations by or for drug users. If run solely by active drug users, they will be exposed to vulnerabilities due to the usually unstable lifestyle of drug users and the repression of drug policies. This is basically a matter of the constituency of drug user organisations and whether these consist of drug users who are still using illegal drugs or of former drug users. 19 As is shown in this publication, different solutions are applied in order to overcome problems related to drug user organisations’ constituency and strategies. The way that organisations are run seems to be in a constant state of flux and their strategies to be constantly re-negotiated. The issue of interest organisations’ recognition and legitimacy is crucial, and an enormous amount of energy is invested in pursuing that legitimacy. On some occasions, drug users even compete with former drug users, with different groups all claiming to speak on behalf of all drug users, as discussed by Brandsberg Willersrud & Olsen and others. In the process of gaining recognition, new organisations are founded at the same time as others are closed down, as outlined by Tammi in this publication. The survival and success of drug user organisations is never a matter only of suitable strategies, but merely an indication of how the messages articulated are heard and interpreted in a certain place and at a certain time. Therefore, as discussed above, the impact of the institutional contexts, national drug policies, patterns of drug use and dominant ideological and moral perceptions of drug use all contribute to the existence and survival of user organisations. The emergence of user organisations in the Nordic countries during the past decade also show that these are no isolated events, but part of a broader movement and network. Networks and what Melucci (1996) has called the invisible phases of social movements are crucial to the development and understanding of social movements. They provide the necessary foundation for meaning work, and they are basically a prerequisite for the mobilisation of resources and for the creation of shared understandings of aims and strategies. So perhaps the fragmented initiatives of association and user participation – the efforts of the more or less invisible networks – that we are witnessing today, may prove to be an initial phase of a broader organisation and self-awareness among marginalised groups of the welfare society? Literature Asmussen, Vibeke (2003): User participation: possibilities and limitations in Danish social services directed towards drug users. In: Houborg Pedersen, Esben & Tigerstedt, Christoffer (Eds.): Regulating Drugs – Between users, the police and social workers. NAD Publication No. 43. Helsinki: Nordic Council for Alcohol and Drug Research (NAD), pp. 11–32. Asmussen, Vibeke & Jöhncke, Steffen (Eds.) (2004): Brugerperspektiver – fra stofmisbrug til social politik? [User perspectives – from drug misuse to social policy?] Århus: Aarhus Universitetsforlag. 20 Bjerge, Bagga (2005): Empowerment og brugerinddragelse i praksis: mellem forestillinger og det muliges kunst. En antropologisk analyse af forestillinger om "godt" socialt arbejde i relation til praksis blandt svagtstillede metadonbrugere [Empowerment and user participation: practice, perceptions and possibilities]. Center for Rusmiddelforskning, Aarhus Universitet. Bluthenthal, R. N. (1998): Syringe Exchange as a Social Movement: A case study of harm reduction in Oakland, California. Substance Use & Misuse, 33 (5): 1147–1171. Calhoun, Craig (1993): “New Social Movements” of the Early Nineteenth Century. Social Science History, 17:3 (Fall), pp. 385–427. Christie, Niels & Bruun, Kettil (1985): Den gode fiende [The suitable enemy]. Oslo: Universitetsforlaget. Clients in Substance Abuse Treatment/Stakes, 2004 EMCDDA (2005): Annual Report on State of the Drugs Problem, pp. 11-12. Esping-Andersen, G. (1990): Three worlds of welfare capitalism. Cambridge: Polity Press. Eyerman, Ron & Jamison, Andrew (1991): Social Movements. A Cognitive Approach. London: Polity Press. Gossop, Michael (2000/1982): Living with drugs. Aldershot: Arena. Gubrium, J. F. & Holstein, J. A. (2001): Institutional selves: troubled identities in a postmodern world. New York, Oxford University Press. Hakkarainen, P.; Laursen, L. & Tigerstedt, C. (Eds.) (1996): Introduction: Sisters are never alike. In: Discussing drugs and control policy: Comparative studies on four Nordic countries. NAD-publication No. 31. Helsinki: Nordic Council for Alcohol and Drug Research (NAD), Helsingfors, pp. 9–19. Hakkarainen, P. & Tigerstedt, C. (2005): Korvaushoidon läpimurto Suomessa. [The breakthrough of substitution treatment in Finland]. Yhteiskuntapolitiikka 2/2005, pp. 143– 154. Hernes, H. M. (1987): Welfare state and woman power. Essays in state feminism. Vojens, Norwegian University Press. Johnston, H. & Noakes, J. A. (Eds.) (2005): Frames of protest. Social movements and the framing perspective. Rowman & Littlefield Publishers Inc. McAdam, D.; McCarthy, J. D. & Zald, M. N. (1996): Preface. In: McAdam, D.; McCarthy, J. D. & Zald, M. N. (Eds): Comparative Perspectives on Social Movements. Political Opportunities, Mobilising Structures, and Cultural Framings. Cambridge: Cambridge University Press. Melucci, A. (1996): Challenging codes: collective action in the information age. Cambridge: Cambridge University Press. National Reports to the EMCDDA, 2003–2005. 21 Partanen, P.; Hakkarainen, P.; Holmström, P.; Kinnunen, A.; Lammi, R.; Leinikki, P.; Partanen, A.; Seppälä, T.; Simpura, J. & Virtanen, A. (2001): Amfetamiinien ja opiaattien käytön yleisyys Suomessa 1999 [The prevalence of amphetamine and opiate use in Finland 1999]. Suomen Lääkärilehti, 43: 4417-4420. Reinarman, Craig & Levine, Harry G. (1997): Crack in America: demon drugs and social justice. Berkeley: University of California Press. Rucht, D. (1996): The impact of national contexts cross-movement and cross-national comparison. In: Zald, M. N. (Eds.): Comparative Perspectives Opportunities, Mobilising Structures, and Cultural University Press. on social movement structures: A McAdam, D.; McCarthy, J. D. & on Social Movements. Political Framings. Cambridge: Cambridge Skretting, A. (2006): Treatment and Harm Reduction Measures. In: Kouvonen, P.; Skretting, A. & Rosenqvist, P. (Eds.): Drugs in the Nordic and Baltic Countries. Common Concerns, Different Realities. NAD-publication nr 48. Helsinki: Nordic Council for Alcohol and Drug Research (NAD), pp. 73–104. Stenius, K. (2006): Citizenship, civil society and substance abuse – an exploration of the Finnish and Swedish logic of inclusion and exclusion (unpublished). Stenius, K. (1999): Privat och offentligt i svensk alkoholistvård. Arbetsfördelning, samverkan och styrning under 1900-talet [Private and public in Swedish alcoholism treatment. Division of labour, co-operation and management principles during the 20 th century]. Lund: Arkiv. Tammi, T. (2005): Discipline or contain? The struggle over the concept of harm reduction in the 1997 Drug Policy Committee in Finland. International Journal of Drug Policy, 16 (6), pp. 363–438. Tarrow, S. (1994): Power in movement: social movements, collective action and politics. Cambridge: Cambridge University Press The Fight against Drugs – Action Plan against Drug Abuse (2003). København: Indenrigs- og Sundhedsministeriet [Ministry of Home Affairs and Ministry of Health]. Tilly, C. (2002): Stories, Identities, and Political Change. Lanham, Md.: Rowman & Littlefield Pubishers, Inc. Tops, D. (2001): A Society With or Without Drugs? Continuity and Change in Drug Policies in Sweden and the Netherlands. Lund, School of Social Work. Wieloch, N. (2002): Collective Mobilization and Identity from the Underground: The deployment of “oppositional capital” in the harm reduction movement. The Sociological Quarterly, 43 (1): 45–72. Williams, Fiona (1999): Good-Enough Principles for Welfare. Journal of Social Policy, 28 (4), 667–87. Wittgenstein, L. (1953): Philosophical Investigations. Oxford: Blackwell. VWS (2005): Ministry (Http://www.minvws.nl) of Health, Welfare and Sports, The Netherlands Zald, M. N. & McCarthy, J. D. (1987): Social movements in an organizational society: collected essays. New Brunswick, N.J.; Oxford, Transaction Books. 22 Who is the Expert? Patient Groups and Finnish Substitution Treatment Policy Tuukka Tammi Introduction Based on their literature review, Hunt and Barker (1999) conclude that the client’s experience of drug treatment is the single most uncharted area in drug treatment research. Although substitution treatment (with methadone) is one of the most investigated treatment modalities, research on clients’ perceptions and experiences is virtually non-existent: researchers have been more concerned with documenting the use and efficacy of treatment services and less concerned with the clients’ perspective on the treatment they receive (Hunt & Barker 1999, 129– 131). However, the rare – often ethnographic – studies that have been conducted on the methadone clientele show how clients are not passive recipients, but instead active participants within the world of the clinic, and they may successfully resist the surveillance as well as the new particular identity offered to them as clients or patients (ibid.; Skoll 1992; Fraser 1997). This article contributes to the limited research on client experiences of substitution treatment. It describes the claims-makings of two Finnish client organisations with regard to substitution treatment. These organisations were born out of dissatisfaction with the slow progress and poor quality of substitution treatment in Finland at the turn of the millennium: they are an association for the support of opiate addicts (Opiaattiriippuvaisten tuki ry; ORT) and an association for the support of substitution treatment (Korvaushoidon tuki ry; KT). As will be described below, both of these groups started out in response to a sense of being deprived of something as patients. Until the mid-1990s, both the use of drugs and related problems were still relatively marginal in Finland when compared to most other Western European countries. The situation then began to change: not only experimentation but also intravenous drug use and related harms began sharply to increase, which also drove up the demand for treatment and drug-related crime (Partanen & Metso 1999; Virtanen 2005). This resulted in various mobilisations in the drug policy field: committees and working groups were set up, action plans were drafted, and various professions called for more resources. As a consequence, many concrete changes followed (for more on these changes, see Tammi 2002, 2005a & 2005b; 23 Hakkarainen & Tigerstedt 2004). One was the dramatic change in substitution treatment policy, which saw the number of clients increase from just a few patients in the mid-1990s to almost 1,000 in 2005. The rapid changes have been explained not only by reference to the changing drug situation, but also by the forceful campaigning of a medical lobby for substitution treatment. Initially this lobby consisted of just a couple of medical doctors, most notably Pentti Karvonen, a private MD whose liberal practice of buprenorphine prescription first gave rise to official warnings, then to his being struck from the medical register, and eventually to a prison sentence for illicit trafficking and distribution of buprenorphine to his clients. At the same time as this drama was unfolding, the lobby for substitution treatment continued to grow and even many official players in the drug treatment policy field became more favourably inclined towards the new practice. Particularly influential in this regard was the advocacy of substitution treatment by Osmo Soininvaara, the Green Party Minister of Social Affairs, and Mikko Salaspuro, a prominent medical expert (Hakkarainen & Tigerstedt 2005). While at the beginning of the 1990s expert committees on drug treatment (Report on arranging treatment for addicts in Helsinki 1991; Working group report on developing medicinal treatment of opioid addicts 1993) had still taken a negative stance on substitution treatment, by the end of the decade working groups on drug treatment (Working group report on developing drug treatment 2001; Working group report on developing medicinal treatment of opioid addicts 2001) as well as general drug policy strategies (Drug Strategy 1997 – Report by the Finnish Drug Policy Committee; the 1998 and 2000 Government Decisionsin-Principle) were advocating a widening of substitution treatment. Funding has also been made available to local authorities for the start-up of these treatments. Needless to say, when we look at the range of actors who took part in this policymaking process, we find that the field was predominantly authority- and expertdriven: the actual target of the policy, the drug user, had a very little role in policy-making. This, of course, does not mean to say that users have no views and opinions on how the policies should be developed. In what follows, I give voice to the two user groups mentioned above. My data consist of documents produced by the groups concerned as well as of interviews, discussions and email exchanges with group members. I first provide some background information on the groups’ formation, composition and activities, and then move on to their claims-making. I conclude with a general discussion of drug policy and user participation in Finland. 24 Evolution and Activities of the Patient Groups The Partisans: Association for the Support of Opiate Addicts (Opiaattiriippuvaisten tuki ry; ORT) ORT worked in 1997–2003 to “increase the availability of treatment for opiate addicts and generally develop the quality of these treatments”. The group lobbied particularly for buprenorphine-based substitution treatment, this being the drug with which the above-mentioned doctor Karvonen had treated his patients. ORT was keen to adopt the so-called “French system” 1: in France buprenorphine has become the main form of substitution therapy, with some 70,000–80,000 (OFDT 2004) people being prescribed it, often by private doctors. In general, ORT wanted to “improve the way that these people who wanted buprenorphine were treated” and “to increase lay people’s knowledge about the fact that drug use is a disease that leads to many other difficulties (such as crime, domestic violence, use of child protection, infectious diseases, etc.) if not treated properly”. As mentioned, one of the main advocates of substitution treatment in Finland was a private MD who readily prescribed buprenorphine to opiate users in the Helsinki area, until the National Authority for Medicolegal Affairs (TEO) in May 1997 withheld his rights to prescribe these drugs and eventually struck him off the medical register. The formation of ORT was ultimately prompted by this decision. At the time of the decision (according to ORT) the doctor had some 200 patients who were suddenly deprived of their medicine. A group of parents and other people close to these patients approached the relevant authorities and treatment organisations in an attempt to get the treatments re-started. However, they soon noticed that the authorities “didn’t know anything about the prevailing problems and their attitude was very ignorant”.2 When the association was started in 1997 it had a membership of ten. Next year the number increased to around 30, at which level it remained until its dissolution in 2003. Who were these people? During the first two years the association consisted of drug users’ support persons and other closely related persons, in 1999 and 2000 they had also other “support members”, and from 2001 onwards ORT also reported having among its members “ex-users who are in treatment”. 3 So 1 2 3 The term was used e.g. in a letter from the ORT to the Ministry of Social Affairs and Health, dated 17.12.1998. About the French substitution treatment policy, see Bergeron (1999). ORT, Report on activities 1997. ORT, Reports on activities 1997–2003. 25 although the association was open to (ex-)users, ORT was not run by users but rather by their parents or other people close to them; therefore the association could be regarded as a semi-user group. The group had some success in its efforts to break into the formal field of drug policy-making. For instance, their opinions were consulted by the Ministry of Social Affairs and Health when the regulations on substitution treatment were updated; they testified to an expert working group on substitution treatment; they were invited to deliver a speech at a high-level conference on “evidence-based drug treatment” in 19994; and in 2001 they also received funding from the state gaming monopoly RAY, the main source of NGO funding in the field of social welfare and health, for a two-year project. In other words, ORT achieved recognition as a valid claims-maker in the field. In spite of this relative success, ORT was closed down in 2003. In the words of the ORT chairperson, this was done “in frustration after banging our heads against the wall in talking about heroin users as worthy human beings, about their rights to treatment, equality with other patient groups and so on”.5 However, during its six years of existence the group had actively advocated its cause. It wrote newspaper pieces, sent letters to politicians, submitted petitions to officials responsible for drug treatment, and maintained its own website. To give a few examples, one of the first petitions was submitted in 1997 when the Ministry of Social Affairs and Health had issued its first regulation on substitution treatment (1997:28). ORT submitted a list of demands on how the regulation should be amended. Its demands included a significant increase in the number of substitution treatment places; the allocation of resources and responsibilities to private clinics; a shift in emphasis from inpatient to outpatient treatment; the separation of drug user clients from mental health care patients; the setting up of drug-free units and needle exchange services in prisons; patient involvement in their treatment and medication; and the removal of the threemonth ceiling to treatment periods. One of ORT’s biggest efforts took place in August 1999 when they filed a complaint to the parliamentary Ombudsman together with the ombudsman for clients of substance abuse care, who provides free legal counseling for clients in drug or alcohol treatment.6 The Parliamentary Ombudsman is an institution to 4 5 6 26 These so-called consensus conferences are arranged by the Finnish Medical Society Duodecim together with the Academy of Finland; the idea is to offer a forum for discussion between medical scientists and decision makers around a given medical problem and treatment alternatives. Letter from the chair of the ORT to the author, dated 13.7.2004. The ombudsman is a project funded by the RAY, the national gambling monopoly, and it is being run by A-Kiltojen liitto (“A-Guilds Union”) which is a wide network of local associations of the clients of “A-clinics”, the outpatient treatments units for substance abusers. In practice, this association focuses purely on people with alcohol problems, but the above-mentioned service has been actively used also by the clients in drug treatment. whom citizens can file complaints if they suspect that a public authority or official has breached the law or failed to perform their duties.7 Briefly put, the content of the complaint was that the cities of Helsinki, Vantaa and Espoo (the latter two are neighbours of Helsinki) had failed to organise buprenorphinebased treatments according to patients’ needs, and that this was a contravention of legislation. The decision from the Parliamentary Ombudsman came more than two years later (dated 31 Dec, 2001) and was based on replies from the three cities as well as on three statements by the Ministry of Social Affairs and Health. This process had forced the officials to give an answer to ORT, although the passage of time and changes in substitution treatment policy had already resolved part of the problem by the time that the Ombudsman’s decision finally came through. By late 2001 buprenorphine-based treatments were increasingly accepted and offered, but the Ombudsman took the view that at the time of the complaint (1999) ORT had been in the right: demand had exceeded the supply of substitution treatment with buprenorphine. Although the Ombudsman was of the opinion that the patients had a fundamental right to treatment, she took a negative stand on the patients’ subjective right to choose what they regarded as the best treatment (i.e. substitution treatment with buprenorphine); according to the decision the patients do have the right to refuse a particular treatment, but not to choose another treatment instead. This stand was a major setback for ORT who from the outset had maintained that they and the patients were the best experts, based on both patient experiences and the latest scientific research from abroad. Patient Activism from Inside: The Association for the Support of Substitution Treatment (Korvaushoidon tuki ry; KT) Support for substitution treatment (KT) is a new association that is based on the same kind of underlying idea as the SBF (Svenska Brukarföreningen) in Sweden and the DDUU (Brugerforeningen for Aktive Stofbrugere) in Denmark. It has been set up by patients themselves around the inadequacies of substitution treatment with the aim of influencing treatment from within, from the client perspective. Although the group is still very small and young (indeed it is not yet clear whether it will survive the early dispute described below), it deserves to be introduced here because it reflects the changes that have taken place both in the drug (treatment) policy field and in user activism: just a few years ago an association like this would not have been possible because both the target of action (the content of substitution treatment) and the actors (patients in substitution treatment) did not exist in Finland. While ORT was still about influencing the system from the outside and calling for the provision of buprenorphine-based substitution treatment, the setting in the case of KT is 7 The Parliamentary Ombudsman is based on the Constitution of Finland and pays special attention to the implementation of fundamental and human rights. 27 different: here the aim is to influence the existing substitution treatment system from within, as patients who have been admitted to treatment. Changes in the policy field have made possible new forms of collective protest. KT was established in spring 2004 by four clients of a substitution treatment clinic in southern Helsinki8. The overall aim of the association is to “improve the quality of treatment and to promote treatment practices that respect drug users as equal and normal human beings”. The initial impetus for the association was the sudden decision to change the founding members’ substitute drug without consulting their opinions as patients, despite the side-effects that the patients reported to the treatment personnel. The drug was changed from Subutex to Suboxone, which is a combination of buprenorphine and naloxone. Naloxone is a drug that has been used to help users who have overdosed as it should block the effects of medicines and drugs like methadone, heroin, and morphine. The idea of combining naloxone with buprenorphine is to stop people from injecting the drug: according to the manufacturer’s website, “The naloxone in Suboxone is likely to precipitate withdrawal symptoms when injected by individuals dependent on heroin, morphine, or other full opiate agonists. Therefore, it is assumed that Suboxone would be less attractive to ‘street addicts’ and less likely to be diverted. Therefore, it is strongly recommended that Suboxone be used whenever unsupervised administration is planned.”9 In Finland, too, street-use, i.e. injecting buprenorphine has become quite common and attracted criticism as an undesired effect of the expansion of substitution treatment – this was the official reason for the switch to Subuxone. KT rejected this official argument for the change of drugs and countered it with its own experience-based information. In a petition to the doctors-in-charge of four substitution clinics, they stated: “We, as patients, feel that we are being used as forced, unpaid laboratory animals. If our situation is compared with some other patient group (e.g. diabetics, epileptics) for whom a new drug is prescribed; if the new drug did not help them, this would hardly mean that instead of going back to the old drug the only option would be to try another new but useless drug or quitting treatment”. The alternative to Subuxone offered by the clinic was methadone, which KT members considered too strong and addictive compared to buprenorphine. To date, KT’s activities have consisted of writing petitions to experts and officials as well as meeting with their counterparts and others concerned (such as representatives of the pharmaceuticals company that sells both buprenorphinebased drugs). Like ORT, KT invokes the Act on the Status and Rights of Patients 8 9 28 Touting for new members has been going on since but according the funding members this has been difficult because other patients fear they will be sanctioned if they’ll join the group (Petition, dated 27.4.2004). http://www.suboxone.org/Suboxone/patients/faqs.htm & http://www.suboxone.org/Suboxone/phys/faqs.htm in support of their demands. At the core of their argument is section 6 of that Act, according to which “The patient has to be cared for in mutual understanding with him/her. If the patient refuses a certain treatment or measure, he/she has to be cared for, as far as possible, in another medically acceptable way in mutual understanding with him/her.” In addition to the adverse side-effects from and ineffectiveness of the new drug, KT reported that, contrary to the thinking of the officials, Subuxone was being sold and injected in the streets just like Subutex.10 KT members claim that the motive for the change of drugs is ultimately of a political nature and not based on medical knowledge; they report that despite repeated requests for research information on the side-effects of Subuxone, no answers have been given. Six months later, KT received a reply from the doctor who was in charge of their treatment (letter dated 16 Dec 2004) – a dispassionate response which made no promise of changing back to Subutex. It is noteworthy that this was just two days after Professor of Addiction Medicine Mikko Salaspuro, whom KT had approached earlier, had sent the doctor a letter in which he informs his colleague about a relevant piece of research and takes a stand in favour of the patients’ right to receive their former medication: “A recent study from Australia shows that the shift from Subutex to Subuxone with similar doses does not work smoothly and unproblematically. (...) Referring to the study above, permission to change drugs should always be obtained from the patient. Additionally, the patient must have the right to revert to his old medication when side-effects occur”.11 Getting the professor on their side in this struggle was certainly a small victory for KT. Importantly, this episode also created divisions among substitution treatment professionals. Patients Claim Expertise and Just Treatment I move on now to characterise some of the most central claims made by ORT and KT about themselves and other actors, and what they see or saw as problems that need to be resolved with drug treatment. I do this by describing how they typify the problem in general and what kind of examples they give of the problem, as well as the new orientation they suggest for resolving the problems (cf. Best 1989). Generally speaking, both groups aim to challenge and deconstruct the restrictive social category of problem drug user. They want to break the cultural identity of injecting drug user that no doubt is one of the most miserable and narrowest in our societies: users are seen as marginalised and also potentially criminal, 10 11 KT, interview & petition, dated 27.4.2004. Quotation from the letter dated 14.12.2004. 29 although these attributions increasingly display the user’s “disease of the will” (Valverde 1998), failure of responsible self-control that they can’t help. Both ORT and KT accept the disease concept of addiction, in fact it is the very starting-point for their self-definition as patients. Since they are patients, they should have the same kind of rights as any other patient group (the act on patients’ rights is repeatedly referred to) and they should not be treated differently from other patient groups. The core message is that disease, as a medical problem, is something for which individuals should not be held responsible, but also that despite their disease of addiction they are normal and reliable patients – but now they lack the rights of patients and thus of citizens more generally. In their petitions and other material, both groups offer illustrative accounts of punishments, humiliations and overly strict rules at clinics. These are presented to exemplify the more general culture of control that pervades practices in treatment, which again conflicts with the medical perspective. The stories draw attention to the use of unskilled staff, attitude problems, an unprepared system, and also the general atmosphere of repression in drug policy. For instance: Every morning, pills are distributed in a very unpleasant and disgusting way. Instead of natural conversation, the patient is stared at for 15–20 minutes while the Subutex pills melt under the tongue. After this his mouth is checked to make sure that no unmelted pills remain. (ORT, 17 Dec 98) Therefore, the negative attitudes of treatment personnel must be changed … The behaviour towards addicts and their relatives must be humane and show respect … As it is, it is best described as belittling, sometimes derogatory. (ORT, 3 Oct 97) It is also emphasised by the groups that patients are individuals who are at different stages of the disease and therefore they should be treated individually: Patients are individuals, they have different histories of drug use and different life situations. (ORT, 3 Oct 97) Furthermore, not only are they unique individuals, but they are also experts on their disease and life around drug use. This is a world to which no outsider has access. The claim on expertise shows up in demands according to which patients should have a say in deciding on the treatment and medication that suits them best: after all it is the patient who will feel the effects or non-effects of the drug. In addition, they also claim that they have other related expertise (from “the streets”), as in the following excerpt: The medical director … argued … that the health risks and street dealing of Subutex make Subuxone a better choice. This information is incorrect: once Subuxone treatments were started, it was immediately dealt in the streets, and in 30 contrast to what is claimed, it can be and is used intravenously. (KT, 27 April 2004) In sum, ORT and KT present themselves as patients suffering from the disease of addiction, which should be treated medically. The problem is that currently this is not the case: the system is presented as an ill-prepared and unskilled machinery of control that fails to respect their patients’ rights. Accordingly, the groups demand that they be treated both as individuals and as experts of their disease and life around it. The solution proposed by ORT and KT can partly be placed under the general heading of evidence-based medicine. Moreover, the specific treatment practices are to be imported, particularly from France in the case of ORT. If this were to happen, patients would receive proper treatment for their disease and they could lead a useful life: In the so-called French system … the patient can lead a normal social life: travel, work, get an education … the patient can feel that the main thing is living a life and substitution treatment is a minor point . (ORT, 17 Dec 98) Thus ideally, being a patient would be a secondary status for them, whereas in the current repressive treatment practice they are primarily and inescapably reduced to the social status of drug abusers with a fatally troubled personal life that needs to be continuously controlled from the outside. But as the patients claim that their own expertise should be taken into account, there is a strong element of ambivalence related to the relationship between medical expertise and the users’ own life-world expertise. This is especially visible when it comes to the debate on preferred treatment: although there has been increased support in the medical camp for substitution treatment, there is an obvious tension between the medical profession and patients about the dividing line between the right to get treatment versus the right to get preferred treatment. For instance, the following statement (from a newspaper interview, HS 4 Oct 1999) by a doctor from a substitution treatment clinic goes to show how scientific and life-world expertise do not necessarily meet each other: I don’t know whether the number [of patients who are given substitution treatment] should be the same as the number of patients who want it. After the expansion it will, however, meet the medical need. The juxtaposition of medical and life-world expertise raises many sociologically interesting questions, such as: Who claims the right to correct knowledge? What is the relationship between scientific and professional knowledge and “lived” lay knowledge about the effects of the same drug (buprenorphine)? The gap between these two epistemic positions has been a central theme in medical sociology since Talcott Parsons (1951) created his classic concept of sick role, and it has become ever more topical; this due to two trends that have amplified the clients’ 31 or patients’ voice in Western social and health care settings. The first of these is the trend towards greater consumerism, which is particularly clear in the health care context where patient activism has burgeoned since the 1970s (Halpern 2004). With the growing number of technologies used in health care, rising educational level in patients, the increasing availability of health and drug information and with patients actively seeking for information from different sources, people have increasingly come to feel that they should have more control over decisions affecting their bodies and be able to challenge the physician’s authority and modes of practice (cf. Toiviainen et al. 2005). The second trend is the growing discourse on empowering clients through partnerships between them and the professionals, the desired end-result being active, self-governing and self-observing clients (cf. Asmussen 2003). In today’s reality of drug treatment in Finland, however, it is definitely too early to speak about consumerism or empowerment. Treatments for opiate users still seem to involve a strong element of control and the users’ rights to influence treatment basically means the right to refuse treatment. The situation is also complicated by the fact that the drug in question – buprenorphine – is a synthetic opiate that can potentially be abused. In other words, the reluctance on the part of the doctors to accept shared decision-making in the case of substitution treatment is not only a question of patients’ rights, but it may also have to do with moral judgements concerning intoxication. Epilogue: The Future of Drug User Groups? The two user groups introduced in this article are still rather weak examples of drug user activism. In contrast to the situation in Denmark and the Netherlands, Finland has not yet had any really influential drug user interest groups. Why is this? Are drug users in Finland – of whom 16,000–21,000 are classified as “problem users” (Virtanen 2005) – too oppressed or too satisfied to mobilise themselves collectively in defence of their rights as users, clients, patients and citizens? Like all social movements, drug user movements are conditioned by national and local factors: by the political norms and culture on a general level, and by the local drug situation and its history more specifically. To answer the question as to why user activism has remained so modest in Finland, we need to think of these preconditions. To put this in more conceptual terms, we need to ask what are the necessary prerequisites for such activism in society more generally; what kind of space for action in society in general and in the drug policy field in particular is needed for stronger drug user lobby groups not only to emerge but to be taken seriously by other actors in the field? 32 One direction where we could look for better answers is the short history of the current drug situation. As institutional mobilisation and creation of critical mass take time, one candidate for a general answer to the why-not-user-activism question is that the current drug situation, with increased levels of use and related harms, is still new to Finnish society. As described at the beginning of the article, it is only recently that the “first round” of institutional mobilisation and adjustments in drug policy has been accomplished. Presumably we might expect to see an expansion of the policy field, including more contentious users’ voices, in a second round of policy-making (a prerequisite for such a second round is that drug use remains at the same level or increases). Another, somewhat more specific explanation for the lack of user participation also relates to the short Finnish history of mass drug use. On average drug users in Finland are relatively young compared to many other European countries: in 2002 the mean age of all drug-related clients in outpatient treatment centres 12 in Finland was 25.1 years, whereas in Denmark it was 31.6 years and both in Sweden and in the Netherlands it was 33 years. Presumably, in order to become politically conscious and active, users need to reach a certain age and/or have a long enough “drug user career”, and it also takes time to form the necessary critical mass. So perhaps in Finland user activism will rise somewhat later than in the other Nordic countries? We should also look at the dynamics of the drug policy field per se: to what extent can the modest level of user activism be explained by the field of Finnish drug policy and its established actors? In the social movement literature, the political opportunity structure refers to the “dimensions of the political environment which either encourage or discourage people from using collective action” (Tarrow 1994, 18). Political opportunities are composed of several factors, key among which is the division among policy-making elites. In the case of substitution treatment policy in Finland, there were initially some significant divisions among treatment experts, officials and researchers, but these divisions soon faded and the medical lobby for substitution treatment, drawing on “evidence-based medicine”, came out on top of the battle. What is relevant, from the user influence point of view, is that the professional/medical lobby was strong enough to make the change on its own; the users weren’t their allies, at least publicly. Given the “narcophobic” cultural climate in Finland (Partanen 2002), an alliance between the medical lobby and user-patient groups could in fact have hampered the advocacy of substitution treatment in the late 1990s. However, once substitution treatment has reached an established position in the drug policy field, user interest groups focusing on patient rights could be growing in importance and establish a position in the field. Finnish treatment experts (see Halonen 2004; Holopainen 2004) have already hoped for an 12 The number of clients in outpatient care is the only context where somewhat comparable data from different EU-countries is available. 33 evolution of drug patient unions. Opiate users in substitution treatment may slowly be winning recognition as “normal” patients alongside other patient groups. References Asmussen, Vibeke (2003): User participation: possibilities and limitations in Danish social services directed towards drug users. In: Houborg Pedersen, Esben & Tigerstedt, Christoffer (Eds.): Regulating Drugs – Between users, the police and social workers. NAD Publication No. 43. Helsinki: Nordic Council for Alcohol and Drug Research (NAD), pp. 11–32. Bergeron, Henri (1999): L’État et la toxicomanie. Histoire d’une singularité française, Paris, P.U.F., coll. “Sociologies“. Best, Joel (1989): Introduction: typification and social problems construction. In: Best, Joel (Ed.): Images of issues: typifying contemporary social problems. New York: Aldine de Gruyter. Drug strategy 1997 – Report by the Finnish drug policy committee. [Huumausainestrategia 1997. Huumausainepoliittisen toimikunnan mietintö]. Komiteanmietintö 10. Helsinki: Sosiaali-ja terveysministeriö. Fraser, J. (1997): Methadone clinic culture: The everyday realities of female methadone clients. Qualitative Health Research, 7, pp. 121–139. Hakkarainen, Pekka & Tigerstedt, Christoffer (2004): Conflicting drug policy – normalization of the drug problem in Finland. In: Heikkilä, Matti & Kautto, Mikko (Eds): Welfare in Finland. Helsinki: Stakes. Hakkarainen, Pekka & Tigerstedt, Christoffer (2005): Korvaushoidon läpimurto Suomessa. [The breakthrough of substitution treatment in Finland]. Yhteiskuntapolitiikka, 70 (2): 143–154. Halonen, Ilkka (2004): Missä viipyy päihdekuntoutujien etujärjestö? [How long before drug rehabilitees get their own interest organisation?] Yhteiskuntapolitiikka, 69 (2): 216– 218. Halpern, Sydney Ann (2004): Medical Authority and the Culture of Rights. Journal of Health Politics, Policy and Law, 29 (4–5): 835–852. Holopainen, Antti (2004): On aika lopettaa päihdepotilaiden syrjintä. [It’s time to stop discriminating against drug patients]. Yhteiskuntapolitiikka, 69 (4): 433–436. Hunt, Geoffrey & Barker, Judith (1999): Drug treatment in contemporary anthropology and sociology. European Addiction Research, 1999; 5; pp. 126–132. OFDT (2004): Substitution treatments in France: recent results 2004. Trends No. 37. Review of the latest research. June 2004. (www.ofdt.fr/BDD/publications/docs/eftaack6.pdf) Parsons, Talcott (1951): The Social System. New York: The Free Press. Partanen, J. & Metso, L. (1999): Suomen toinen huumeaalto. [The second drug wave in Finland]. Yhteiskuntapolitiikka, 64 (2): 143–149. 34 Partanen, Juha (2002): Huumeet maailmalla ja Suomessa. [Drugs abroad and in Finland]. In: Kaukonen, Olavi & Hakkarainen, Pekka (Eds.): Huumeiden käyttäjä hyvinvointivaltiossa [Drug user in a welfare state]. Helsinki: Gaudeamus. Report on arranging treatment for addicts in Helsinki (1991). [Narkomaanien hoidon järjestäminen Helsingissä. Työryhmän raportti]. Helsingin kaupunki. Skoll, GR (1992): Walk the Walk Talk the Talk: An Ethnography of a Drug Abuse Treatment Facility. Philadelphia: Temple University Press. Tammi, Tuukka (2002): Onko Suomen huumepolitiikka muuttunut? [Has Finnish drug policy changed?]. In: Kaukonen, Olavi & Hakkarainen, Pekka (Eds.): Huumeiden käyttäjä hyvinvointivaltiossa [Drug user in a welfare state]. Helsinki: Gaudeamus. Tammi, Tuukka (2005a): Diffusion of public health views on drug policy: The case of needle-exchange in Finland. In: Hoikkala, T.; Hakkarainen, P. & Laine, S. (Eds.): Beyond Health Literacy – Youth Cultures, Prevention and Policy. Finnish Youth Research Network, publications 52 & Stakes. Helsinki. Tammi, Tuukka (2005b): Discipline or contain? The struggle over the concept of harm reduction in the 1997 Drug Policy Committee in Finland. International Journal of Drug Policy, 16 (6): 363–438. Tarrow, Sydney (1994): Power in movement: Social movements, collective action and politics. Cambridge: Cambridge University Press. 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Helsinki: Sosiaali- ja terveysministeriö. 35 Active Drug Users – Struggling for Rights and Recognition13 Jørgen Anker Introduction This article investigates the processes through which a group of drug users 14 seek to gain recognition and legitimacy as an interest organisation in The Danish Drug User’s Union (DDUU) (BrugerForeningen for aktive stofbrugere). The case of the Danish Drug User’s Union is particularly interesting because the organisation seeks to organise and represent a group of citizens that are normally excluded from channels of participation and interest mediation.15 From a broader perspective the attempt to form an interest organisation of drug users is interesting because it may form part of a process whereby different excluded groups and social clients attempt to gain rights to participation and voice in the welfare state. What is of particular interest here is how the DDUU attempts to change their stigmatised position as drug users into a position, where they are recognised as a legitimate collective actor/interest organisation. The article describes the position, aims and strategies of the DDUU. It explores how the DDUU seeks to advance an alternative image of drug users as able, respectable and active, thereby opposing the dominant image of drug addicts as irrational, passive and irresponsible. The article also provides an insight into the strategic dilemmas of the DDUU. On the one hand the organisation receives public funding and seeks to use formal channels of interest representation, on the other hand the organisation struggles for an alternative drug policy, which challenges the official drug policies in Denmark. Three questions will guide the discussion: First, the article seeks to explain why and how an organisation of drug users is enabled to emerge, in spite of the strong 13 14 15 36 I thank Niels Christian Juhl Elsborg and Siri Seidelin who have been attached to the project as research assistants. I am also grateful to Vibeke Asmussen and Jørgen Jepsen who commented earlier drafts of this article. When I refer to drug users in this article, I basically refer to opiate users. Activists and members of the DDUU are primarily using heroine and methadone, but they may also have a supplementary use of e.g. cocaine, cannabis, alcohol and benzodiazepines. This study forms part of a research project which discusses the possible formation of welfare movements among homeless and drug users in Denmark. The research project is supported by the Danish Social Science Research Council. stigmatisation of drug users in society. Second, the article will dwell with the question of how the drug users attempt to overcome stigmatisation. Third, the article offers an account of the impact of the organisation. Empirically, the analysis is based on 7 tape-recorded qualitative interviews with activists in the DDUU, and 2 tape-recorded interviews with the Parent Organisation that is located in the offices of the DDUU. The analysis is further informed by observation and informal conversations with activists or users in the DDUU during opening hours or in late afternoons, participation in celebrations of the anniversary of the organisation and other acts or meetings arranged by the organisation.16 Documents from the organisation (the president’s annual reports, internal minutes – so called duty reports – of daily activities etc.) have also been analysed. To supplement these data, other actors in the field that know or interact with the organisation have in interviews and conversations been asked for views and interpretations concerning the organisation. These interviews cover: 6 participants in other drug user organisations in Denmark,17 4 participants of associations of users of drop-in centres, 3 participants in associations of ex-users, and approximately 10 actors with a professional position in the drug field. Finally, the study also includes analysis of 116 newspaper articles that deal with the organisation. Social movement theory is used as the principal theoretical framework to examine the emergence and the importance of the organisation. The DDUU in itself is an interest organisation in the drug field. Yet it may be compared to a social movement organisation (Zald & McCarthy 1987), because it is one of a number of associations, networks and actors that form part of broader transnational network which seeks to favour harm reduction initiatives (and seeking a liberation of drug control policies) globally. In this sense the DDUU, as a single organisation, may be seen as forming part of a broader social movement. Drugs, Control and Stigmatisation The use of drugs is condemned and rejected in most of the world. It is perceived as harmful, dangerous and leading people into unwanted destructive life-styles, perhaps because the use of drugs challenges the rational of the ascetic, hard 16 17 The organisation has been visited approximately 20 times, with visits lasting from one to five hours. After these visits, notes were carried out, which have formed part of the empirical material for the analysis. In Århus, interviews were done with activists in Stris (Drug users’ rights in society) [Stofbrugeres rettigheder i samfundet]. Like the DDUU, Stris was formed in 1993 but the organisation never reached the same degree of continuity and stability. In Herning, one interview was conducted with the president of the local user association, which also functions as an open drop-in centre. 37 working and self-controlled modern subject. Becker (1966) describes the situation of drug users in this way: The drug addict, popularly considered to be a weak-willed individual who cannot forego the indecent pleasures afforded him by opiates, is treated repressively. He is forbidden to use drugs. Since he cannot get drugs legally, he must get them illegally. This forces the market underground and pushes the price of drugs up far beyond the current legitimate market price into a bracket that few can afford on an ordinary salary. Hence the treatment of the addict’s deviance places him in a position where it will probably be necessary to resort to deceit and crime in order to support his habit. The behaviour is a consequence of the public reaction to the deviance rather than a consequence of the inherent qualities of the deviant act. (Becker 1966, 35) Drug users are often thought of as incapable of being involved in normal life activities such as holding a job, maintaining a place to live and fulfilling the role as a parent (Bluthenthal 1998). Moreover, drug users experience stigmatisation and are also often treated by state officials (police, health workers or personnel in the judiciary) as undeserving criminals (Valiente 2003). When new houses for homeless or drug users are planned, protests often arise from neighbours. A national survey on relations of solidarity in Denmark thus showed that almost 20 percent of the population would involve in protest and 10 percent would possibly move to another place if a publicly supported community of drug users was established next door (Juul 2002). The experience of stigmatisation is known by the participants in DDUU. One of the activists explains: This is the lowest [position], you can’t get any lower in this country than a drug addict. I mean it’s much easier to come from Pakistan, to be black or woman or to belong to any other repressed group. But a drug addict, that is the worst… and moreover it is a dog’s life because you have to find money for drugs.18 In the interviews and conversations with activists from the DDUU and other drug users’ organisations, it is repeated that people who use drugs generally have miserable living conditions. The interviewees emphasise the very negative consequences of drug use and how these influence the overall life conditions of drug users. People who use drugs constantly have to consider how to get money for obtaining drugs, and some have to involve in criminal activities or prostitution. Moreover, once known as a drug user by the police repeated controls and searches come to form part of a very stressful life (Frantzen 2005). Attempts to organise drug users have to be understood in this light. Compared to the other Nordic countries, Denmark has traditionally been represented as a country with a rather liberal drug policy where harm reduction aims have played an important role in determining concrete policies and measures since the beginning of the 1990s (Laursen 1996; Laursen & Jepsen 18 38 Quotes of interviewees were translated into English by the author. 2002). Harm reduction can be defined as initiatives that aim at reducing the harmful consequences of the use of drugs or improve the (often horrible) life conditions of drug users without punishing the user for illicit drug use (Bluthenthal 1998; Asmussen & Jöhncke 2004). Concrete examples are syringe exchange programs, low threshold activities, outreach work and consumption rooms (consumption rooms are not allowed in Denmark, however). Denmark introduced many of these harm reduction measures earlier than Norway and Finland and to a wider extent than in Sweden (e.g. free access to needles and methadone treatment). Denmark has also traditionally maintained a more liberal attitude towards hashish and alcohol. However, while harm reduction initiatives on the one hand have gained wider acceptance in policy formulations and in practice (as seen in outreach work for example, see Asmussen 2003), control measures have been tightened up simultaneously. As Laursen (1996) argues, it appears that a rather pragmatic and problem-solving Danish approach to criminal justice policy has given space to a combination of both liberal and conservative measures. Harm reduction initiatives are thus an integrated and accepted part of the official policy as long as they are not contradicting the overall aim of bringing the use of illicit drugs to an end. The abstinence oriented policy is emphasised in many policy papers, but it is also mentioned that to some of the most affected groups of drug users, harm reduction measures are more important because abstinence in practice remains unrealistic (Sundhedsstyrelsen 2004). Defining the kind of initiatives that are acceptable under the heading of harm reduction constitutes one of the ongoing struggles between supporters of harm reduction initiatives and more sceptical actors. The Danish liberal-conservative government has emphasised the need to define some clear lines between acceptable and non-acceptable measures. In October 2003, the government published an action plan against drug abuse. The title of the plan – “The fight against drugs” – signalled a turn towards a more repressive and less liberal drug policy. The war/struggle rhetoric framed the problem of drugs in time-typical and well-known geopolitical terms, signalling an intention of adopting a zerotolerance policy on drugs.19 In the action plan, the government emphasises the need to adopt hard measures on drug related crime, giving priority to law enforcement over harm reduction measures, although still involving treatment, prevention and harm reduction (Regeringen 2003). Penal policy and drug policy has been tightened up: This has resulted in increased levels of punishment, allocation of more resources to the police, construction of new prisons, prison departments for special groups etc. A more restrictive policy on drugs has also been effectuated through a more restrict approach to cannabis use. Possession of drugs – particularly cannabis – for one’s own use has traditionally not been fined, but only a warning from the police has been handed out. According to bill 19 Jepsen (2004b) describes this in a blueprint for a Danish version of the War on drugs. 39 no. 175, however, the first time reaction is now a fine, and repeated offences will give harder penalties (higher fines or prison) (Jepsen 2004b). Moreover, the government rejects the idea of allowing consumption rooms or to allow treatment with heroine. The Social Democrats (which are currently in opposition) have supported the tightening up of penal policy and the attempts to adopt harder measures on drug related crime. On the other hand, the entire opposition to the liberal-conservative government except the right wing party Danish People’s Party (Dansk Folkeparti) supports further harm reduction measures. In 2003 and 2005 the opposition proposed to legalise consumption rooms in Denmark, but the proposal was turned down by the government and Danish People’s Party. The Danish Drug User’s Union The DDUU was formed in November 1993, when a popular public activity centre for drug and methadone users was closed down. Some of the users agreed to form a drug users union in cooperation with some supporters (social workers and a group of drug user’s relatives). In Denmark there are only a few organisations of drug users, and most of these have only a few (5–10) active participants. The DDUU, which is based in Copenhagen is the biggest and the most important of the drug user organisations in Denmark. It has 160 paying members and 387 passive members who have not paid their membership fee this year (Hansen, Malmgren et al. 2005). The character and the appearance of the physical facilities of the DDUU are rather remarkable. There is plenty of space, rooms are well-equipped, cosy and very clean, always ready to receive visitors and guests. The DDUU describes the facilities with these words on its own homepage: 700 square metres headquarter in a citizen house in central Copenhagen. Here the Drop-in Centre’s cosy café is open daily from 10 AM to 15 PM. After this hour all activities continues but now only for active members, who’s got a fitness room, gaming room, healthcare room, Internet and computer learning centre, bicycle service, hobby workshop, large specialized narco related library, study room, 70 persons lecturing room with an overhead and a large video screen, as well as several high tech equipped administrative offices. The DDUU is a formal organisation with an elected chairperson, an elected executive committee, annual general meetings, by-laws etc. (Asmussen 2003). The overall aim of the organisation is to represent and further the interests of drug and methadone users.20 Moreover the organisation opposes discrimination and it seeks to remedy powerlessness. It runs activities of support, information 20 40 The following description is based on the rules of the association, signed by the chairman 18 September 2004. and advice. It works for exposing the social, political and economic conditions in the drug field and to uncover how these conditions affect the individual drug user. It wants to generate debate, and it is stipulated that the organisation is wholly committed to follow democratic means and practices to serve its interests. Finally, it is explicitly written that the organisation must be reliable in its relation to authorities, politicians and users. For some of the activists, international contacts and networks are very important. This provides them with new inputs and arguments to the debates on drug policies in Denmark, and it serves as a form of recognition of the organisation. The DDUU has supported the formation of a similar organisation in Norway and Sweden and it has close contacts to user organisations in many countries around the world. The DDUU has a number of international contacts and participates actively in various conferences and harm reduction networks, e.g. NAMA (National Alliance of Methadone Advocates).21 The DDUU is also a member of ENCOD, which is a network of approximately 120 NGOs that seek to influence and reform international drug policies seeking more transparency and democracy in drug policy-making processes. In practice the work of the organisation is divided into two equally important areas. On the one hand, the organisation serves as a national interest organisation for drug users in Denmark. On the other hand, the organisation carries out social work and functions as a drop-in centre (an open café) that is open for all drug users. In the morning breakfast is served and during the day there is always coffee and tea ready for visitors. The chairman explains: In the morning, people come in because coffee is free and a lot of other things, of course; free newspapers, and you can sit together with equal-minded people, and that is probably the most important reason. Here you don’t need a façade, and as a drug user you are very conscious about that anywhere else. Wherever you go, you know with certainty if the persons around you are aware of you being a drug user. With the experiences of stigmatisation and mistrust that often characterise the efforts for and offers to drug users, the drug users in the DDUU emphasise that the organisation and its facilities serve as a place where they can breathe freely, without being met with suspicion and devaluation because of their drug use.22 The activists carry out social work, give advice and provide information. The organisation runs a newspaper archive with articles on drug related issues and it also has a library with literature on drug policies. It is mainly drug users who seek personal advice on different issues, yet relatives to drug users also contact 21 22 The chairman of the DDUU is international director of NAMA. The importance of meeting drug users with respect instead of control is also emphasised as one of the important aspects of user participation in the article by Vibeke Asmussen in this publication. 41 the organisation to get advice and information. Moreover, social workers, students, health personnel and others often seek information at the DDUU. In the internal duty reports it is documented that approximately 35 persons in average visit the organisation each day (Hansen, Malmgren et al. 2005). Approximately two thirds of the users are men, and an equal share of the users is more than 40 years old.23 Nearly all the users (except two) started taking heroine more than 10 years ago, and one half more than 20 years ago. The vast majority are in some kind of maintenance treatment with either methadone or buphrenorphine.24 The most active members stay in the organisation in the afternoon and evening. The activists dedicate themselves to different activities that support the organisation and they organise different recreational activities. They go on picnics in the summer, they go biking and bowling, and they also arrange a summer camp (team building). A group of activists celebrate Christmas Eve together in the organisation. The DDUU collects used syringes that have been left by drug users in the streets in specific areas of Copenhagen. In 2004, they collected 301 kilos. 25 When collecting used needles in the streets the activists wear yellow jackets with the words needle-patrol written on the back. This, first of all, serves to increase the visibility of the organisation in public. Secondly, it provides the activists that collect needles with a certain degree of immunity vis a vis the police. The Emergence of Drug Users as Collective Actors The question of why social movements or social movement organisations emerge is probably one of the questions that are most frequently asked and sought explained in social movement theory (Goodwin & Jasper 2003). To explain why drug users began to organise as collective actors, I follow a broader line of explanation than the traditional political process approach (e.g. Tarrow 1994; McAdam, Zald et al. 1996), which often limit the scope of analysis to the political field and the concept of political opportunity structure. Political opportunity structure refers to the consistent but not necessarily permanent elements of the political environment that provide incentives for people to 23 24 25 42 These and the following figures are taken from a questionnaire that was answered by 61 users (of a total number of 72) who were registered as visitors/users in the organisation from May to September 2005. The questionnaire formed part of an evaluation of the organisation, which was commissioned by the Ministry of Social Affairs and the Municipality of Copenhagen (Hansen, Malmgren et al. 2005). 10 of the 60 persons who answered the question do not form part of a maintenance treatment programme. According to the DDUU this equals nearly 20,000 used syringes. undertake collective action affecting their expectations for success or failure (Kitschelt 1986; Tarrow 1994). Certain aspects of the DDUU’s action repertoire as an interest organisation are political in character. Due to the Government’s and the opposition’s different views on specific measures of harm reduction initiatives, the DDUU for example has an opportunity to seek alliance partners to forward its views and arguments in relation to concrete initiatives (for example in relation to a parliamentary debate on consumption rooms). The DDUU thus occasionally co-operates with some of the political parties of the opposition or other alliance partners to generate debate and advance its views. Being aware of the existence of potential political allies in the Parliament, who sympathise with the aims of the DDUU, the members will find it easier to expect that the organisation is able to make a difference. Some political dimensions (e.g. the government’s formulation of a drug policy and the existence of allies in the drug field) are thus important to understand the emergence, the consolidation and importance of drug users’ organisations in Denmark. But the political approach is generally better suited to explain the emergence of collective actors that engage in political conflict. The emergence of the DDUU, however, is not to be considered an expression of genuine political protest. Moreover, the aims and efforts of the organisation are directed towards both political aims (influencing drug policies) and social aims (different kinds of self-help activities and initiatives to help and support individual drug users). In addition, the traditional political approach often focuses on actors that are already united by some kind of pre-existing network or interest organisation (Melucci 1996; Crossley 2002). It is therefore less useful when trying to explain how networks and unity is created. For this purpose, Melucci (1996) provides a more valuable argument first and foremost because he insists that social movements (and social movement organisations in this case) are to be treated and analysed as social processes. Instead of taking a movement as the starting point, analysts should try to explain how the entity comes into being. One has to explain how the participants are united, and what kind of relations create the foundation for any kind of collective unity. So, how can the emergence of the DDUU be explained? I see the following dimensions as facilitating the process: First, the emergence of the DDUU and other user organisations in the field are an outcome of the ways drug users are treated and dealt with in the treatment system.26 This argument relies on the formulations and studies of Järvinen and 26 With the treatment system, I refer to the different institutions, treatment centres, doctors, social workers, nurses and other actors who take part in providing services, treatment or help to people who use drugs. 43 Mik-Meyer (2003) and Gubrium and Holstein (2001), who have focused on the relations between welfare institutions and social clients and how identities of clients to a certain extent are formulated and formed by the features and rationality of the institutions. The welfare institutions – physical spaces with their own rules, rationality and power relations – come to form an important role in the lives and identities of their clients. The point is that problem-identities of homeless, drug users, alcoholics, or unemployed people are formed and influenced by the institutions that are set up to help them. I do not question the influence of the welfare institutions on the lives of social clients, yet I will argue that welfare institutions may also provide spaces for alternative attempts to form more autonomous actors. Thus, even if welfare institutions may be said to partially create ‘problem identities’, these categories and identities may eventually also come to form the basis of resistance and collective action. My argument is that the drug users’ organisations did not emerge as an autonomous network of drug users who decided to organise independently of the treatment system. The conditions of drug users are often too extreme and many drug users struggle individually to survive and get hold of drugs. These life conditions limit the possibilities of creating a shared frame of reference from which a collective identity could be formed. Yet the treatment system, the way the treatment system is organised and the way it unites drug users, creates spaces from where user organisations may be formed. The two oldest user organisations in Denmark were both formed by a group of users of particular treatment centres. Moreover, the issues that have mobilised drug users in protest are often related to practices at local treatment centres. In the treatment system drug users are provided with a space where they meet, they are treated with standardised measures and they are thereby enabled to acknowledge that they have many things in common and may share a number of interests. Moreover, the treatment system also opens for alternative ideas and interpretations, which provide openess towards new forms of treatment (e.g. under the heading of harm reduction) and new forms of user involvement. Outreach work or low threshold offers are examples of initiatives that are aimed at reaching drug users by new methods opening for new ideas and different practices of social work. Second, the acceptance of methadone maintenance treatment was also important for the formation of drug users’ organisations. Methadone treatment enabled certain groups of drug users to create sufficiently stable life conditions so that they were able to engage themselves actively in the formation of organisations of drug users. The long Danish tradition of methadone maintenance treatment – since the 1970s in Denmark – contrasts the situation in other Nordic countries, where maintenance treatment has been introduced later (Norway and Finland) or has been more restricted (Sweden). Drug users in Norway, Finland and Sweden may thus have had more difficulties reaching a sufficiently tolerable life 44 situation, which could provide them with energy to form and engage in user organisations. This could be used as one possible explanatory factor for the later emergence of drug users’ organisations i.e. in Norway (1996) and Sweden (2002). Third, harm reduction strategies in Denmark opened opportunities for drug user organisation. Bluthenthal (1998), Friedman, Southwell et al. (2001) and Wieloch (2002) associate the appearance of harm reduction measures with the emergence of a harm reduction movement. The harm reduction philosophies and the harm reduction movement simply created a space for the acceptance and recognition of drug users’ organisations. Harm reduction arguments provided drug users’ organisations with an important basis from which, arguments and critique could be raised. Harm reduction approaches offer an alternative to traditional moral approaches; 1) the war on drugs and 2) the disease model of addiction (Wieloch 2002, 47–48). Claiming that initiatives have to support drug users instead of punishing or controlling them form a part of a larger cultural field or meaning system (Wieloch 2002). Relying on this meaning system facilitates drug user’s organisations’ opportunities to gain recognition and frame their claims. Fourth, the existence of a favourable environment, with a number of supporting actors may also help explain the emergence of drug user organisations in Denmark. A good example is a Parents’ organisation (“Parents Association to drugs-influenced children”; Forældreforeningen til Narkoramte børn) that was formed in 1974. This organisation had the explicit aim of seeking to obtain a general acceptance and use of methadone maintenance treatment in Denmark. In practice, in the 1970s, before methadone was accepted as a treatment measure, the organisation attempted to find doctors who would prescribe methadone to drug users. A lot of the work of the president of the organisation consisted in coordinating and delivering methadone to drug users from doctors who were willing to prescribe methadone.27 Later the participants in the organisation also supported the formation of the DDUU.28 Finally, a general trend of user orientation in welfare policies in Denmark created an institutional platform for user organisations. The Ministry of Social Affairs played an important role in this process, providing support and legitimacy for the DDUU.29 On the one hand, this orientation secured resources and financial support, on the other hand, it opened channels for interest 27 28 29 Interview with Poul Thyge Petersen. Former president of the organisation of relatives to drug users that supports harm reduction initiatives. There is also another organisation of relatives to drug users in Denmark, which is much more critical of harm reduction initiatives. Today, the organisation is called Landsforeningen for human narkobehandling (The national association for human drug-treatment). It works closely together with the DDUU and its office is situated within the premises of the DDUU. For further discussion of this, see Anker 2005. 45 representation. The interest in user participation has been institutionalised in the social legislation (see Asmussen 2003), and the discourse which favours user participation has opened opportunities for drug users to make claims towards the system on behalf of their position as users. The status as users of social services thus provides drug user organisations with a certain degree of legitimacy, when they attempt to organise (Asmussen & Jöhncke 2004). The Self-representation of the DDUU The DDUU seeks to construct an image of drug users that opposes the stereotyped image of drug addicts. This may be seen as part of a symbolic struggle, and an attempt to redefine the meaning of ‘drug user’. In short, the DDUU attempts to elevate a stigma to a position of status (Wieloch 2002). The organisation struggles for giving drug users a status and a position of recognition as decent citizens and it claims a right for the drug users to be treated with respect and to be heard when drug policy issues are discussed. The DDUU seeks to advance a positive image of itself in the public towards the exterior. But the self-representation also forms part of a collective identity, a collective understanding of how ‘we’ – the group of activist and members/users of the organisation – are. This self-understanding is influenced by the ways drug users are characterised and dealt with by the welfare- and treatment institutions, the media, politicians and the public in general. In its attempts to construct a specific image of itself the DDUU emphasises the word ‘active’, which is given a double meaning. On the one hand, it means that the users and activists of the DDUU have an active use of drugs, on the other it means that the users and activists are ‘actively’ involved in different activities. The very existence of the DDUU and the fact that the DDUU is driven effectively and autonomously by active drug users themselves is emphasised as a living proof of drug users’ capabilities. Active Drug Users The name of the organisation is in itself a symbolic challenge to public stereotypes. In Danish the formal name of the organisation is the Users’ Union for active drugs users – BrugerForeningen for aktive stofbrugere. The chairman explains: They wouldn’t call it the drug misuser’s association or the association of drug addiction, but the users’ union. 46 But we agreed that the starting point is active users of drugs and we work for the active drug users. We don’t declare ourselves drug addicts. We make the distinction that if you pay your rent each month and take care of yourself, then you are a consumer, no matter how you use your money. And we, then, are consumers of drugs, but we also have a lot of activities, so it has double connotations: The union is for active drug users that take drugs, but also want to be actively involved in different activities. The organisation thus seeks to detach itself and its members from the denomination drug addicts or drug misusers, claiming that they rather be considered as consumers. Whereas drug addicts or drug misusers are persons that are so troubled that they need help and support, consumers are persons who have their own resources and follow their own interests. Moreover consumers have rights and ultimately they also have a right to use the kind of drugs they want and physically need. Indicating that the organisation represents a group of people who have an ’active’ use of drugs (primarily heroine and methadone) in itself represents a symbolic challenge in a society where illegal use of these drugs is prosecuted. Additionally the name indicates a difference to groups of ex-users who organise in different groups of Narcotics Anonymous. Initially, the members of DDUU were afraid that ex-users should become too dominant in the organisation, so in the by-laws, it is stipulated that only active users of drugs can become board members. Yet ex-users are still welcome in the organisation and a former president who is no longer an active drug user is occasionally invited as a speaker to public meetings or celebrations. But ex-users often tend to take on a very moralising attitude towards drug users, activists in the DDUU explain. This means that some ex-users can have difficulties accepting that others continue with their drug use, whereas they have themselves managed to stop. The DDUU does not condemn ex-users and the people who manage to quit, but the organisation claims a right to continue with drug use without being condemned by others. Active Participation The meaning of active also in many ways constitutes the boundaries used to distinguish members and activists of the DDUU from other organisations and drop-in centres in the field. It dissociates the organisation from places and drug users that are not formed around an intention to involve in collective activities. The organisation is described as a place of activity. This means that the people who show up regularly are expected to participate actively in the different daily tasks. It is not well-seen, and it is commented upon, if people do not participate in any activities. Active in this sense thus signals that drug users are not just 47 passive social clients but rather active and engaged subjects. The DDUU seeks to emphasise this through involvement in different events, teaching activities etc. In practice the meaning of active, also serves as a differential mechanism, which defines who are included in the group and who are not. Being active means being involved in activities for the good of the organisation. The degree of activism forms one of the mechanisms of internal differentiation. Only a smaller group of people – an ‘inner core’ – holds the formal title of ‘activist’ (approx. 15–20 members). Activists take ‘duties.’ This means that they are responsible for the activities that take place in the organisation on the day of their duty. They have to make breakfast, answer the telephone during the day, say hello to visitors and a number of other practical tasks. Being an activist is a formal status that provides the person with a key to the organisation, and activists can thus come and go as they like. To become an activist, one has to follow one of the persons on duty for a longer period of time. Only after having participated actively in 15–20 or more duties, it is decided if people are trustworthy to be given a key to the organisation. The key represents the ultimate symbol of trust. It serves as a sign of recognition and belonging. The chairman of the DDUU explains: Well, we don’t make contracts with people… and anyway it wouldn’t help… [.. ] so if we give a key to the wrong person, and this person empties the place for all values, then we can’t do anything…. [….] .. but we choose to be a little more strict on this issue and have the rule that the keys are something that people must qualify for. It is the ultimate sign of honour you can receive… so to say. As explained above this rather formal selection procedure of activists is meant to protect the organisation from unintended loss. The organisation has experienced various examples of theft and loss. To prevent theft, all offices are locked and have to be opened with a key, if there is no one present in the office. Gaining the recognition as an activist with a key thus provides an improved position in the internal hierarchy of the organisation and it also gives certain privileges (contribution to the payment of transport or mobile phone and possibility to participate in the team-building tour in the summer). To become an activist with a key, you have to show – through your continued effort for the good of the organisation – that you deserve recognition as an activist. The most active, the ones that work the most are also the people that decide, the ones with status and power. The meaning of the name of the organisation is not just used to provide an alternative image of drug users in the public. It is also used as the logic through which internal hierarchies are formed and boundary work is carried out. It is used in the process of constructing a collective self (Hunt & Benford 2004). Autonomous and Able Drug Users 48 One of the issues that activists in the DDUU repeatedly raise, when talking about the organisation, is that it is an organisation run by and for drug users themselves. The requirement of only letting active drug users into the board is meant to secure that the organisation remains controlled by the activists and members themselves. Self-determination and autonomy are very important in the collective self-understanding of the organisation. It is not an organisation operated or influenced by social workers – or others – who act on behalf of drug users. This creates a feeling of autonomy, a sense of being accepted among equals. The activists describe the organisation as a success, which is often related to a perception of self-reliance which also forms part of the narrative of the organisation’s history. The history is told as a story of how the activists gradually developed a stronger belief in their own capacities. In the beginning, it is explained, people were clientilised,30 yet gradually – after some unpleasant incidents with non-users who suddenly became too dominant in the organisation – the users realised that they were able to take the responsibility and to manage by themselves. On this basis, the activists claim a right to live an autonomous life, without interference from people who believe that they are more capable because they do not use drugs. Another important and related aspect in the self-understanding of the activists is that the physical facilities always appear clean and tidy.31 Keeping rooms clean and tidy, the DDUU seeks to gain and show an image of drug users that contradicts the normal stereotypes of drug users as messy and unable to take care of things. The image of a professional, well-functioning organisation with good facilities thus becomes an ideal expression of the position aimed at. This is how the organisation wants to be seen by others. This is the kind of recognition the active drug users seek: Perhaps different, but still basically the same, and in any case responsible and able. Seeking Legitimacy Many of the activities which are carried out by the DDUU are aimed at gaining recognition for the union as a useful, serious and reliable organisation, which carries out important social work to help drug users to gain a better reputation in society or to inform about drugs and drug users’ problems in the public. As mentioned, the needle patrol is one example of this strategy. Another example is the attempts to carry out social work for drug users in the street. A few years ago, the DDUU thus had a project in which they carried out outreach work in 30 31 Meaning that they felt like clients. They didn’t think they were capable of running the organisation by themselves. This is often mentioned in my informal conversations with the activists. It is also noted repeatedly by visitors from abroad. 49 Vesterbro in Copenhagen where many drug users gather. The activists made an effort to get in contact with drug users in the street and offer support, help or treatment. The DDUU has gained legitimacy because of its work, and this can be illustrated by the public support for the organisation. To receive public funds is also to be accorded legitimacy (Valiente 2003). Over the years, the DDUU has gradually gained more public funding to a degree where the organisation today appears to be entirely dependent on funding from the authorities. The DDUU has been able to adjust or transform its aims and strategies to projects and activities that are perceived as acceptable and needed by the local and national authorities. In 2003, the DDUU received a total of 1.7 million DKR. (approx. 226.700 Euro) from the public authorities, half of this amount from the Ministry of Social Affairs, and the other half from the Municipality of Copenhagen. In 2003, for the first time in the history of the organisation, the DDUU was guaranteed an appropriation for three years. Yet, because of the illegal character of drugs, drug users’ organisations are placed in a difficult intermediate position. The organisations admit or openly emphasise that their members have an active use of illicit drugs, implicitly acknowledging that they are involved in illegal acts of buying and possessing drugs. The organisations thereby run the risk of being condemned and repudiated by the surrounding society as illegal and illegitimate organisations. The DDUU has faced this threat in various occasions. Confronting the risk of being denied a right to exist, the organisation has opted for seeking legitimacy through good behaviour. Most harmful to the organisation are accusations of illegal drug dealing in its rooms, brought up by the tabloid newspaper Ekstrabladet in April 2000. A journalist had visited the organisation for a few days, and the paper claimed to possess recordings which proved that drug dealing took place in the rooms of the organisation.32 The story immediately raised a political debate on the conditions of public support and if public means were used to finance drug dealing. 33 As a result, police investigations and financial revisions were started. The DDUU maintained that individual members who use drugs obviously sometimes buy drugs together to get them cheaper. But even if such arrangements occasionally take place they do not involve the organisation as such, the chairman argued in the newspaper. Neither the police investigations nor the financial revisions of the organisation found any proofs of illegal activities. In 2004, the DDUU again confronted a problem due to members’ active use of illegal drugs. The chairman was convicted to prison for nearly a year for possession of heroine. The group of activists was stopped by the police, 32 33 50 Ekstrabladet 3 April, 2000. Ekstrabladet 4 April, 2000. precisely when they had taken off to go on the yearly summer vacation. The conviction led once more to financial revisions as well as an external evaluation of the organisation. Yet the organisation succeeded to continue its activities while the chairman was in prison. The DDUU maintains that the use of drugs is a private matter. The aim of the organisation is not to form a club that provides the infra-structure for taking and using drugs, but to be an interest organisation and a drop-in centre for drug users. On the other hand, in some cases the activists in the organisation have to show acts of solidarity with individual users. This has occurred on occasions, when drug users in methadone treatment have been excluded from the treatment programme and suddenly are standing on the street with abstinences. In such cases, the activists have ‘passed the hat around’, trying to help in the specific situation.34 While this practice indeed illustrates the caring and helpful atmosphere of the DDUU, it can also give rise to myths and bad press.35 Another example of how difficult it is for an organisation of drug users to put forward arguments that may be judged as controversial in the public was exposed in a parliamentary debate on a proposal of introducing health or consumption rooms in Denmark.36 In the debate Birthe Skaarup, MP, from the right wing party Danish People’s Party (Dansk Folkeparti) argued that the idea of health or consumption rooms was supported by a powerful drug-industry (and maybe drug dealers) involved in lobby-activities to increase the amount of drugs sold in Denmark. She argued that the DDUU was one of the organisations that had positive remarks on the proposal prior to the parliamentary debate and that the DDUU had supported an international campaign in favour of liberalising international drug conventions. Such attempts to de-legitimise the organisation’s raison d’être clearly illustrates that there are limits to the kind of proposals and actions that stigmatised groups can support or get involved in without being suspected of having criminal intents. To protect the organisation from suspicion and critique, the organisation seeks to provide an image of itself as a nice, clean and well-functioning organisation with well-functioning activists. The activists do not deny that they take drugs, but on the other hand they are very cautious not to bring forward 34 35 36 Ekstrabladet 4 April, 2000. The newspaper articles in this study were searched on the Internet site ‘infomedia’, which contains newspaper articles from all the newspapers in Denmark. A total of 116 articles were found which had ‘The Danish Drug Users’ Union’ included in the text. Of these 116 articles, 10 were very critical or negative in their description of the organisation, indicating that bad publicity is not a general trend of the media representation. The articles found dates back to May 1996 and carry on until November 2004. It must be noted that not all Danish newspapers have been represented in the data base in this period. Proposition B 68 proposed 14 January 2003. The following references are from the parliamentary debate of 28 February, 2003. 51 views that would be too controversial in relation to the current drug policy in Denmark. The organisation has given priority to seeking legitimacy and providing an image of drug users as basically decent and able citizens, instead of following a more disruptive and confrontational strategy. Balancing the Claims: Critical But Useful Politically, the DDUU seeks to advance harm reduction initiatives in a broad sense (including any initiative which could improve the situation of and respect for drug users). To the DDUU the problem is not so much the drugs. The issues of importance are the life conditions of drug users and the ways whereby drug users are treated by society, the police and treatment institutions. The DDUU favours health rooms or consumption rooms, where drug users can inject their drugs under more secure conditions. It also favours treatment or maintenance programmes with heroine. The DDUU claims that allowing these measures in Denmark would reduce the number of drug related deaths and harms significantly. But these proposals are only occasionally raised as clear-cut demands in the public. Some years ago, the organisation organised a public demonstration in favour of heroin maintenance, but it does normally not use a strategy of protests to call attention to its claims. The organisation rather seeks to behave as ‘good’ and responsible citizens, adhering to a strategy where the activists show a good example (as responsible drug users, who – for example – clean up the used syringes of other drug users). In this way, the activists attempt to provide an alternative image of drug users in the public, seeking to challenge stigmatisation, but also seeking to establish a position from which they may be taken seriously by the authorities. Thus, instead of calling attention through interrupting or challenging strategies, the organisation seeks to gain legitimacy as a serious organisation, which can participate in direct negotiations and dialogues with the authorities. Even if public funding provides the organisation with official legitimacy, public funding also works as a co-opting mechanism which tends to limit the strategies that are available to the organisation (Jepsen 2004a). Too much critique of national policies or specific treatment measures could have a negative impact on the possibilities to gain resources in the future. It could also harm the image of the organisation in the public. The chairman explains: We have to be aware of the national conditions, and we have to adapt ourselves to the fact that we have a weak foundation. We are not supported by the population, we have these public funds and our subscriptions…. So we are very conscious to move carefully on the thin ice, if we pass the line, we react immediately and turn around. We are not going to stick our necks out, so we don’t go out and make a lot of noise. 52 The DDUU thus seeks to establish and maintain good contacts with the different actors in the field (social workers, civil servants in the Ministries and municipalities, health personal, doctors, experts, and politicians). The DDUU has in this way succeeded in forming informal alliances with many different actors in the field, gaining influence through networks and personal contacts. One of the ways to establish these contacts, is among other things the celebration of the anniversary of the organisation. On this day, a user-friend’s prize is awarded to someone who is working in the field.37 Most of the relevant actors in the drug field show up on this day, including representatives from the Ministry of Social Affairs. The organisation also gives priority to carrying out information activities. The DDUU reaches a number of different actors in this way, gaining recognition as reliable actors, who present the views of drug users. From January 2004 to July 2005, 42 formal lectures were given for approx. 735 persons and moreover minor groups of students and other visitors often get information in informal conversations (Hansen, Malmgren et al. 2005). The DDUU is thus able to reach decision-makers, administrative personal, and also front line workers (police officers and social workers) whom the drug users often face in their interaction with the authorities. When the DDUU attempts to call attention to its objectives and its proposals for alternative drug policy measures, the organisation often use symbolic acts. Each year the organisation organises a memorial act to honour and call attention to the users who have died from drug-related deaths during the year. This ceremony takes place at a memorial site that was established in 2003 with support from the municipality of Copenhagen. In 2004 one cross for each drug user that died were placed in the memorial site. In this way the DDUU attempts to get attention from the media and to raise debate on the consequences of a control oriented drug policy. But in spite of the recognition that the DDUU has gained, it remains in a difficult position. The DDUU risks to loose funding and to damage its image as a responsible and serious organisation if it brings forward views that are too controversial or if it involves in activities that would be condemned by the public. The DDUU is in other words, constrained by what can be said and done. As argued by Meyer (2004), even if social movement organisations make choices about how to present themselves and their claims, they do not themselves design the circumstances (Meyer 2004, 53). 37 This is a good example of the connections between national user organisations and how the action repertoire is copied across national frontiers. The idea appears to have originated from user organisations in The Netherlands (see the article by Dolf Tops in this publication). It is now also applied by other similar user organisations for example in Sweden. 53 Achievements and Limitations The traditional way to assess the significance of social movement organisations is to evaluate the political influence of the organisation (Gamson 1975; Giugni, McAdam et al. 1999). I want to claim, however, that a delimited political focus is insufficient for understanding the importance of the DDUU. The significance of the DDUU as an interest organisation in the field only refers to one dimension of DDUU’s work. First, I will argue that the existence of an organisation of drug users in itself is a remarkable achievement that deserves recognition. The DDUU is run by people with an active use of opiates or methadone, without interference from professionals or non-users. Running an effective and well-functioning user organisation38 by principle challenges the stereotyped image of drug users as untrustworthy, self-centred addicts who are unable to be trusted with responsibilities. In this way, the DDUU is an existing proof of the organisation’s own claim; that an active use of opiates does not in itself lead to non-social behaviour, and that it is possible to live a decent life as a drug user (Jepsen 2004a). When the organisation appears in the media, it invariably provides an alternative image of drug users. But even if most articles about the organisation are positive, it still has limited possibilities of changing denigrating practices and stereotyped images of drug users. Providing an alternative image is one thing, changing practice is a completely different thing. Through its continued efforts in the field, the DDUU has gained recognition as an entity which should be taken seriously. The authorities recognise DDUU as a legitimate interest organisation, and as such it is facilitated by public means. The chairman explains how they are taken into consideration by the authorities: Things that are related to us are circulated to us for consideration. When a new law is being processed, we are asked and so on. I will say that being asked provides us with a certain degree of status. Well, perhaps they do not follow our arguments, but sometimes at least we are able to put our fingerprints on the content. A few years ago, the DDUU also had a seat in the Board of Narcotics, where the chairman could participate in different working groups and bring forward the opinions of the organisation. The board was closed down in 2002, however, and the organisation thus lost an important platform for mediation. 38 54 Jepsen (2004a) characterises the organisation as well-functioning and this assessment is supported by interviews with other actors in the field. The DDUU had a saying regarding treatment with methadone. On the one hand, the organisation influenced the formulations that became part of the revisions of the methadone circular. On the other hand, the DDUU has also been able to call attention to – and to achieve changes in – local practices that have been experienced as denigrating and harmful to drug users. Thus the DDUU with support from a lawyer opposed the practice of mixing juice and methadone. The president explains: They mixed juice and methadone to prevent people from injecting it. When people injected it anyway…. it meant that they got staphylococcus in the heart valves and things like that… We were very determined to get rid of that. The DDUU was able to change this practice, and it has also in other occasions been involved in attempts to question or change specific practices at the treatment institutions. Yet, apart from these achievements as an interest organisation, the DDUU must also be valued for the importance it has for its members. The organisation serves as a unifying point of a social network of drug users who often lack more stabile life conditions and social relations. Through the work and experiences in the DDUU, the activists gradually gain self-confidence, they gain a position, an identity: Well, we seek not just to de-criminalise but also to de-stigmatise [drug use]. We think that this is important, and we experience it right here… You can look around at the people who are here now, none of them walk around hiding themselves. They are satisfied with being here and with the work they are doing. They are doing something important, you see… They are not ashamed, because they gradually have realised that we actually have something here to be pleased with, and to be proud of. We made this project thrive. Through the activities of the organisation, the drug users become part of a collective, which has the organisation and its activities as their shared point of reference. The organisation provides a space where the activists feel that they can involve in meaningful activities. Asked directly, if the organisation may be compared to some kind of movement, the chairman replies that it is rather to be seen as a big family. What is entailed in this statement is that the internal life and the close social networks between the activists and members in many ways appear to be more important than mobilising activists in collective action. To many of the activists, the organisation serves as a primary social network. It is the space and context of many of the daily activities and the place where many recreational activities take place. I gain from this because I’m able to get out of bed in the morning, to do something, instead of just sitting at home without doing anything. So, I’m very happy to come here in the association. Before I started coming, I had a 55 depression for three years, where I just took my methadone but stayed in my bed. For almost three years. And then I started coming here..[…]… And I started to learn to take duties and so on. And then I had something to wake up to, and I was able to get out of that stupid bed. The activists in the DDUU in many ways care for each other like in a family. If people do not show up, when they are expected to, some of the activists try to make contact to them to ensure that nothing is wrong. In my view, it is very important to emphasise the significance of this internal solidarity. As an interest organisation, the DDUU holds an important role because it has gained a position from which it is able to speak up for drug users. As a self-help organisation it serves as a unifying entity, which gives new meaning and content to the lives of many of its members. The primary strength of the network of activists could – from a social movement perspective – also form a barrier to the organisation, if it ends up as a selfsufficient network that is unable to recruit new activists. This dilemma relates to another problem that is well-known in these types of organisations, namely that it is a relatively small number of activists which carry out most of the work (Hansen, Malmgren et al. 2005). If the organisation is not able to recruit and involve new members and activists, it may be difficult to continue the work with the same kind of energy and results. Conclusion The DDUU reflects to a wide degree the developments and the organisation of the treatment system. First, the treatment system provided the space that enabled user organisations to emerge. Second, the DDUU was formed by users of a treatment centre that was closed down, and in many ways it gains its legitimacy from its interaction with the actors of the treatment system. Third, the organisation serves as an alternative offer to drug users, through which people can involve themselves in activities without interference from social workers, health workers, etc. It is also noteworthy that the DDUU does not make a lot of efforts to challenge penal policy. It rather focuses on seeking to expand the kind of measures that are accepted as harm reduction initiatives (injection of methadone, treatment with heroine, consumption rooms etc.). In this way the work is directed towards the issues that are currently open for political debate, and issues where differences between the political parties provide a space for advancing the users’ view. Stigmatisation of drug users and dependence of public means influence the strategies of the organisation. Bad publicity that questions the activities that take place in the organisation, illustrates how delicate the position of the organisation is in a society that condemns the use of illicit drugs and drug users. Drug users 56 are almost automatically looked at with suspicion, and consequently an organisation of drug users has to prove that it is trustworthy to a wider degree than other social organisations. The DDUU has succeeded in gaining recognition as a reliable, serious and useful organisation, and following this strategy it has gained influence on policy documents and concrete practices in the treatment system. The DDUU claims rights for drug users (rights to be treated with respect). An important part of the efforts of the DDUU is manifested in activities that are intended to prove that drug users basically are like any other citizens. They have skills, resources, and they are able to run an organisation effectively, just like any other interest organisation in the welfare society. More than attempting to challenge the system, it seeks to become part of it. Therefore, it takes on responsibilities and carry out activities, which are recognised as important and useful by the surrounding society. The DDUU informs about drugs, it is involved in social work, and it collects used syringes on the streets to improve the image and understanding of drug users and to alleviate stigmatisation. So, the DDUU is not a radical movement in the sense that it organises a number of protests to call attention to the drug problem or change drug policies. Instead the organisation seeks a position from which it can get into dialogues and negotiations with authorities. It does not exist outside the legitimate institutions, and the success of the organisation in fact depends upon the apparatus of the state (Wieloch 2002, 66). 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New Brunswick, N.J.; Oxford: Transaction Books. 59 Stretching the Limits of Drug Policies: An Uneasy Balancing Act Dolf Tops Introduction Organisations for and by hard drug users have been a common phenomenon in the Netherlands ever since the late 1970s. The user organisation in focus in this article, the Amsterdam-based Interest Association for Drug Users or MDHG was founded almost 30 years ago. Unlike most Scandinavian user organisations, the MDHG is neither a self-help group/client organisation, nor closely related to a treatment system or treatment issue. Instead, it proclaims to represent and defend the interests and rights of drug users, and its main goal is a political one, namely the legalisation of hard drugs. This makes the MDHG a particularly interesting case from a Nordic perspective, for such an objective is taboo or would at least not be explicitly declared by user organisations in the Nordic countries. My purpose in this article is to describe how the Dutch context has made possible the emergence of a relatively autonomous group of user organisations. I will illustrate how user organisations are influenced by general drug policy and by the institutional structure of the political system. Based on the principles of harm reduction, Dutch drug policy differs quite considerably from the Swedish goals of a drug-free society and therefore provides an interesting backdrop for an analysis of how it influences the modus operandi and goals of user organisations. The harm reduction approach does not focus on illegal drug use as such, but on preventing and reducing the risks of drug use to both users themselves, the immediate environment and society. Reducing the risks for society is the origin of the public nuisance policy that incrementally paralleled the harm reduction approach in the Netherlands and that is targeted at the behaviour of the drug user rather than drug taking as such. The drug-free society approach, on the other hand, is aimed at eliminating illegal drug use altogether, and one of the means of achieving this is by the criminalisation of drug use. Logically, the approach determines the limits for the organisation of users as well as for their aims, strategies, activities and action repertoire. Apart from drug policy, another important aspect facilitating the emergence of user organisations is the institutional structure of the political system. In this case, both the Nordic countries and the Netherlands can be characterised as 60 cooperative states with long traditions of involving civic organisations in the policy-making process. A third relevant factor concerns the constituency of drug user organisations. Although drug use does not necessarily and automatically imply individual or social problems, the constituency of organisations for and by hard drug users usually consist of marginalised people with multiple problems, including drug use, homelessness, psychiatric disorders, etc. This presents a special challenge to these organisations in terms of encouraging users to get involved and to sustain that involvement. In this article I will be describing the ways in which the MDHG is working to stretch the limits and possibilities imposed by society by focusing on its organisational form, the issues that are raised, its action repertoire and aims in relation to the local context. Social Movement Organisations and Their Context Structure The MDHG may be described as a social movement organisation, i.e. an organisation that pursues a political goal by means of collective action. My choice to call it a social movement organisation instead of a social movement is deliberate. According to Tilly (2004, 4), one of the characteristics of social movements in the West is that participants concert public representations of WUNC: worthiness, unity, numbers and commitment on the part of themselves and/or their constituencies. In this sense, the MDHG is not a social movement because even though it promotes the W and the C certainly is present, user organisations do not display numbers (they do not march in ranks) and there are also questions about unity. However, if we regard the emergence of user organisations in Western Europe as a social movement, local organisations are part of this phenomenon and thus social movement organisations. This argument is strengthened by the fact that there exist international networks of user organisations where information about local developments is exchanged and where the action repertoire is emulated. User organisations also support initiatives to set up new organisations where such do not exist. One way of analysing social movement organisations is via the concept of context structure (Rucht 1996). In this concept, conditions external to a movement (or set of movements) either restrict or facilitate the building and maintenance of a movement structure devoted to conducting protest activities (ibid., 189). The most crucial contextual dimensions are the cultural, social, and political contexts: 61 • The cultural context refers to the attitudes and behaviours of individuals who may (or may not) provide support such as money, organisational help, or personal involvement in protest events. This depends on how a movement’s issue and demands resonate with the experiences and interests of larger sections of the population. This resonance is a function of the distribution of cultural patterns among certain groups in the population and the framing of the problems at stake. Here both general values and more situationally dependent issue perceptions come into play. • The social context is the embedding of social movements in their social environment. One aspect consists of the social milieus and networks, which either facilitate or restrict the forming of collective identity and the building of movement structures. For example, population density facilitates communication and mobility between networks. • The political context is where conceptions of political opportunity structures are focused, singling out factors such as access to the polity, political alignments, presence or absence of allies, and conflict among the elites (ibid., 190). In this article I use the concept of context structure to describe the MDHG and its operation. The focus is on what McCarthy (1996, 142), referring to Tilly (1985), described as a key task in the study of mobilising structures, namely to characterise “the social movement” by its typical social location and associated strategic and tactical approaches. In effectively choosing mobilising structures, activists must successfully frame them as usable and appropriate to the tasks of social change they employ. The targets of these framings are both internal – adherents and activists of the movement itself – as well as external, including bystanders, opponents, and authorities. This means that the framing of action is intimately related to the cultural context in which a social movement builds its mobilisation structure (ibid., 149). The empirical data for the article consist of interviews in April 2005 with three persons working in user organisations and one official from the Department of Social Affairs. The magazine “Spuit 11”, published by the MDHG since 1981, and the organisation’s annual reports have also provided important sources of information. Additional material has been collected through the Internet. In the following the main focus is on significant aspects and changes in the Dutch context that have contributed to the emergence of the MDHG and some other user organisations. 62 From Drug Free to Harm Reduction One important contextual factor is of course the national drug policy and its impact on possibilities for drug user organisation. Dutch drug policy is characterised by a two-track approach, with separate policies on cannabis products and so-called hard drugs. This principle, as set out in the Opium Act of 1976, has been at the centre of Dutch drug policy ever since. The focus here is on the policy on hard drugs, i.e. heroin and cocaine, for it is precisely these users who are targeted by user organisations in the Netherlands. Heroin appeared on the Dutch illegal drug market in 1972, presenting the authorities and treatment organisations with a whole new problem. Based on experiences and research from abroad, especially the United States, there were fears of a heroin epidemic, particularly among socially marginalised sections of the young population. These fears materialised sooner than anyone had expected and in 1976, the number of people addicted to heroin in Amsterdam was estimated at 5,000–7,000 (Tops 2001, 123). The number of problem users peaked at 8,800 in 1988, and has declined until 1998.39 This decline has been explained by the return of German and Italian users to their home countries. The number of problem users of opiates (most of whom also used cocaine) in 2003 was estimated at 4,530. The use of cocaine (coke base) seems to be primarily a big city phenomenon and common among homeless people (Trimbos 2005). A major shift occurred in national drug policy in the early 1980s. The philosophy and goals of the traditional treatment system were increasingly called into question (not least because of its poor results) by user organisations, left wing parties and progressive treatment professionals. Eventually, the system bowed to the pressure. Instead of taking abstinence as the only goal for treatment, politicians began to accept more differentiated goals. Coming off drugs, for those who were able to, and a policy of “harm reduction” for those who were not (yet) able to quit drugs, were adopted as the leading principle for care and treatment institutions. It was considered a kind of social contract where society, on the one hand provided assistance that enabled drug users to reduce the risks of drug use, for example by low-threshold assistance facilities, and drug users on the other hand would and could behave as common citizens (whatever that might be). This policy became denoted as the normalisation of the drug user and entailed a further categorisation of drug users into socially normalised and integrated users, on the one hand, and those who could not or did not want be normalised, on the other, eventually becoming problem users or extreme problem users.40 The latter two categories became the constituency of the MDGH. When compared internationally, the adoption of what later became known as the policy 39 The number of problematic drug users in the Netherlands was estimated at 32,000 (2001) which compared to most other EU countries is quite low (Trimbos 2004). The number of drug addicts per 1,000 population in the Netherlands was 3.0, in Denmark 7.2, Sweden 4.5, Finland 3.5 and Norway 4.2 (EMCDDA 2005). 63 of harm reduction, in which the aim was to reduce the risks of drug use to the user and society instead of curing all drug users, took place at a rather early stage.41 One of the consequences was particularly visible: thousands of addicts from abroad (many from Germany) sought and found refuge in Amsterdam. Another part of the social context concerns the period in which drug user organisations emerged. User organisations were one among numerous action groups that emerged in the 1960s and later. In many fields of social life, groups of people felt oppressed and claimed the same human rights as other citizens. To name just some, homosexuals, psychiatric patients and women’s liberation movements called for equal rights, squatters for housing, and students for the democratisation of universities. In this pandemonium of protests, drug user organisations were just one among several actors with the same action repertoire, including pamphlets, rallies, demonstrations and occupations of treatment organisations’ offices. Their chief goal was not to get better treatment, but rather to be treated like other citizens with the same human rights, even if they were using hard drugs. However, their situation was only made worse by the prevailing drug policy. From the very outset, therefore, user organisations aimed to change Dutch drug policy in terms of drug users having legal access to hard drugs. However, such a fundamental change was a long-term goal; their shortterm goal was to improve the living conditions of drug users. In 1981, “Junkiebonds” (Junkie Unions)42 emerged in a number of cities across the Netherlands (Spuit 11, No. 3, 1981). The number of user organisations has varied over the years from 15 to 30. Some have closed down, especially those wholly organised by drug users, but many of them have returned with new, often charismatic instigators (Jepsen 2004). In some cities, they are organised in statutory associations or foundations, in other cities they consist of loosely organised user groups. The Emergence of Local Initiatives Social problems tend to concentrate in big cities, and drug use is no exception. The Dutch government was concerned that the drug problem might spread from the cities to the rest of the country and therefore closely monitored developments 40 41 42 64 Problem use is defined as the use of a substance in such a way that it causes physical, mental or social problems or social nuisance. Problem use does not always imply addiction. “Misuse” is a type of problem use that it still not a matter of addiction (Trimbos 2005). Germany, Belgium and France, for example, adopted elements of harm reduction in their drug policies during the 1990s. The adoption of the concept of “junkie” (from junk, meaning rubbish), follows an old Dutch tradition since the 16th century of reclaiming a derogatory name and using it as a positive label of empowerment within one’s own movement (Vuijsje & van der Lans 1999). This is a case of framing that it is embedded in the cultural context. in Amsterdam and the country’s three other major cities, Rotterdam, The Hague and Utrecht, collectively known as the 4 G. The 4 G have played a major role in drug policy issues since the 1960s, and they have discussed their local drug problems and drug policies directly with the national government (Tops 2001). This means that local initiatives also have an important impact on national drug policy. Harm reduction practices, such as coffee shops and needle exchange programmes, for example, first emerged in the 4 G before they became part of national drug policy. Likewise, drug user organisations have jointly pursued actions to influence policy measures on the national level, and there have also been some national drug user organisations. The MDHG was founded in 1975 in a neighbourhood known as a marketplace and gathering place for opiate users in Amsterdam, on the initiative of a local resident who was convinced there should be viable alternatives to the repressive drug policy (Hondius 2005). Among the other people involved were an outreach worker, physicians, local pharmacists, users, and parents of drug users. The National Dutch Federation of Junkiebonds (FNJB) was established in 1980 to promote the exchange of information between local user organisations and discussion of developments and events at local and national levels. When necessary, concerted actions were pursued. In June 1980, members of user organisations in Amsterdam, Rotterdam and other cities occupied the premises of the Federation of Agencies for Alcohol and Drugs (FZA), an umbrella organisation for ambulatory drug treatment institutions in Bilthoven (near Utrecht) and demanded to speak with the board in order to discuss its policy on the prescription of methadone (Spuit 11, No. 4, 1981). Another example of the ability of these organisations to carry out orchestrated actions is provided by the conference staged by user organisations in response to the introduction in 1980 of compulsory care for hard drug users by the Lord Mayors of the 4 G. On this occasion 500 participants, among them many drug users, gathered in The Hague (the residence city) to discuss the proposal and to persuade public opinion and politicians (MDHG 1981). Indeed this and other actions probably contributed to the government’s decision to reject the proposal. In May the same year, at another conference staged by user organisations, a proposal was floated for the prescription of opiates (including heroin) to heroin users. This, at that time, was a politically impossible option, but it was eventually realised twenty years later, just as compulsory care. It was indeed a distinctive characteristic of national user organisations at this time that they were very much oriented to direct action. In 1992, another type of national drug user organisation emerged with the foundation of the National Supporting Point Drug Users (LSD). The LSD was established on the initiative of an ex drug user who had been previously involved in a peer-to-peer harm reduction activity. The main goal of the LSD is to support 65 the creation of local drug user organisations. One of its functions is to mediate between drug users and policy makers at both the local and the national level and to provide advice in conflict situations between user organisations and treatment organisations. It also aims to assist and encourage drug users to organise themselves in local organisations. Other activities include the provision of information about drug use and drug users at juvenile prisons and health care institutions, to political parties, etc. Together with the Trimbos Institute, the national knowledge institute for mental health care, addiction care and social work, it has developed guidelines for the country’s 35 using rooms.43 In these contexts, drug users should be considered “experience experts”. The LSD received funding for its operation from the Department of Social Affairs (VWS). As far as the VWS is concerned, “the LSD is like any other association of clients, and it is important in the policy making process to know what is happening in the world of drugs and drug users”.44 However, VWS funding to the LSD had to be discontinued in 2005 due to cutbacks in the national budget. The government’s policy today is to withdraw its funding for activities that are a matter for local politics and authorities. How this will affect local user organisations in the future remains to be seen. Organisations in the 4 G have now turned into professional organisations which (for the time being) have stable resources and can survive even without the support of the VWS. Organisations in smaller cities face a more uncertain future.45 It is probably because of its stable organisation that the MDHG has played an important role in many of these initiatives on the national level and in networks between local drug user organisations. The text below proceeds to look into the aims and role of the MDHG in closer detail. It starts with a short description of some important developments within the local Amsterdam drug policy. Public Nuisance and Reducing Risks to the Environment A significant change in local drug policies that influenced the everyday lives of drug users was the launch of a programme aimed at reducing drug-related public nuisance. The definition of this nuisance reduction policy and the way it was implemented calls for some discussion. In Amsterdam, an area near the Central Station46 was known since the 1960s as a major marketplace for opiates: there were large numbers of opium users in the local Chinese community and therefore the area also attracted opium addicts. 43 44 45 46 66 The term “injection room” is not used in the Netherlands. A large majority of drug users smoke their heroin/cocaine and the premises are therefore called “using rooms”. Interview with official from the Department of Social Affairs. Interview with founder of the LSD. This was the area in which the MDGH was established. When heroin became the most widely used opiate, users began to gather in this area. Heroin was of course available in others parts of the city as well, but the sheer number of drug users here made them more visible. At first, the public nuisance consisted mainly of petty crime, but eventually the mere appearance of drug users was seen as a source of disturbance. Drug-related nuisance was most noticeable around the Zeedijk, a street in the Red Light District, where drugs were sold and used in the open. Local residents and shopkeepers consequently began in the mid-1970s to insist that the authorities take action to intervene. However, the complaints were not unanimous. For example,the present chairman of the MDHG lived opposite the organisation’s offices and he initially took an interest in the MDHG as he observed the people visiting the office from his window. Furthermore, a letter from the Lord Mayor in which he advised people in the area not to offer coffee, sandwiches or shelter to drug users, also goes to show that not all local residents experienced the presence of addicts as a nuisance (Spuit 11, Winter 2000). In 1987 the police introduced what is colloquially known as the “Dike prohibition”, which has been a thorn in the side of the MDHG ever since. This local regulation gives the police the powers (in the name of the Lord Mayor) to expel people from the area for up to eight hours if they are found consuming drugs, if they are in possession of a drug-using device, or if they gather in a public place in groups of four or more. At the same time, the individual or individuals concerned will be summoned to court, where they will be issued a fine of between 75 and 120 euros or given a five-days prison sentence. In cases where people have received an expulsion order five times within six months, the police can impose an expulsion period of 14 days. Violations may result in prison sentences of six weeks to three months. Another exponent of the nuisance policy in Amsterdam was the so-called streetjunkie project that started in 1989 and that was specifically aimed at a hard core of some 300–400 problem drug users. Drug users who repeatedly committed petty crimes more than four times during one year were given the choice of either going to prison or attending a drug aid programme (Mol & Trautmann 1991). A third example of the nuisance reduction policy is a penitentiary regulation, SOV (Measure for the Criminal Care of Addicts), that came into force on an experimental basis in 2001. According to this regulation a hard drug user who has received more than three prison sentences and who is re-arrested within five years, may be sentenced to compulsory care during a maximum period of two years. It is clear then from these examples that there are no grounds whatsoever to the common notion that Dutch drug policy is liberal or permissive. This may be true for cannabis users, but as far as problem users of hard drugs are concerned (and 67 particularly heroin and cocaine users), public and political attitudes are far from liberal. As Mol & Trautmann (1991) have shown, Dutch drug policy has followed an increasingly repressive course since the late 1980s. This new direction, as we will see, became a major target for the MDHG’s action programme, which was based on the view that is the “illegality of drugs” that creates the black drug market and causes nuisance to the environment (Spuit 11, Spring 2001). MDGH: Working for an Alternative Drug Policy The MDGH was founded as an alternative to the Netherlands’ repressive drug policy in 1975. In a memorandum from 1977, the founder and first chairman of the organisation proposed three starting-points, viz. a generous prescription of substitutes (methadone, heroin and other opiates), ambulatory first line assistance and a neighbourhood-oriented approach (Riemens 1977). When the organisation turned into a union of drug users in 1981, its founder decided to leave because in his opinion this move would lead to a further stigmatisation of drug users (Hondius 2005). Until 1986, the official name of the MDGH was the Association of MedicalSocial Service Heroin Users (MDHG); the name was then changed to the Interest Association of Hard Drug Users (MDHG). The change from “heroin” to “hard drug” users was made because hardly any of the members were on heroin only. Since the 1990s, the organisation has been called the Interest Association for Drug Users (MDHG). As the name of the organisation describes its main target group, it is interesting to note that the MDHG no longer uses the epithet “junkie”, a label that its constituency no longer appreciates. It is the organisation’s position that the criminalisation of drugs and repressive drug policy both adversely affect the social position of drug users and constitute a major obstacle to the normalisation of drug users. The organisation conveys this view in its contacts with politicians, the authorities, the public and the media. Its main goal is to promote an alternative drug policy, including the legalisation of drugs, and the normalisation, emancipation and public acceptance of the drug user (MDHG 2004). In the shorter term, the organisation aims to promote low threshold and user-friendly assistance programmes, including methadone and heroin prescription, with a view to improving the everyday life of drug users. Another goal is to work against the prejudice in society towards drug users, especially in neighbourhoods where drug users live or gather. The interests of the organisation’s constituency are promoted in numerous contexts. The “user’s voice” is put forward in various fora; in contacts with the judicial system, treatment institutions, the media and the polity. One way to 68 achieve influence is to get drug users involved in client councils of care institutions, such as the municipal health authority in Amsterdam that runs methadone programmes and the heroin prescription programme. According to the Bill on Client Participation in Care Facilities (WMCZ) from 1996, all care institutions are to have client councils in order to ensure client participation in matters that are of immediate concern to them (NIVEL 2005). Another strategy of gaining influence is through the representation of drug users on advisory boards of projects such as the Measure for the Criminal Care of Addicts (SOV) in Amsterdam. Below, I describe some of the issues that have been raised by the MDHG as well as activities and actions for and by its constituency. I make a distinction between more or less regular activities directly aimed at the constituency and actions aimed at the public and the policy-making domain. Together, these constitute the organisation’s action repertoire. Policy Challenging Activities The MDHG is not a single-issue organisation, but its action repertoire covers various aspects of the problems encountered by its constituency. It ranges from challenging actions such as protest marches to the City Hall and occupying institutions to more conventional information activities such as distributing leaflets. A recurrent issue concerns police activities to reduce drug-related nuisance, or what the MDHG and its constituency regard as “police harassment”. Since the 1980s, the City of Amsterdam has been increasingly concerned about its dubious reputation as a mecca for drug users, both in the Netherlands and abroad. In 1987, Amsterdam published its new drug policy in a booklet specifically aimed at foreign drug tourists: “Addicts who are not from Amsterdam are not welcome here. Amsterdam is not a rose garden for junkies” (Amsterdam Information Office 1987). In the opinion of the MDHG, domestic junkies were not welcome either, and the City’s message has been a main target for the organisation’s activities and actions. Not surprisingly, this also accounts for nuisance reduction actions such as the Street Junkie Project and the Measure for the Criminal Care of Addicts (SOV). The MDHG works to combat the “hounding junkies” policy in several ways. In winter 1991, the organisation’s magazine Spuit 11 included four pages of information for drug users on how to act in case they were arrested, detailing the procedures as well as the rights and obligations of drug users and police officers. In winter 2000, an allied (star) lawyer (and former member of the board) prepared a standardised form of appeal to be used in case of a police summons for violation of the Dike prohibition. In Spuit 11 (Winter 2000), drug users are 69 cautioned not to neglect a summons, but to bring it to the MDHG offices where they will be assisted in filling out the form of appeal. Another activity through which the MDHG works to combat the anti-nuisance strategy is its “habituation course” for newly arrived police officers in the area, informing them about the situation of drug users. This course imitates the Netherlands habituation course that is obligatory for immigrants, who are supposed to learn the language, the history, and the values and norms of Dutch society. Another illustration of a more light-hearted action is the “Willem Schild (an Amsterdam police officer) Award” for the user-friendliest police officer in Amsterdam, launched in 2001. However, no police officer has be nominated for the award since 2002. The organisation’s action repertoire also includes more militant actions. On 19 September 2002, a group of 50 drug users entered a room where the Lord Mayor was chairing a commission meeting, to protest against the police practice of “hounding junkies”. The MDHG insists there is need for more using rooms. The Lord Mayor was offered a peace pipe. He listened for a full hour, but rejected an invitation to visit the MDHG for a discussion with drug users (MDHG 2003). As the protesters made their way back, the police booked 15 of them for gathering in the street (De Telegraaf, 20 September 2002). The MDHG came up with an inventive strategy to circumvent the Dike prohibition in 2004 when it established the Association Meeting Point and claimed it was organising outdoor debates under the constitutional right of meeting. By organising large numbers of meetings, the MDHG hopes to reduce the number of fines issued for gathering. During these meetings, participants wear a button which reads: “Do not disturb – meeting going on”. Other issues addressed by the MDHG concern treatment arrangements, such as methadone programmes and particularly the control practices and subsequently the sanctions imposed through methadone programmes. It also closely monitors the experimental heroin prescription programme. Complaints about the quality of heroin used in the programme concerned its effects on the lungs when smoked. Accustomed to street quality of diluted heroin, drug users were not used to the purity of the prescribed heroin. Another target of criticism has been the Amsterdam policy on using rooms: there are too few of them, they are far too restrictive (users only have access if they are registered) and they are only open during the daytime. Self-help as Action Although the organisation has explicitly stated that it is not a self-help organisation, it does engage in activities that are directly aimed at catering for 70 the needs of its constituency. The best-known among its self-help activities was the world’s first needle exchange programme in 1984. The initiative that started out as a protest against the lack of sterile injection equipment eventually became an integral part of regular drug treatment programmes. Other important activities include practical support for members, for example in the form of assistance with correspondence with social service agencies, making and keeping appointments, finding a place to sleep, applying for an ID card or access to legal aid. These activities are carried out in the streets, at drop-in centres, using rooms or at the MDHG offices. Another self-help activity is the so-called women’s afternoon. On Friday afternoons, female drug users can meet female volunteers to talk about their problems, get a massage, a haircut and smoke a little. This activity started in protest of a decision by the municipality to close down a facility for female drug users. A more challenging activity that has been organised from the very outset is a drop-in consultancy centre, intended primarily as a means for the organisation to keep in touch with its constituency. Drug users can drop in for information, advice, to complain or just to have a cup of coffee or a smoke. Opening hours and days have been changed several times because of complaints by local residents or orders issued by the police. Visitors represent a cross-section of the drug using population in the area (and the prime target group for police antinuisance actions). In addition, wherever drug users meet and consume drugs, drug dealers are not far away. Drugs have been used during drop-in hours and tolerated by the staff. In 2004, however, the drop-in centre turned into an unofficial using room with a daily average of 70 visitors. It was intended as an alternative to established using rooms (nine rooms in 2005), most of which are in the centre of the city, where drug users can smoke their heroin and cocaine. These using rooms are run by assistance agencies, who also select and register the visitors (in some cases visitors are also selected by the police), and their main aim is to reduce the amount of nuisance caused to the general public by drug use. Drug dealing on the premises is prohibited, and an experiment with house dealers was ended in October 2004 when the police raided the MDHG premises on suspicion of drug dealing. In the MDHG action plan for 2005, the drop-in centre (“experimental self-management using room”) was described as a success on account of its low-threshold character, and plans were announced for its continued operation. However, not all local residents were pleased and opening hours were reduced to three days a week (MDHG 2005). In April 2005, the police raided the drop-in centre once again. After four months of surveillance, the police had collected evidence of drug dealing, and this time the Lord Mayor took the decision to close the premises. After discussions with the municipality, the MDHG was allowed to reopen its offices on condition that the drop-in centre remained closed. 71 The examples above show how the MDHG uses self-help activities for purposes of achieving various goals. The women’s afternoon started in protest against the lack of facilities for female drug users. The self-management using room, launched as an alternative to the municipal policy on using rooms, was more controversial and met with repressive actions. In particular, the house dealer in hard drugs as a way of regulating not only drug use but also the retail trade of drugs, challenged the very core of the national drug policy on hard drugs. Obviously, in this case the limits were stretched too far. Information Activities Another important MDHG activity is the provision of information about the organisation’s goals and its constituency to the media, the general public and the authorities. Information is also provided on request, for example to the Police Academy in Amsterdam. Furthermore, the MDHG participates in conferences both in the Netherlands and abroad. One important instrument in this information function is the quarterly magazine Spuit 11, which has been published (irregularly) since 1981. It is edited by MDHG staff and volunteers and it has around one thousand subscribers. The title is rather ambiguous and relates to someone who always comes too late, but “Spuit” is also the Dutch word for syringe. Reports about actions by the MDHG and other user organisations are an important topic. Under the heading of “Sounds of the Street” (or Junk mail), drug users report on their encounters with the police or the treatment system, usually in critical terms. Occasionally, Spuit 11 contains obituaries of drug users who were actively involved in the MDHG. Another, now defunct way of informing the public about the everyday life of drug users was the open evening, which until 2005 was held every Thursday evening at the MDHG premises. It was open to anyone interested, often with an invited speaker addressing an issue related to drug use. Sometimes local residents were invited to discuss problems allegedly caused by drug users, and how to address these problems. A standing subject of conversation at these evenings consisted of reports by drug users about their experiences during the last week. This also provided an opportunity for staff to keep themselves informed. A lawyer was also present to provide advice, free of charge, to drug users who needed advice in legal matters. The service ended last year because this voluntary lawyer retired and it was too expensive to hire a replacement. However, the open evenings were not without their problems because they were not intended as a drop-in for using drugs, but for serious discussions, and these two activities did obviously not mix very well (MDHG 2003). The staff placed a message (Sorry, no smoking, just talking) at the front door, and eventually the open evening moved to Wednesdays (Jezek 72 2000). In 2005, the open evening was discontinued because it placed too heavy a drain on personnel resources. Another way to highlight the living conditions of the organisation’s constituency is through research. One example of the MDHG’s research from a user perspective is provided by a study (Dope and Detention) on the situation of detained drug users (MDHG 1994). Furthermore, students from De Hogeschool van Amsterdam conducted a study on the subject of coping with bereavement among drug users. The study explores the question as to how far it is possible to mourn while using drugs and looks at the role of treatment in this process (LSD/ MDHG 1999). The MDHG was also involved in a study called Free heroin… Medical prescription from a users’ perspective conducted by the LSD in five cities where 40 drug users were interviewed (by drug users) about their experiences of the heroin prescription programme (LSD 2002). As mentioned earlier, the MDHG has also played an important role in national initiatives and in establishing contacts between local drug user organisations. One example is the “four cities consultation” in which representatives of user organisations in Amsterdam, Rotterdam, The Hague, and Utrecht meet four times a year to discuss developments in their cities and in national policies – an analogy to the meetings of the Lord Mayors of the 4 G. Here it is interesting to consider the impact of the social context both on framing activities and on the creation of networks through the high population density, which facilitates communication and mobility. The Netherlands is one of the most densely populated countries in the world; by comparison drug users from Stockholm and Malmö in Sweden, for example, would have to travel 600 km to meet each other. The MDHG also participated in the preparation of the annual International Drug Users’ Day, organised by the LSD until 2003 and financed by the Department of Social Affairs. At this meeting drug user organisations from around 20 countries got together to exchange information and experiences. In summary, the MDHG’s action repertoire is multifaceted, ranging from support to drug users in everyday matters through political actions to research. It is also noteworthy that the issues covered and the activities and actions pursued have been remarkably stable over time. Tensions between what the organisation wants to achieve and the conditions embedded in its structure and social, political and cultural context are discussed below. Dilemmas of Representation An important issue in terms of representation is whether a user organisation is organised for or by drug users. Some take the view that only users can represent themselves. Others refer to the circumstances in which drug users live their lives, 73 very much hampering their ability to run a stable organisation. So what kind of organisation does the MDHG actually represent. Kriesi (1996, 154) outlines two ideal types of organisation that are of interest here. First, there is the grassroots model, which is characterised by a relatively loose, informal, and decentralised structure, an emphasis on unruly, radical protest politics, and a reliance on committed adherents. Secondly, there are interest organisations that are characterised by an emphasis on influencing policies (via lobbying, for instance) and a reliance on formal organisation. The MDHG describes itself as an interest organisation for and by drug users. Even though it has attempted over the years to encourage stronger grassroots participation, its main feature remains that of a formal organisation. The MDHG is open to drug users, ex drug users, their relatives, and all others who share the goals of the organisation. Non-drug using supporting members do not, however, have a vote at the annual meeting (Spuit 11, Winter 1999). As from 1977, the MDHG has been formally organised as an association with a board consisting of five to seven members. The board is elected by the members every three years. It accounts for its work (and that of staff members) in an annual report submitted at the annual meeting, which is also where questions of policy and activities for the next year are decided. The members of the board are elected on the basis of their commitment to the issue and their professional affiliation; they include lawyers, staff members of drug assistance organisations, scholars, but also parents of drug users. To ensure that the organisation’s constituency retains a voice, the board always includes at least two drug users. Among the board’s several functions, the most important is to guarantee continuity in the organisation. A common difficulty for user organisations that hope to be an organisation for and by drug users is how to actively involve users in activities within and outside the organisation. Since the use of hard drugs is illegal, users often find themselves preoccupied by obtaining drugs and therefore have no time for organisational work. On the other hand, if and when users do succeed in obtaining drugs, that may also undermine their ability to work for the organisation. Furthermore, drug users occasionally end up in prison or die. These problems also apply in the case of the MDHG. According to the organisation’s director, it is very hard to encourage members of the constituency to attend annual meetings, for example, and consequently drug using members usually are in the minority. The board also has a responsibility as an employer. The working relation between the board and staff members can vary from a rather distant one to a more active interplay. Today, contacts are close and the director and the board meet every other month. Staff and volunteers who have daily contact with the constituency can address issues that are important to them. 74 Financial Resources Financial and human resources are important to the development of a social movement organisation and affect its internal structure. The MDHG depends on the municipality for financial resources, which means that it has to give something in exchange, such as services that the regular assistance system cannot adequately provide. As in other countries, the spread of HIV among drug users has dramatically increased the availability of financial resources for HIV prevention activities (Tops 1991). User organisations suddenly became important allies for public health authorities, for example in peer-to-peer campaigns for the prevention of HIV. In other words, the flow of financial resources very much influences the organisation’s activities. Since 1977, the MDHG has been subsidised by the City of Amsterdam, and it is currently subsidised directly by the Office for Social Development (DMO). One of the office’s tasks is to assist district councils in developing and executing services in a number of fields, including the care of drug users. To “earn” this subsidy, the MDHG has to advise the DMO on such matters as when a district is planning to open a using room. Another minor source of income is a subsidy from the Amsterdam Patient and Consumer Platform (APCP), which is based on the number of members. In April 2004, the MDHG had 1,200 members, about half of whom were supporting members.47 For 2005, the organisation’s budget is 150,000 euros: this has to pay the salaries of full-time staff (director, secretary and assistants), the office rent, the magazine Spuit 11, etc. In summary, the MDHG is a formal and professionalised organisation that largely works for its grassroots members, i.e. drug users. The mode of financing can also bring about a certain level of professionalisation, including staff appointments. MDHG staff consists of a co-ordinator, regular staff members and assistants (usually drug users employed with labour market subsidies from the state or municipality for a maximum period of two years). While daily operations are in the hands of the director and secretary, the assistants are busy with activities directly aimed at the constituency, such as running consultancy hours or visiting drug users in using rooms or in the street. For assistants, the job provides an opportunity to stabilise their drug use and social life. Much of the organisation’s activities are based on the commitment of volunteers. However, doing voluntary work in a user organisation is no easy task, and requires the ability to communicate with people who are not always organised or prepared to put the interests of the organisation first (LSD 1998). 47 Interview with the director of the MDHG. 75 Co-optation After 30 years at the same location, the MDHG moved in September 2005 to new premises. The main source for its subsidies, the Office for Social Development (DMO), stressed that the MDHG should find new offices in affiliation to an assistance organisation. 48 The MDHG, however, preferred to remain independent and finally found a new location on the edge of the city centre district, much against the will of the district council and police authorities: they took the view that assistance agencies should move out of the district because they attracted drug users. However the MDHG was allowed to reopen on condition that it organised no using room activities on the premises. Now, the MDHG has consultancy hours on an individual basis from nine to five every day. This enables the organisation to pursue one of its most important tasks, namely to understand the problems encountered by its constituency. Other ways in which this can be achieved is for staff members to visit drug users at using rooms and other locations. These latest developments highlight some interesting issues. First, they draw attention to the tension between two elements of the organisation, i.e. its ambition to represent the grassroots members who have only limited ability to organise themselves, and on the other hand its role as a formal professional organisation that works for its constituency, the grassroots. Secondly, they highlight the risk of co-optation, with the organisation becoming ever more closely integrated into the official assistance system and in this way making it harder to criticise the system. In the MDHG’s 2002 annual report, the chairman of the board cautioned against excessive involvement in all kinds of consultations with the authorities, because these consultations can also be exploited to legitimise drug policy decisions. The organisation is at risk of getting bogged down in endless meetings, while the constituency is keen to see action (MDHG 2003). It is possible that the MDHG will slowly, but obviously not unnoticed, become involved in a process of institutionalisation and formalisation in order to ensure its access to a stable flow of resources. This will obviously influence its internal structure and its integration into established systems of interest intermediation. However, the organisation has managed to avoid some of the consequences of such a transformation: for example, it has neither moderated its goals nor conventionalised its repertoire. Furthermore, it has resisted demands by funding bodies to affiliate with assistance agencies. As for its internal structure, the organisation has shown long-standing stability, presumably due to its structure as an association. However, there are also some signs that at the staff level, things are changing. Today, the co-ordinator has the title of “director”, and the 2004 48 76 Interview with the director of the MDHG. annual report of 2004 features the terms “managing director” and “finance director” (MDHG 2004) This professional approach is probably also reflected by Spuit 11, which today is a glossy magazine. Whether this is simply an adjustment to the changing social structure or a fundamental change in the organisation’s internal structure, is as yet unclear. Future Challenges: Stretching the Limits User organisations have been a common social phenomenon in many Dutch cities since the 1970s. Although many of them have disappeared over the years, some have shown great strength of survival and maintained their activities. The MDHG provides a good example. One of the reasons for its strength is that the organisation is an association with a board consisting of both non-drug users and drug users, which has provided a stable structure over time. Secondly, the presence of a professional staff also contributes to stability. Thirdly, a steady flow of financial resources is important for any organisation. The MDHG is an organisation for rather than by drug users, and its main task is to promote the interests of drug users in contacts with the policy-making domain, treatment systems and the media. To achieve these goals, the organisation has to be in close contact with its constituency, either through drop-in consultancy hours, open evenings (until 2005), individual contacts in the street, using rooms, or treatment centres. Looking at the political context, it is clear that local authorities are important actors on the Dutch political scene. Dutch drug policy is largely an outcome of local developments, although it is also constrained by international commitments. Dutch user organisations therefore operate mainly on a local level, because it is there they can make a difference for their constituencies – and hope that their actions can make a difference at the national level as well. The emphasis on local activities can be explained by the historical social context. In the process of state making and in drug policy issues, the largest cities in the Netherlands (the 4 G) have played a dominant role since the 1960s (Tops 2001). However, as the MDHG itself has found out, it is very hard to gain access to decision-making processes. The MDHG still has no part in commissions that are involved in activities directly aimed at drug users. However, the MDHG can influence the local policy-making domain through its official mission at the Office for Social Development (DMO), namely by putting forward the voice of drug users. Another avenue of influence is through participation in client councils, but here again there is the question as to who represents whom. Even if drug users have a representation in client councils, the difficulty remains as to how to keep in touch with the constituency they represent. A third way of gaining access to decision-making fora is through the professional networks of 77 board members. A fourth, indirect way is by seeking to persuade politicians through the media. It is of course hard to assess the true influence that the MDHG has on the policy-making process. However, the frequent appearance of the organisation in the media suggests that the MDHG is at least thought to speak on behalf of drug users. Another intriguing question concerns the rationale behind the municipality’s decision to subsidise an organisation that over the years has been one of the fiercest opponents of the City’s drug policy, particularly its “hounding junkies” policy. The same applies, until recently, to the national government. There are several possible answers to that question. Firstly, as pointed out by the MDHG chairman, (limited) involvement by the organisation in the local drug policy domain can be exploited to legitimise policy decisions. Secondly, the MDHG performs functions that are not possible for the established assistance system. A third possible explanation relates to the structure of the treatment and assistance system in the Dutch social/cultural context. For historical reasons, the bulk of social and health services are organised and executed by non-governmental organisations, which means that national and local authorities depend heavily on these organisations in pursuing a policy. Consequently, this institution with long roots in the past opens up opportunities for new actors in this sector. There is yet another salient feature of the Dutch cultural context that should be mentioned here. Dutch society is often described as a “consultation nation” where special value is attached to the achievement of consensus between conflicting parties (Andeweg & Irwin 1993; Lendering 2005). The Dutch even have a special word for this that goes back several centuries: “polderen” means that relations between central government and the cities, between the cities and their citizens, between employers and trade unions, etc., are dealt with in deliberations between the two parties. This time consuming procedure, which may involve an indefinite number of meetings, might be considered a rather ineffective way of decision-making, but it has in fact proved to be quite effective in reaching consensus. This might explain why the policy-making domain refuses to neglect the socially and politically marginalised minority of problem drug users, but on the contrary finances and consults their organisations. Obviously, the City of Amsterdam seems to be of the opinion that the organisation holds an important intermediary position between drug users and the drug policy domain and the treatment system. Otherwise, it would be hard to understand why it has subsidised the organisation for over 25 years. One aspect of the social context is represented by national and local drug policies. The harm reduction approach adopted in the Netherlands is described as relatively successful when compared to other European countries (VWS 2003). In 2003, the number of problem hard drug users in Amsterdam was estimated at 4,530 (Trimbos 2004); some 1,000 of them are categorised as extremely 78 problematic (Amsterdam 2005). The average age of methadone clients in Amsterdam in 2003 was 44 years (32 in 1989), 51 years among drug users born in the Netherlands and 42 years among those born abroad (Trimbos 2004). The mortality rate among problem drug users is relatively low, and consequently a considerable number of drug users are still alive and constitute a residual group of the drug using population. This group consists of people who are homeless, who suffer from psychiatric problems, are in a poor physical condition and use drugs – indeed a very vulnerable group with which neither the drug treatment system nor the police seem to be able to cope. It is clear from this that there is a need for alternative activities such as those carried out by the MDHG and that partly form the organisation’s raison d’être. Another relevant social aspect is that many drug user activists belonged to the generation that grew up during the 1960 and 1970s. Most of these first generation activists are now dead or have left the drug scene, a fact that may emphasise the need for a formal user organisation. If the MDHG had been solely an organisation by drug users, it is hard to imagine it would have celebrated it 25-year jubilee. The MDHG has survived as a social movement organisation without changing its goals and even without making many changes to its means of action. However, it is possible that structural changes in its external environment are forcing changes in its internal structure as well. For example, there is the legal obligation since 1996 for all institutions that provide care or treatment to establish a client council or to have client representatives on their board. This regulation might have the effect of formalising and canalising user influence. The requirement introduced in 1999 that all member be registered in order that the organisation qualifies for subsidy, or the professionalisation of the organisation’s management, may also contribute to formalisation. This process also includes the creation of a formal leadership and office structure, leading to professionalisation with a management of directors and paid staff members. However, the staff by means of actions like the self-management using room and conflicts with its financiers, has demonstrated that the process of professionalisation does not necessarily impair the action repertoire. As regards external structures, the organisation depends on two main sources of income, one of which is also a target for its actions. This puts the organisation in a classic dilemma, that of co-optation. The creation of client councils not only opens up opportunities to influence treatment practices, but may also lead to cooptation. This is something the organisation clearly is conscious of, but which is hard to escape from. Participation in all kinds of councils and working groups can be a double-edged sword. It can provide an opportunity to exert influence and promote the interests of the constituency, but on the other hand the organisation may also be inundated by the flood of meetings and deliberations. It can also make it difficult to take direct action, such as obstructing the police or 79 occupying offices of treatment organisations. In this situation, the organisation has to decide to take part in legal/illegal actions. In the case of the consultancy drop-in centre that turned into a using room, the MDHG obviously crossed the line and the centre was closed down. At this point, the organisation has to maintain a balance between being both a grassroots organisation and an interest group. The tension between being an interest group and providing assistance to members is also a delicate one because assistance activities such as a large scale drop-in centre takes up a lot of resources at the expense of the interest promotion side. If the organisation is forced by its political and social context into one type of movement organisation, then it has to decide which direction to take. If it chooses to become a pure formal interest group, then it may risk losing contact with its constituency. However, if it chooses to become a pure grassroots organisation, then it risks losing its financial resources and influence in the policy making process. A delicate balancing act indeed. References Amsterdam (2005): Drugsbeleid [Drug policy]. Http://www.amsterdam.nl/gemeente/volg_het_beleid/drugsbeleid Amsterdam Information Office (1987): The Amsterdam policy on Drugs. Problems, Aims and responsibilities. Andeweg, R. B. Irwin, A. G. (1993): Dutch Government and Politics. Hong Kong: Macmillan. De Telegraaf, 20 September 2002. EMCDDA (2005): Annual Report. Lisbon. Hondius, H. (2005): Plaatsingslijst van het archief van Vereniging Medisch Sociale Dienst Heroïne Gebruikers (MDHG) 1979–1989 [Inventory list of the archive of the MDHG]. Http://www.iisg.nl/archives/html/b/10773838.html. 2005-03-14 Jepsen, J. (2004): Brugerforeninger – selvorganisering, interessevaretagelse og gensidig støtte [User organisations – self organisation, interest promotion and mutual support]. In: Asmussen, Vibeke & Jöhncke, Steffen (Eds.): Brugerperspektiver – fra stofmisbrug til socialpolitik? [User perspectives – from drug misuse to social policy?]. Aarhus: Aarhus University Press. Jezek, R. (2000): Recht op roes. Druggebruikers en belangenbehartiging [Right on high. Drug users and interest protection]. Alkmaar, René de Milliano en Landelijk Steunpunt Druggenbruikers. Kriesi, Hr. (1996): The organisational structure of new social movements in a political context. In: McAdams, D.; McCarthy, J, D. & Zald, M. N. (Eds.): Comparative Perspectives on Social Movements. Political Opportunities, Mobilising Structures, and Cultural Framings. Cambridge: Cambridge University Press. 80 Lendering, J. (2005) De wortels van de Nederlandse overlegcultuur [The roots of the Dutch consultation culture]. Amsterdam, Atheneum-Polak & van Gennep. LSD (1998): Jaarverslag 1997 [Annual report]. De Wijk: LSD. LSD/MDHG (1999): Rouw en verliesverwerking bij druggebruikers [Mourn and coping with bereavement among drug users]. De Wijk, LSD LSD (2002): Gratis heroine… Medisch verstrekking vanuit gebruikersperspectief [Free heroin... Medical prescription from a users’ perspective]. De Wijk: LSD. McCarthy, J. D. (1996): Constraints and opportunities in adopting, adapting, and inventing. In: McAdams, D.; McCarthy, J. D. & Zald, M, N. (Eds.): Comparative Perspectives on Social Movements. Political Opportunities, Mobilising Structures, and Cultural Framings. Cambridge: Cambridge University Press. MDHG (1981): Gedwongen afkicken of niet? Een verslag van de conferentie gehouden te Den Haag 26 jan’81 [Compulsory detoxification or not? Report from the conference held in The Hague 26 January 1981]. Amsterdam: MDHG. MDHG (1994): Dope & Detentie [Dope and detention]. MDHG: Amsterdam. MDHG (2003): Hard aanpakken. De belangenvereniging druggebruikers MDHG in 2003 [Rough approach. The Interest Organisation for Drug Users, MDHG in 2003]. Amsterdam: MDHG. MDHG (2004): Doelstellingen [Aims]. Http://www.mdhg.nl/doelstelling.html 2004-11-16 MDHG (2005): 2006 en verder [2006 and on]. Amsterdam: MDHG. Mol, R. Trautmann, F. (1991): The liberal image of the Dutch drug policy. Amsterdam is singing a different tune. International Journal on Drug Policy, No. 2, 16–21. NIVEL (2005): http://www.nivel.nl/oc2/page.asp?PageID=430 Riemens, J. W. E. (1977): De heroine epidemie. Een aanklacht en een recept [The heroin epidemic. An accusation and a remedy]. Amsterdam: MDHG. Rucht, D. (1996): The impact of national contexts on social movement structures: A cross-movement and cross-national comparison. In: McAdams, D.; McCarthy, J. D. & Zald, M. N. (Eds.): Comparative Perspectives on Social Movements. Political Opportunities, Mobilising Structures, and Cultural Framings. Cambridge: Cambridge University Press. Spuit 11, No. 3, 1981. Amsterdam, MDHG. Spuit 11, No. 4, 1981. Amsterdam, MDHG. Spuit 11, 1999 Winter, Vol. 19/3. Amsterdam, MDHG. Spuit 11, 2000 Winter, Vol. 20/3. Amsterdam, MDHG. Spuit 11, 2001 Spring, Vol. 21/1. Amsterdam, MDHG. Tilly, C. (1985): Big Structures, Large Processes, Huge Comparisons. New York: Russel Sage Foundation. Tilly, C. (2004): Social movements, 1768-2004. Boulder, London: Paradigm Publishers 81 Tops, D. (1991): Organiserad självhjälp [Organised self-help]. Slå Tillbaka, nr 6. Tops, D. (2001): A Society With or Without Drugs? Continuity and Change in Drug Policies in Sweden and the Netherlands. Lund: School of Social Work. Trimbos (2004): Jaarbericht Nationala drugmonitor [Annual report 2004 National Drug Monitor]. Trimbos, Utrecht. Trimbos (2005): Jaarbericht Nationala drugmonitor [Annual report 2005 National Drug Monitor]. Trimbos, Utrecht. Vuijsje, H. & van der Lans, J. (1999): Typisch Nederlands. Vademeeum van de Nederlandse identiteit [Typical Dutch. Vademeeum of the Dutch identity]. Amsterdam/Antwerpen: Uitgeverij Contact. VWS (2003): Ross verdedigt Nederlands drugsbeleid [Ross defends Dutch drug policy]. VWS Nieuwsbericht, 16.04.2003. 82 Democracy or Closer Control? Emergence of Drug User Participation in Norway Astrid Brandsberg Willersrud & Hilgunn Olsen Introduction We give here an account of the current status in Norway on drug user participation in drug-related policy making and intervention design. The past ten to fifteen years have seen major developments not only in respect to public policy means and ends, but also in treatment, health and social care legislation. Alongside these developments, in the last decade user organizations and active drug users are increasingly prepared to go public in defence of their interests. That political and healthcare authorities increasingly express that they consider user interests both important and timely represents a relatively unfamiliar situation in Norway. We ask therefore why the authorities want to bring a historically so marginalized group on board at this particular point in time. What started the ball rolling in Norway in the mid-1990s? We compare user organizations to be extant 1996– 2004, asking what unites them and, conversely, what divides them. Do user organizations foster a sense of empowerment among individual users? How well do they discharge their role as participants in public policy making? Is society ready to listen to what users really think, including views which even by today’s liberal standards could be called politically incorrect? Or are politically “safe” organizations more likely to catch the ear of policy makers? We discuss below the relevance of concepts of power and social control in relation to the user perspective on this group. We define “user” here as a person who uses illegal substances regularly; “former user” is a person who has been a regular user but has stopped using drugs. History of User Participation in Norway The user perspective and user organization are two relatively recent phenomena in the field of drug policy in Norway.49 It was only with the emergence of HIV 49 Homeless alcoholics formed an action group in the 1970s following the decriminalization of public drunkenness. Homeless people became more conspicuous, 83 and AIDS in the late 1980s, followed by methadone substitution treatment which became available in the 1990s, as the decade became increasingly focused on health and care, that the first user organizations were formed. This should be seen as a part of the general perception at that time of drug use as a law and order issue, where the police and the judiciary until then had had the major role in fighting drugs and thereby also drug users. Indeed, between the 1960s and early 1990s, consensus united all political parties in Norway on the idea of an ultimately drug-free society (see e.g. Stortingsmelding nr 13, 1985–1986; Andenæs 1994). Users were in consequence generally ignored; not even on matters related to their own situation were they consulted. Prevailing public policy and treatment ideology gave users a simple choice: stop using drugs and become “good citizens”. Giving up the habit was conceived largely as a matter of willpower and morals, and neither medical nor biological approaches were given headroom in the “social education” model in vogue at the time (see e.g. Watten & Waal 2001). Drug users who would not or could not kick the habit were considered weak, low on moral fibre, a threat to the established social order and coming generations (see e.g. Christie & Bruun 1985). It is therefore not surprising people saw users as a public enemy, nor that politicians and the media neither sympathized with nor showed much interest in what users themselves might think or feel. But as HIV/AIDS became an increasingly urgent issue in the late 1980s, user participation was aired as a means of improving HIV prevention among injecting drug users (Blindheim 1999). It was quickly forgotten, however, possibly because initial efforts aimed at HIV/AIDS and users were justified by inflated fears of a society in jeopardy, less about what benefited the drug user (see e.g. Skretting 1997; Brandsberg-Dahl 2000). There was no structural nor social context then to enable users to articulate their views or indeed be heard (see Rucht 1996); a notion like “user participation” had simply no currency in the political climate and therapeutic ideology of the 1980s and early 1990s. So what happened on a rainy June day in 1997 surprised many people. Who would have expected the most run down elements of the Oslo central station group of users to stage a protest march along Oslo’s main thoroughfare bearing homemade placards, stop outside parliament and proclaim their demands? In the days running up to the march, a core group of activists had handed out leaflets among fellow users, and they marched with a sense of purpose through the centre of town – headed by the mounted police. For the first time, the voice of and were blamed for the rise in robberies and assault. They attended public consultations arranged by the city council, and it is said the action group brought about a change in policy to their advantage, with greater attention given to their difficult circumstances (see Mathiesen 1975). The campaign proved short-lived however. 84 the ostracized was heard at the centre of national politics. Politicians’ refusal to meet the marchers was something the media were quick to seize on in their reports (Aftenposten 21.06.1997; Arbeiderbladet 21.06.1997; Demonstrasjon for metadon 1997). This event could be taken as symbolizing a sea change in Norwegian drugs policy, insofar as users presented themselves as ordinary human beings – with opinions about their own “hopeless” situation, and the “impertinence” to demand a hearing. Sinners or Sick? By the mid-1990s, policy makers and healthcare authorities in Norway were beginning to espouse a more person-centred approach, targeting harm reduction measures at individual users (see e.g. Skretting 1997; Alcohol and Drugs in Norway 1998; Brandsberg-Dahl 2000). It was prompted by the large number of drug users, including those who rejected help towards a drug-free life, whose needs the welfare state could no longer ignore on ethical or moral grounds. A record mortality rate was another key factor behind the change in strategy. Mortality rates in Oslo in the mid-1990s were embarrassingly high compared with other European cities. In the 30–39 age-group, mortality increased rapidly between 1990 and 1995: 29 died in 1990, 49 in 1993, and as many as 84 in 1995. Mortality in the 40+ age-group rose several hundred per cent over the same period, from 3 in 1990 to 26 in 1995. Mortality rates in the 15–19 and 20–29 age-groups remained relatively stable, however (Alcohol and Drugs in Norway 1998, table 2.2; see also, e.g. Frantzen 2001). Overdose deaths continue to rise sharply in the late 1990s, from 148 cases in 1997 to 338 in 2001. As of writing, mortality rates have stabilized at a relatively high level (Kouvonen 2006). These figures should be seen as contributing to a more realistic approach among policy makers and health officials to the often limited rehabilitation prospects of the eldest and most run down drug users. On January 1st 2004, responsibility for drug users and therapeutic institutions devolved to the ordinary health service and came under healthcare legislation. On September 1, 2004, the scope of the Patient Rights Act was extended to include users of illegal substances. According to the provisions of the Act users have a right to be informed and consulted (Bedre behandlingstilbud... 2004). One of the purposes of the amendment was to strengthen the rights of users to treatment and to be consulted on issues affecting their everyday life. The amendment sought further to ensure users with special needs and/or other somatic disorders and problems were dealt with more effectively by healthcare professionals and hospitals. Heroin users admitted to hospital today are often prescribed methadone to relieve abstinence symptoms even when they are not on a methadone substitution programme. This was unusual before (Watten & Waal 85 2001), when opiates were still a controversial method of treating abstinence, practised only by the state-run methadone programmes. Users dependent on heroin may well have found it difficult to consent to necessary treatment if it required hospitalization. We note, then, a change in the official status of users in Norway, from client to patient, and from “criminal” to “sick”. In other words, from representing a problem to having a problem. Participation as a Means of Control? How much better and easier it is to be a user today is difficult to say. In our opinion, it is not necessarily very easy. Wide-ranging structural and attitudinal changes are required before the life chances and status of a particular group are likely to improve, especially when the group in question is as marginalized and condemned socially and morally as drug users continue to be. Much more is needed than a new terminology and redefined concepts to change entrenched structures. It is easy to let new designations obscure the fact that old approaches are still largely at place, contrary to general belief (Christie 1982). Christie says, for example, when discussing terminological changes in the correctional and probation sector, that Pain and suffering have disappeared from the textbooks and the labels attached to the measures. But not, clearly, from the experiences of inmates. (ibid.: 17) Addressing these issues, French philosopher and sociologist Michel Foucault saw society’s definition and exclusion of criminals, the mentally ill, gays and other deviant groups as an expression of power and a function of power. This is particularly pertinent in the history of the correctional system and psychiatry (Foucault 1973 & 1977) – where the overriding aim of control of deviant groups is essentially the same, despite modernization and terminological facelifts. Coming at the issue from this angle, there is no room for a concept like user participation, at least not in any significant sense, because deviant individuals perform a service to society by their very definition as deviants. The concept could, however, help ensure closer control of deviant groups, for instance by empowering them nominally rather than substantively. In a Foucaultian perspective, methadone substitution treatment is today’s version of the incarceration of users practised fifteen years ago, the control of a specific deviant group by established power structures to enhance their legitimacy and raison d’être. There is no point in claiming this as an underlying motive of policy makers in Norway today. But at an aggregate level, user participation could become a device which enhanced the legitimacy of established structures if users are encouraged to join in, but not taken seriously. 86 The Thinking Behind Harm-reducing Measures and Methadone Substitution Treatment in Norway Before the 1990s it was extremely rare to see the media criticizing alcohol and drug policies and attitudes. In fact, the media, in their role as merchants of doom, helped justify in the eyes of the public, a strict policy of control by judicial means. It was simply incorrect politically to criticize alcohol and drugs policy, its intentions and instruments – and people who did were simply ignored (Andenæs 1994). The ’90s changed all this, abruptly and comprehensively. Statistics (such as those compiled by SIFA in 1998) indicated a rising population of substance users and growing market for illegal drugs despite decades of repressive control and relatively robust therapeutic interventions (Skretting 1997). The findings were shocking. Politicians started to criticize current policy, and debates which only a few years before were inconceivable (such as the discussion on distributing heroin) became daily fodder in the mass media within a few years. Danish and Swiss approaches were explored in detail, particularly steps to ease access to methadone, heroin dose distribution and special facilities where users could inject safely. Some politicians believed these ideas were worth trying out in Norway as well (Aftenposten 29.08.1995, 30 & 31.08.1997; Arbeiderbladet 03.09.1997; VG 29.09.1997; Dagbladet 13.08.1998). It was also becoming clearer at the time that Norway had a growing population of elderly, sick, impoverished users, who in their destitute state were increasingly conspicuous, particularly in the capital. The response of society was generally one of sympathy and compassion, not the disgust and fear. People didn’t deserve to live like this in the welfare state. Rising mortality rates noted above in the older age-groups probably accelerated the change in public attitudes towards users. There is little doubt that the media played a key role in this process, not only as a vehicle for debate, but by portraying the people concerned in a more positive light, more offended against than offending (Brandsberg-Dahl 2000). It is therefore safe to say that the media played a crucial (if somewhat selective) role, furnishing evidence and information and framing the political agenda. Conventional roles were turned upside-down, with the erstwhile enemy of society (the user) transfigured into victim, and the once sorely tested victim (the state) now acting the part as public enemy number one (Christie & Bruun 1985; Brandsberg-Dahl 2000). Alongside these political, cultural and social structure shifts in alignment, drug use was increasingly seen as a medical and biological phenomenon. Where individual and social psychology once prevailed as explanatory models, modern medical and biological explanations became increasingly popular (see e.g. Watten & Waal 2001; Skretting 1997). It is a global trend in fact, the increasing tendency to explain drug addiction biochemically and genetically. 87 In the 1990s then, social, cultural, political and theoretical contexts changed in Norway. In line with Dieter Rucht (1996), all these elements are essential to the mobilization of resources (“user involvement”) of a largely powerless group of people. These various developments affect each other, of course, and with regard to alcohol and drugs, a new national context gave credibility to how users viewed their personal situation. Why these developments happened more or less at the same time, facilitating wide-scale, rapid change, may have something to do with the enduring period of stagnation that went before. The policy area was simply ripe for change, and rising mortality figures in the 1990s, the AIDS/HIV “epidemic” and focus on a comprehensive healthcare system which had failed so signally to rehabilitate users, provided the triggers, and explain why change didn’t come sooner. The watershed event of the ’90s was the methadone substitution programme, MiO, a four-year trial conducted in Oslo. It was controversial politically and medically, and, not surprisingly, descended into a “trench war” mentality, laced with prejudice, ignorance and absence of evidentiary substance on all sides. It was a sea change in relation to the established therapeutic approach, with its focus on rehabilitation and a drug-free life, where medicine and biology were non-starters (see e.g. Skretting 1997; Brandsberg-Dahl 2000). The project was up and running by autumn 1994, if not without considerable teething problems. But it is precisely here we find the origins of Norway’s first user organization, founded in 1996. That methadone substitution treatment is so directly linked with the emergence of a user perspective is not as surprising as it might seem at first glance. Medicine as a means of controlling deviant behaviour and marginalized individuals has a long history, especially in the psychiatric field (see e.g. Conrad & Schneider 1992; Kringlen 1996). We define medical social control here with Conrad & Schneider as the ways in which medicine functions (wittingly or unwittingly) to secure adherence to social norms – specifically, by using medical means to minimize, eliminate, or normalize deviant behaviour. (1992, 242) Methadone substitution treatment for people addicted to heroin comprises a level of patient control, insofar as patients are as physically dependent on a daily methadone dose as they were on the daily heroin dose. One important aspect of methadone treatment (and other drugs that cause dependency) is that it is not motivated by a desire to control a recalcitrant group of people while pretending to offer treatment, as Foucault writes, but forms part of an integrated strategy based on sound therapeutic thinking to improve people’s quality of life and reestablish a sense of dignity. Because methadone substitution treatment unleashed strong political and medical sympathies and antipathies, it came to be seen as a form of rehabilitation leading to freedom from drugs, which in turn automatically led to a higher level of patient control (see e.g. Skretting 1997; Brandsberg-Dahl 2000). Recently, however, as treatment is increasingly adapted 88 to patient needs and coping skills, the control aspect of methadone substitution treatment in Norway has receded somewhat. To methadone users, control of the drug can seem rather severe at times. They feel relatively powerless vis-à-vis the therapists: by withholding the daily dose of methadone, therapists can cause users to become physically ill. Users in medication-free treatment have greater control over what happens to them – and in the event of an insoluble conflict, they can get up and go. A radical solution like this is not available to methadone users, most of whom would consider the loss of their methadone a disaster they would do “anything” to avert (Ervik 1997; Frantzsen 2001). In this light then, methadone could be used to control users, and for that reason, users, by virtue of their new status as patients are more likely to press their case and stand up for their rights than before. User Organizations and Associations in Norway 1996–2004 The ’90s were the decade when users’ idea of forming an organization came to fruition. Previous efforts had never met with tangible success, but seeing that methadone users took the lead, other user groups joined in. In what follows we look back on the emergence of the leading national organizations and associations and highlight similarities and differences. Despite differences however, they face relatively similarly challenges and issues. The table below breaks the major organizations down into three classes: 1) those that are run for and by active users; 2) those that are run for and by former users; 3) those that are run for and by methadone users. Active Users Former Users Methadone Users Drugs Policy Association (Narkotikapolitisk forening, NF), establ. 1970s. Recovered Addicts’ Interest Organization (Rusmisbrukernes Interesseorganisasjon, RIO), establ. 1996 Methadone Users’ Interest Group (Metadonbrukernes interessegruppe, MIG-96), establ. 1996 Tønsberg Users’ Association (BrukerForeningen i Tønsberg, BFiT), establ. 1999 Users’ Interest Group (Brukerens interessegruppe, BIG-98), establ. 1998 LAR-NETT, establ. 2004 Oslo Association of Users (Oslo Brukerforening, OBF), establ. 2000 89 The organizations for methadone users are Metadonbrukernes interesseorganisasjon (Methadone Users’ Interest Organization), Brukernes interessegruppe (Users’ Interest Group) and LAR-NETT. As noted above, the Methadone Project in Oslo (MiO) was surrounded by controversy and debate. The project’s patients formed the “Methadone Users’ Interest Group” – MIG-96 – in 1996, with a view to promoting their own treatment-related interests, raise public awareness about methadone treatment, establish a positive image of methadone users and encourage a more humane therapeutic approach and make the treatment more widely available. This organization worked within the framework of an existing methadone project and did not promote the interests of other users. MiG-96 established good relations with the methadone project management, and was welcomed as a positive and serious organization. One thing the Methadone Users’ Interest Group accomplished was to extend access to a “Thinktank” (Ideverkstedet), a council-run shelter and activity centre for former users and users in rehabilitation, to methadone users. Their interest organization therefore lodged a complaint with Oslo Alcohol and Drug Addiction Service, resulting in a lifting of the ban in 1997 (Ervik 1997). When the expanded Methadone Project in Oslo was put on a permanent footing in 1998, the Methadone Users’ Interest Group was replaced by the Users’ Interest Group/BiG-98, by which time the initial organizers had stepped down. Users’ Interest Group/BiG-98 received no financial support, and could be described as an organization with ambitious ideas but a relatively unstable leadership. Activity levels fluctuated, reaching a low point in 2004. One individual in particular worked hard to promote BiG and empower methadone users, but experienced highly variable contributions from other users. He is surprised, he says, at the low level of interest in working for user participation and promoting the organization (Frantzen 2005). The history of the Methadone Users’ Interest Group/ MiG-96 and Users’ Interest Group/BiG-98 serves to illustrate the challenges facing this type of user organization. Several methadone users used other substances regularly treatment notwithstanding. Some came to meetings with MiO management while still under the influence, and were simply not taken seriously. The stable, resourceful person whose efforts led to the organization’s establishment had departed, partly because he felt others were destroying what he had built by representing the organization while they were doped.50 It is difficult to see how members of MiG-96, given certain exceptions, could have made much of a difference. How difficult it can be to organize users is illustrated by an event that took place in the autumn of 2004. There was widespread dismay among methadone users with the way the project was going. BiG’s prominent leader therefore arranged a 50 90 The author Astrid B. Willersrud worked at the time at MiO, and observed events at first hand. She also made a telephone interview with the leader (in March 2004) where he described the situation and the reason he stepped down. meeting with the project management where users could air their grievances. In the event, only seven methadone users showed up. LAR-NETT51 is the latest organization to seek user empowerment. LAR-NETT designates itself a forum for users. The first national conference for drug users took place on October 11, 2004. Entitled “Metaphor” and arranged by methadone users it explored the issue of “user participation”. To the organizers the conference represented the “definitive breakthrough” for the user forum approach in Norway. LAR-NETT’s membership is mainly people undergoing substitution treatment, but users, professionals, family/friends and others are welcomed too. The three organizations of active users are Narkotikapolitisk Forening (Drugs Policy Association), BrukerForeningen i Tønsberg (Tønsberg Users’ Association) and Oslo Brukerforening (Oslo Association of Users). The Drugs Policy Association is not a membership organization; it works as a pressure group and agenda-setter in the area of drugs policy. Its history stretches back to the 1970s, but it was dormant for many years. Today, its prominent leader gives the organization a face in the media, and has about fifty letters/articles published yearly in the print media. Tønsberg Users’ Association (BFiT) was formed in 1999 to promote the social and societal interests of drug users, and provide support and advice for members. It derives its inspiration from the Danish Drug Users’ Union (Brugerforeningen). It is an organization for active users and has concentrated on normalizing substitution treatment, making it more “socially acceptable”. Here too a few prominent individuals have featured in the media; it is difficult for outsiders to know how much activity there is in the organization. Oslo Association of Users is a relatively small organization. It was founded around 2000 and run by an articulate, socially aware individual, with a history of drug use spanning thirty-five years. At the time he used methadone, however. In terms of objectives, the organization sought to help, support and inspire active users in their everyday lives, and promote users’ social and societal interests – virtually a “trade union” for active users (Dagbladet 26 July, 2003). Oslo Association of Users has never had more than fifteen to twenty paid up members, and the leader has said that organizing users is no easy matter. The only organization for former users among the organizations mentioned here is Recovered Addicts’ Interest Organization (Rusmisbrukernes intresseorganisasjon – RIO), founded in 1996 as an organization for former and active users, run by former users. It helps people find their way in the health and social services, briefing them on their rights. Priority concerns are integration and 51 This is not an abbreviation of a longer name, though the letters LAR did stand originally for substitution treatment (legemiddelassistert rehabilitering). 91 aftercare (Brukerforeningene 2001). The organization seeks to highlight people’s innate resources, and has local branches in many areas of the country. The leader is active, often in the media, and sits on the board of the National Substance Abuse Association (Landsforbundet Mot Stoffmisbruk – LMS). All active members of RIO have either used drugs or alcohol, but the organization does not tolerate any consumption at all of alcohol or drugs. Relapsing members are served a three-month quarantine notice. RIO is in that sense not an organization for active users interested in advancing common interests. Empowerment and Collaboration Hence it seems that some user organizations find it difficult to sustain activity levels, and based on the sample above, all-round organizational activity does seem to depend on the commitment of certain prominent figures (see e.g. Jepsen 2004). In that sense, the organizations face an uphill struggle to convince government, specialist environments and the public of their credentials. Appearances in the media seem to be the principal way of making the organizations and policies known. The mere fact that the media give them space indicates their inherent newsworthiness and importance in a broader societal framework. Media appearances do not result in greater leverage in the shorter term, but they give users a public platform to address issues related to policy making or treatment. Being invited to take part in a consultation on some political or medical issue is possibly the closest the organizations gets to wielding power in practice. But public consultations also involve specialist, ethical and legal interests, and users may well feel disadvantaged in such company. Whether users are empowered in practice, despite government efforts to ease and encourage involvement in various fora, remains therefore something of an open question (see e.g. Fosse 2001). The extent to which the organizations themselves believe what they say matters varies, and they also pursue different policies and speak to different audiences. When we asked the leader of the Drugs Policy Association to put a number on the organization’s power, he said that the value of features in press and appearances in debates were underestimated by many people. 52 It often happens that he gets feedback from people who say they have changed their attitudes and views on a certain issue after they have heard his contribution. In his opinion, the organizations enjoys a certain leverage. The Recovered Addicts’ Interest Organization (RIO) is more likely to be invited to sit on consultation panels than any of the other user organizations. RIO is also the most media-savvy organization. Despite this, the organization’s leader was 52 92 Conversation with Arild Knutsen, 28 October 2004. complaining in 2001 that their expertise and experience were not appreciated and that “nothing happens” despite all the talk about listening to users among politicians and professionals (Brukerforeningene 2001). Three years later, in 2004, his opinion was the same; the organization is still relatively powerless.53 The organizations are frequently used as an alibi, he believes, though that may be changing. That aside, consulting drug users’ interest organizations on government policy, is just “a big joke”, he says, because nobody takes their views on board anyway. Without visibility in the media and professional circles, pressure groups are not likely to have much impact on politicians and the public. This is where the Recovered Addicts’ Interest Organization (RIO) has succeeded better than the other organizations. In addition to the leader’s media, conference and seminar activity, other members are active in the media and the public eye. To be considered as a serious partner by government and others, organizations need a stable track record. Too many pressure groups have started enthusiastically but failed to live up to expectations. Barriers to Effective Organization We see then how difficult it can be to run a drug user organization, whether the substance is licit or illicit. The problems described above are, as Asmussen (2003) writes, often caused by member instability. Taking drugs in itself is likely to lead to unpredictability in terms of housing, friends and relations and income. Poor physical and mental health tend to accompany life as an active user, along with crime and longer or shorter spells behind bars. Former users are more likely to lead stable lives, but after so many years spent among hardened drug users, character traits like loyalty, tolerance and cooperativeness are often conspicuous by their absence. It seems particularly hard for ex-users to trust each other, and thinking and acting on behalf of others are alien to many (Brandsberg-Dahl 2002; Johansen 2002). Many find it difficult to cope with stress and frustration (Watten & Waal 2001). Conflicts are hard to avoid, and common goals and concerns easily slip out from mind. Informants we spoke with in the various organizations confirm this general description, and how instability did indeed paralyse activity in the short and longer term. In light of these considerations, the relative success so far of the Recovered Addicts’ Interest Organization (RIO) as the dominant user organization should not surprise us. It is the most stable organization with its membership of former users, many of whom have qualifications in social and welfare studies. 53 Conversation with Jon Storås, 24 September, 2004. 93 One important point about these pressure groups concerns the almost total lack of cooperation. Groups are unaware of each other, and those that aren’t tend to fall out over means and ends. When non-organized users start thinking about rights and empowerment, they would sooner form a new organization than join an existing one of like-minded individuals. It is therefore not only necessary to strengthen alliances between users, authorities and professionals, but users themselves need to learn to work together. User organizations and user representatives are there to articulate the views of their “electorate”. Not an easy job, considering the diversity of backgrounds and current circumstances. In practice, people tend to identify with like-minded groups (Sigstad 2004). This much was evident at a September 2004 consultation arranged by Oslo’s Alcohol and Drug Addiction Service. Represented on the panel were the Danish Users’ Association (DDUU) from Copenhagen, the Recovered Addicts’ Interest Organization (RIO) and Oslo User Association. These and other panel members, and indeed the audience, agreed that mixing current and former users in the same organization was fraught with difficulties. “They’ll never manage to work together”, said one of the Danish participants by way of conclusion. The different user organizations do, however, handle this question in different ways. Some want to enlist and speak up for active users, others see exclusion as the appropriate response to falling off the wagon. Oslo User Association and Tønsberg Users’ Association both want to represent the interests of active users. The Recovered Addicts’ Interest Organization (RIO) pursues a strict policy here: drugs are not allowed, though the organization acknowledges the risk of backsliding. RIO is unusual insofar as it is more akin to temperance movement organizations, and its goals are more “politically correct” than those of the other user organizations. As already mentioned, the RIO is more often in the media spotlight and invited to consultations, and is also considered more dependable. LAR-NETT is in its infancy still, too young to classify on the basis of our criteria, but the start has been promising, and the organization could well become one of the most powerful players. Causes of Conflict Interorganizational strife peaked in mid-2005 in the media. RIO was basically lined up against all the other organizations – in other words, the argument was between current and former users. Harm reduction is the crux; every time a new harm reduction initiative is proclaimed, or an existing one changed, controversy is never far away. Substitution treatment and supervised drug injecting facilities were and remain strongly contested issues, also among the public is divided on them as well. We would like to illustrate the situation with two practical examples. We let media quotes describe the controversies and opinions of the various parties. 94 Case 1 June 2005 saw the publication of a report by the Directorate for Health and Social Affairs on substitution treatment. The report recommended among other things making methadone and buprenorphine-based medication available to a wider group of users (see e.g. Aftenposten 12 June, 2005). The leader of RIO took issue with the proposal, and at a meeting with the Minister of Health called it “pure madness to relax policy on methadone treatment…. We are speaking on behalf of most drug users in the country” (Aftenposten 15 June, 2005). This latter statement irritated Tønsberg Users’ Association (BFiT), who had welcomed the Directorate’s suggestions. In his response, BFiT’s leader said, “What is madness is that so-called user organizations can make statements like this. The Directorate’s suggestion is brilliant, and has given lots of people fresh hope” (Aftenposten 15 June, 2005). Case 2 The summer of 2005 saw the first edition of “= OSLO”. Modelled on the UK’s The Big Issue, a magazine bought and resold at 50 per cent profit by homeless people and active drug users, this first number carried interviews with leaders of the Recovered Addicts’ Interest Organization (RIO) and the Drugs Policy Association (NF). There was no mistaking RIO’s opposition to injection rooms, nor the Drugs Policy Association’s view of them a significant step in the right direction (= OSLO No. 1, 2005). The next edition published a response under the heading “RIO – who do you represent?”, written by a person currently serving a sentence for drug-related offences. Reacting strongly to RIO’s stance, he says among other things, Those that read the article here in prison were all pretty upset by it. We draw the conclusion that this leader of RIO lacks the insight required to lead an interest organization for the average drug user. Leading an organization called RIO – drug users’ organization – comes with certain responsibilities. Whoever this organization actually represents is any one’s guess! It’s certainly not us. (Stig Kvale, = Oslo No. 2, 2005) In these instances it would not have been difficult to predict who said what. Organizations of former users seldom come out in support of harm-reducing measures, preferring instead to encourage users to quit. Organizations of active users want to see harm-reduction measures improved and expanded to ease the lives of current users. Which of them is “best” is impossible for us to say, but we have seen that former users, as the most “politically correct” group, are more likely to be consulted than the others. In that sense, we could say that real “user 95 leverage” remains an unfulfilled hope, because in reality, only people that have stopped taking drugs are listened to. Government and User Consultations – Expert Panels and Action Plan for “Plata” User participation in Norway is not restricted to the work of user organizations’ views; within a short space of time individual users, including active users, were invited to take part in decision making of relevance to their everyday life and future prospects. We describe below two forms of consultation, one at the national level, the other at the local authority level, arranged in this case by Oslo’s Alcohol and Drug Addiction Service. Expert Panel on Drug-related Problems Under the Ministry of Social Affairs An expert panel was set up in 2003 by the Ministry of Social Affairs to report on drug-related issues. Representing several sectors, including research, law enforcement, medicine and healthcare, the panel is spearheading the ministry’s search for new ideas to solve “old” problems. There are two users in the panel moreover, relatively randomly selected on the basis of experience with drugs and publicly stated views. Why user participation is considered necessary is set out in the Government’s “Action plan to combat drug- and alcohol-related problems 2003–2005”. Two expert panels will be appointed to advise on prevention and treatment including harm reduction. It is important that next-of-kin and/or other carers and former substance misusers share their knowledge with these panels. (Regjeringens handlingsplan mot rusmiddelproblemer 2003–2005, 14–15) The leader of the Recovered Addicts’ Interest Organization (RIO) is one of the two users on the panel. The choice of user representatives has been criticized, among other things because one of them is a member of one of Norway’s foremost political families. She was allegedly chosen for speaking openly to the media, and because her family connections and drug abuse were widely known. In her own defence she says she only represents herself, no one else, and wants to share her experience. She feels often misunderstood by the media, and has chosen to lie low. As it happened, working with the rest of the panel did not meet expectations. Neither of the user representatives felt they were taken seriously – but used as a sort of alibi.54 54 96 Conversation with Nini Stoltenberg, 9 March and 13 September 2004; Conversation with Jon Storås, 24 September, 2004. This shows us how user perspectives and consulting with users on policy matters are defined and accepted at the highest political levels, and how users themselves benefit to all intents and purposes from a new, more socially acceptable status, strengthening their right to be consulted. We say “to all intents and purposes” because the experience of the two user representatives on the panel could be framed in terms of power and control mechanisms described by Foucault and Christie, and the fact that new concepts and good intentions do not always translate into new practices. It also indicates a slower pace of change at the social context level mentioned above than one often tends to believe. User Participation in Practice – An Example from Oslo A plan of action was launched at the end of 2002 aimed at discouraging drug users from congregating in downtown Oslo by offering alternative sites. The authors were five ministries, the city authorities and city police force. Drug users used to gather in the square in front of Oslo central station, known colloquially as “Plata”. Users were not consulted during the plan’s preparation, and none were invited to sit on the plan’s steering committee. The plan is one of the most significant drug-related interventions in Norway in recent years. User participation is, however, hardly broached at all in the 38-page document. “Hardly”, because it is mentioned once, in connection with sites where users could conceivably gather – typically known as day shelters (væresteder); (Tiltaksplan for alternativer... 2002). A competence centre under the city of Oslos’ Alcohol and Drug Addiction service published a report in 2004 entitled “Day Shelters – A Low-Threshold Amenity in the Care and Rehabilitation of Drug Users” (Væresteder som lavterskeltiltak i rusomsorgen). The report differentiates various approaches to user participation. User participation may mean taking users seriously by consulting them in all decision making. It may mean organizing meetings with users, house meetings where day-to-day management issues can be discussed. And it can mean employing former users in various types of job/voluntary work/job training. (Væresteder som lavterskeltiltak... 2004) Insofar as no one had envisaged user participation in this light before, opinions of users themselves were extracted from survey interviews in the evaluation of the plan.55 In April and August of 2004, the National Institute for Alcohol and Drug Research (SIRUS) completed six focus group interviews to elicit user opinion of the “Plata plan”, the presence of drug users in downtown Oslo, interaction with the police, and status in general of users who gather in the centre 55 The evaluation was conducted by SIRUS (Norwegian Institute for Alcohol and Drug Research), and Olsen made the referenced interviews. 97 of town. More or less simultaneously with the second round of interviews, the Alcohol and Drug Addiction Service addressed the issue themselves through a number of user consultations. In August and September 2004, the agency held nine user consultations at their low-threshold institutions. Users were asked what they thought of the situation in downtown Oslo, and what was needed to ease their daily lives (Brukerhøringer... 2004). The September consultations were attended by two representatives from the Danish Users’ Association (DDUU). Their stay in Oslo lasted three days, and in addition to expanding the consultation panel, they were treated to lunch by the city and introduced to users and staff. Oslo council voted to spend 2 million kroner in 2005 on a new day shelter for users, and 4 million on a building for users. According to the minutes of the September 2004 meeting of the Plata plan steering committee, the Alcohol and Drug Addiction service emphasized user participation for the first time in connection with projected measures for active users (Styringsgruppa... 2004). In a new development, in 2004, the agency posted details of user consultations and conferences on its web pages. In the wake of these consultations, user panels were created. They convene regularly, some as often as once every week. The panel entrusted with planning the new user building has eight members (active users). This group also intends to form its own organization, though why they are not interested in joining one of the current organizations is not known. This form of user participation and consultation lends itself to interpretation in terms of social control (cf. Foucault and Christie). No attempt was made to conceal the desire behind the action plan to disperse groups of drug users congregating in the city centre (Tiltaksplan for alternativer til rusmiljøene i Oslo sentrum 2003–2005). Opponents of the plan called efforts to disperse the group an act of “social nuisance”, because rather than setting out to help users the idea was to clean up public spaces. The “public” should not have to see them, and the authorities wanted to make sure tourists didn’t see them either on disembarking at the central train station (Dagbladet 5 June, 2004; Aftenposten 4 September, 2004). Helping to design alternative sites would encourage a sense of ownership and make use of them a more attractive proposition. Combined with substitution treatment for drug dependency, it would be easier to monitor and control this segment of the population. Of course, active users may not perceive this type of control in negative terms, since their life chances are improving and they will benefit from a range of harm-reducing and rehabilitative interventions. These initiatives represent a completely new approach by the Alcohol and Drug Addiction Service. The new user panels, in opposition to the old ones, give users a hand in the preparation of new interventions. In this sense, user participation is now integral to the system. The Service sees it as a key endeavour in the effort to disseminate the user-centred approach among partners. It may also be seen as a 98 new policy on the part of the “system” when a government body sees fit to invite organizations of active users to an official arrangement to encourage user involvement in Norway. Something is changing in the area at the level of local government in Oslo, it seems. Conclusion Several coincidental developments in the 1990s made the formation of user organizations possible, triggered by the 1994 methadone project. Of the organizations and associations to appear since then, those intent on promoting the interests of current drug users and those designed to pursue concerns of former users remain divided on policy and practice, which largely depend on which constituency the organizations serve. The seemingly best-functioning organization is the one for former users; at the moment it is consulted more often than any of the others on drug policy issues. In the recent years we have seen two forms of user consultation. One at the national level by the use of an expert panel on drug issues, and another at local authority level by Municipal of Oslo’s Alcohol and Drug Addiction Service. In terms of the number of different user organizations in Norway, user opinion is unevenly represented in consultations. Former users tend to dominate, not active users or methadone users. Former users then determine in part how drug use and related policies are construed. It seems as if society is not quite ready to take active users seriously, and the views of active drug users are therefore not given as wide a hearing as originally intended. By pursuing a policy of user participation, society risks ending up with a control mechanism rather than a means of empowering the people concerned. If the authorities seem ready to listen to the views of a marginalized group and give them what they want (i.e. more widely available methadone substitution treatment, injection rooms, day shelters), it is easier to maintain peace and exercise control over where the group congregates. By and large, organizations for users in Norway are internally fragmented and often at loggerheads with one another. There is no united front, and there is little evidence of efforts to repair relations. On the contrary, it looks as if a new climate will require a new user organization, instead of the established ones adapting to new circumstances. The conflicts that separate user organizations are serious and persistent, and the issues they pursue often reflect whether opinions voiced in public are those of active users or former users. Translation: Chris Saunders 99 References Aftenposten 21.06.1997: I tog for metadon [Marching for methadone]. 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Watten, Reidulf G. og Helge Waal Avrusningstradisjonene i Norge belyst opioidavrusning (UROD) [Detoxification detoxification in Norway in light of Detoxification]. SIRUS Report, No. 3. (2001): Avrusning: fra vilje til medisin. gjennom en forundersøkelse av ultrarask – from will to medicine. Traditional opoid a feasibility study of Accelarated Opoid Væresteder som lavterskeltiltak i rusomsorgen [Day Shelters – A low-threshold rehabilitation service]. Paper, Oslo City Council. Alcohol and Drug Addiction Service, Competence Centre, 2004. VG 29.09.1997: Fortsatt gratis heroin til tunge narkomane i Sveits [Switzerland continues giving free heroin to heavy drug users]. = OSLO (2005) nr 1. = OSLO (2005) nr 2. http://www.rusmiddeletaten.oslo.kommune.no 102 Organisation Among Drug Users in Sweden Leili Laanemets The purpose of this article is to describe and discuss drug user organisation in Sweden, a country that enforces a highly restrictive drug policy (Tops 2000). The ultimate aim of that policy, first adopted by the national parliament in the late 1970s and still enjoying political consensus, is to have a “drug-free society”. Swedish drug policy is commonly described as standing on three pillars, i.e. prevention, control and care. Care is primarily in the form of drug-free treatment, but methadone and buprenorphine-assisted maintenance treatment is also gaining ground (CAN 2004). The Swedish drug abuser is said to live in difficult social, economic and material living conditions, excluded from mainstream society (Svensson 2000). The first wave of client movements in Sweden began to rise in the latter half of the 1960s. Among the earliest was the National Association for Aid to People Addictive to Drugs and Pharmaceuticals (RFHL), which also involved people who had no personal experience of drug use. Self-help movements began to expand and gain increasing influence in the field a couple of decades later. However, it was not until the concept of “welfare service users” emerged on the (social) policy agenda that the views and opinions of drug users, in their capacity as care and service users, began to receive more serious attention in the political and public realm.56 Service users have been officially consulted by the Swedish Minister of Public Health and Social Services, for example, and social projects have been set up around the country to support and promote the empowerment and influence of drug users. In this sense the political environment for organisation is favourable indeed. On the other hand for drug users the heavy emphasis on the drug-free concept means that opportunities for organisation are quite restricted, at least if the aim is to gain official legitimacy. In principle, organisation among drug users is only possible insofar as they are former drug users, or at the very least are committed to quitting drugs. This means that most organisations in which users are actively involved consist of former users. As well as working to persuade public and political opinion, many of them serve as complements and extensions to the official system of professional care for drug abusers. The focus of the discussion below is on the extent that opportunities exist for organisation among drug users in Sweden. Is this a new phenomenon? What kinds of organisations are there for 56 The question of how far the demand for participation has translated into a real influence, is discussed in more detail in the article by Björn Johnson in this publication. 103 drug users? What forms do these organisations take and how do they relate to state power? In order to address these questions we need first of all to go back in time to the mid-1960s when the drug issue first surfaced in Swedish society (Olsson 1994; Lindgren 1993). In addition, we need to have a picture of the Swedish context: public perceptions of drugs and drug users, the extent of drug use and the kinds of organisation there are in the country. This article is therefore chronologically organised and starts out from the mid-1960s. A distinction is made between three different phases of organisation, which are the client movement, the self-help movement and the present-day organisation of drug users. The text is based exclusively on secondary sources, and the purpose is to provide an overview of user involvement as far as drug users are concerned. For the purposes of this text I use the theoretical model developed by McAdam, McCarthy & Zald (1996). The model is structured around three factors that are relevant to all forms of social movement and that I suggest are applicable to Swedish organisations as well. The first of these factors is called “political opportunity structures”, and it consists of the specific and unique context in which the movement originates and operates. Every country has its own historical, material, cultural and social conditions that present both obstacles to and opportunities for organisation, that make the movement what it is and that create the framework to which it must relate itself. The second factor consists of the “mobilising structures” that the movement has to be able to bring together and set in motion in order to succeed. This is about creating, steering and organising resources in such a way that functional channels are created for the mobilisation of people and for involving them in collective actions. Third and finally, it is necessary to have a group of people consciously and strategically working to organise and coordinate their views both on the environment and on themselves in order to motivate and legitimise their collective action. This process of “frameworking” involves constant and continuing negotiation with a view to creating a common frame of interpretation within which to understand and define different kinds of situations or behaviours, and it also provides an opportunity to make adjustments to one’s own subjective identity formation. In what follows my aim is to discuss and interpret the growth of user involvement among drug users in Sweden against these three factors. Public Perceptions of Drugs in Sweden The official stance on drugs in Sweden, the aim of a “drug-free society”, is not really open to negotiation, and certainly difficult to challenge. This is apparent if we look back at past debates on drug policy, which have involved several controversies for instance around methadone treatment (Johnson 2003), Subutex 104 (i.e. buprenorphine) treatment and syringe exchange programmes (Svensson 1988). In international contexts, too, Sweden is firmly committed to a restrictive stance on drug issues (Tops 2001). In a survey of public perceptions on drugs in Swedish society, Bergmark & Oscarsson (1988) identified four dominant ways of thinking which (borrowing a concept from Bourdieu) they said constituted a “doxa”. Doxa refers to fundamental aspects of society that are taken for granted, that are not and cannot be called into question: it is the naturalised way of thinking and argumentation concerning a certain phenomenon. In the case of drugs, the doxa is as follows. Drugs are seen as a serious problem at the level of both society and individual, and they are perceived as extremely dangerous. Drug abusers are victims who are unable to quit on their own, without help. Finally, drug abuse is a condition that requires care and treatment in order to reach the ultimate object of being free of drugs (ibid.). In the Swedish context, talk about drug users is always associated in one way or another with difficulties, since all non-medical use of drugs is defined as abuse. Drug use is criminalised and the police have the right to apprehend suspected offenders for urine and blood tests in order to establish whether or not they have in fact used drugs. The possession of drugs for personal use is a crime that carries a prison sentence of up to six months. According to the Swedish justice system, then, a person can be a drug user only if the substance is prescribed by a medical doctor, such as methadone or buprenorphine for maintenance treatment. Everything else is regarded as drug abuse. Against the background of the above, one might argue that the mobilising structures or political opportunities for people using non-prescribed drugs to ally together, to organise themselves around drug issues and to gain formal recognition and legitimacy for this organisation, are fairly slim. Statistics on the Number of Drug Abusers Sweden has conducted representative surveys of drug use among schoolchildren aged 15 every year since 1971. Based on samples of around 5,000 and questionnaires with virtually identical items year on year, these surveys show that the proportion of schoolchildren saying had tried drugs peaked in the early 1970s (14–16 per cent). The figure then dropped in the 1980s down to 3–4 per cent, only to rise again in the 1990s. In 2004 the proportion increased to around 7 per cent. By far the most common substance used was cannabis (CAN 2004). There have also been three major national case-finding studies to assess the prevalence of heavy abuse. Heavy abuse is defined in these surveys as consisting of all injecting drug abuse during the past 12 months or daily or almost daily 105 drug use during the previous month. In the first study in 1979, the number of heavy abusers was estimated at 15,000; by 1992 the figure was up to 19,000 and in the latest study in 1998 an estimated 26,000. Both the mean age of abusers and the proportion of abusers who had been on drugs for more than ten years have increased over these 20 years. In 1979, the mean age of drug abusers was 25 years and 19 per cent had been doing drugs for more than ten years, whereas in the latest measurement in 1998 the mean age had gone up to 35 years and over one-half had a history of drug abuse that went back more than ten years. On the whole then, drug abusers have become older, but new users are also being recruited into this group (CAN 2004). In the 1960s the use of opiates was in the form of raw opium. In the 1970s that was gradually replaced first by free-base morphine and then by heroin, which was injected. Following low levels of new recruitment in the 1980s, heroin has gained increasing prominence among heavy drug abusers in the 1990s. In the first survey in 1979, 15 per cent were thought to be predominantly heroin users, by 1998 the figure was up to 28 per cent. Drug-related mortality increased sharply during the second half of the 1990s, and in 2001 the number of deaths stood at 336, most of who were men (CAN 2004). Voluntary Organisations and Their Relation to the State The national context can be seen as highly significant both to the emergence and to the development of social movements (McAdam, McCarthy & Zald 1996). Furthermore, certain periods of time are conducive to the formation of certain types of social movement, with the national context forcing other movements into the same format. In the Swedish case a key distinctive characteristic has been the prominent role played by the philanthropic movements of the late 19th century as well as the major popular movements – the labour movement, temperance movements, the universal suffrage movement and women’s movement – not only in Swedish society, but they also came to have a very prominent role in the welfare state project. The active policy of state intervention that began to gather momentum with the building of the “people’s home” (folkhemmet) in the 1930s was based on a heavily centralised and hierarchic system of state development. In this society that was organised through and through, popular movements (or “voluntary organisations”, as they became generically known) occupied a central position. With the close relationship of collaboration and mutual dependence between the state apparatus and voluntary organisations, the Swedish corporatist model allowed for any new, progressive ideas quickly to be picked up, revamped and adapted for application when the initiative came from above (Meeuwisse & Sunesson 1998). Over time, voluntary organisations have taken on various 106 different roles as instigators of new ideas, care and service providers and opinion leaders, and for all this they can receive funding from both central and local government. Meeuwisse and Sunesson (1998) use the term “co-opting” to highlight the importance of collaboration between voluntary organisations and the state apparatus. This, they say, is a relationship where the organisations assume responsibility for the decisions made or for the implementation of those decisions. One way of doing this is to offer seats to voluntary organisations on various decision-making bodies, or to provide public funding for operations that are particularly important for the organisation, but possibly for the authorities as well. This serves to constrain the organisations’ freedom of movement, since in return they are expected to show loyalty in their decision-making. On the other hand, given the collaboration they have with the state apparatus, voluntary organisations will expect that the legitimacy and continuity of their operation is guaranteed. There is some debate and discussion surrounding the concept of voluntary organisations, but it still remains the most commonly used in Sweden for purposes of describing organisations that work in the middle ground between the official state sector and the private, informal sector. Other concepts that appear in this context include non-governmental, civic, and ideological organisations; a more recent arrival is the concept of user organisation. Voluntary organisations have the following distinctive characteristics: They must be formalised in one way or another and have a board and a general assembly for members; they must be “private” in the sense of being independent of the public sector and ideological in the sense that they are not driven by the purpose of generating a profit for the board or the membership; they must be autonomous and selfgoverning and have control over their own activities; the board must not be appointed by either local authorities, the state or private business companies. Furthermore, the operation of voluntary organisations must be based upon ideological contributions in the shape of unpaid labour or gifts (see e.g. Hammare & Stenbacka 2003). Voluntary organisations comprise a wide range of movements. One line of distinction can be drawn on the basis of the leading principle of operation, i.e. between “I-for-you organisations” and “we-for-us organisations”. Meeuwisse and Sunesson (1998) emphasise that most organisations are hybrids and cut across different areas of activity, but nonetheless accept that this distinction can be useful. This provides the basis for the distinction between philanthropic movements in which people pool their resources to help and represent others and movements in which people who share the same problems get together in order to defend and promote their own interests. 107 As far as intoxicating substances (read: alcohol) are concerned, virtually all philanthropic and popular movements since the early 19th century have been concerned to promote either reduced alcohol consumption or total abstinence. Another issue high on the agenda of these early voluntary organisations was to get the state to assume responsibility for the harm caused by alcohol at the individual and the societal level. The first care homes for people with alcohol problems were set up by voluntary organisations in close collaboration with the temperance movement. The results, however, were far from satisfactory, and it was not long before the calls for involuntary treatment started, which since then has become an integral part of the Swedish treatment system for substance abusers (Blomqvist 1998). The Swedish corporatist model is heavily focused on the care of alcoholics, and more recently on the care of substance abusers in general. Stenius (1999) describes care as a common concern, thus emphasising the fluidity of the boundary lines between the public, voluntary and private sectors. The Drug Issue Enters the Scene It was 1968 and for us, young representatives of what was to become known as the psychedelic youth revolt, it was a matter of having your documents all in order and keeping your pockets empty of hashis, marijuana, tin foil, chillum pipes, pipe cleaners and other such stuff. Otherwise you knew you were looking at being questioned and arrested, spending long dreary hours in a police cell, going to trial and being fined or even other worse hassle by the establishment and its “pigs”. As far as we were concerned this was war in which the police represented the hostile force. A force that didn’t have a clue about new music, new hair length, new clothes, new drugs, new forms of socialising, new freedom, new experiences, new consciousness … Instead, it defended the established and the recognized; the bourgeois lifestyle, indifference, suspicion, hostility towards foreigners, dual morality, dance music, alcohol. (Lindgren 1993, 17). As in other western countries, the established system in Sweden came under heavy criticism and attack during the 1960s. The wave of dissent found various expressions from spontaneous protests and demonstrations of different, alternative ways of life (e.g. the hippie movement) through to more organised extra-parliamentary activities and movements (various left-wing movements, women’s movements). These ”new” social movements, largely driven and dominated by young people, differed significantly from ordinary institutionalised movements. They took up position outside the established and traditional social order and the “modern project” (Eyerman & Jamison 1991, 23). It was in this politicized social climate that the drug issue emerged more prominently on the political and public agenda. Drug use was not in fact a new phenomenon in Sweden, but central nervous system stimulating substances had been used quite widely ever since the Second World War, and particularly in the 108 late 1950s.57 However, this use of amphetamines was not labelled as “abuse”, but it was legally and legitimately administered through the system of medical practice. It seems that the concept of drug addiction was reserved mainly for barbiturate and opiate users (Olsson 1994). Hardly any treatment was available, and the problem would be dealt with individually between patient and private physician. In the 1950s and 1960s, a common method was to write out a prescription for the substance in question (Olsson 1994). Drug abuse began to increase in the latter half of the 1960s and indeed this is often described as the period when the modern phenomenon of drug abuse emerged and became established. Estimates based on a study in Stockholm at this time put the number of heavy drug abusers in Sweden in 1967 at around 6,000 (CAN 2004; Olsson 1997). Drugs soon became regarded as a social problem that it was thought would cause the ruin and destruction of the country’s youth. Drug use came to stand for asocial, damaging, risk, and in many ways dangerous behaviour for Swedish society, providing further reason to define the “problem” (drug use) as a legal issue. The tone of debate was highly pitched and there were growing fears of the other and the unknown. Drug addicts were portrayed as enemies of society. The “drug problem” became a useful issue for purposes of diverting the attentions of the mass media and soaking up some of the other current political and social tensions and conflicts (Lindgren 1993). The First Phase: The Client Movement and the RFHL The first user organisation in Sweden was the National Association for Aid to People Addictive to Drugs and Pharmaceuticals (Riksförbundet för hjälp åt läkemedelsmissbrukare, RFHL), which was later to change its name. Launched in 1965, the RFHL was the first among what were to become known as Rassociations, an umbrella concept for the wave of client movements that developed in Sweden that in those days was enjoying strong economic growth and that had large youth cohorts. The Social Democrats had been in power for some time and the welfare state project was in full swing. The need for this grass-roots intervention grew out of a sense of discontentment with the way that society dealt with social policy issues such as drug use, criminal care and mental health care. The movements were inspired by public discussions and debates between professional avant-gardists within the care sector and the judicial system, intellectuals who took an interest in social and criminal policy, and people who had personal experiences of psychiatric care or who had been hooked on drugs or alcohol and/or who had been to prison. 57 According to Olsson (1994), three per cent of the adult population in Sweden in 1942/43 used amphetamines. Among them 3,000 were using the drug at levels that today would warrant the description of “heavy abuse”. 109 Ordinary, mainstream society was criticised for putting people under so much pressure and for causing so much exclusion; the aim was to gain equality and to show solidarity with those who had been driven out and excluded. Sven-Åke Lindgren (1993), former Chair of the RFHL, says that the movements were motivated in part by aspirations to break the power exercised by the state and experts over ordinary people; in part by the ambition to do away with repressive institutions such as mental hospitals and prisons; and in part by the perceived need to create an alternative force that would halt the tendency towards the psychologisation and individualisation of problems. As he put it: the aim was to get away from the state, from the experts, from institutions and away from the soul. The five R-associations58 together published a magazine called “Pockettidningen R” (the Pocket magazine R) in order to give a voice to the “care-stricken”, i.e. clients, patients and prisoners. The magazine was to become a major representative of new journalism, offering critical analysis of society and its institutions. In the mid-1970s, Pockettidningen R had some 17,000 subscribers, with the same number of copies sold through newsagents. These were huge figures for that time, and the magazine became a major influence indeed (Adamson et al. 2004). The original impetus for the foundation of the RFHL was provided by a series of debates where Swedish society came under heavy criticism by Frank Hirschfeldt (later the founder and chairman) and others for the way it dealt with the drug issue. Hirschfeldt was keen to emphasise the humanitarian and social-medical aspects, insisting that the problem could not be resolved simply by means of legislation and increased police intervention. The organisation was soon able to set up an office in a condemned building in the centre of Stockholm. The rent was initially covered by the social welfare department, but within six months it was receiving funds from several other sources as well, including the Christian temperance movement (De kristna samfundens nykterhetsrörelse), the Swedish Save the Children Association (Rädda barnen), the National Board of Health and Welfare, and the Ministry of Health and Social Affairs (Adamson et al. 2004). The office had a staff of three who ran an open house for drug users. Predictably, the early stages of the operation were less than convincing, and it often descended into chaos and violence as drug users took over the premises, threatening to turn them into “drug-user quarters” (Sannegård 2004). 58 Apart from the RFHL, there was the National Society for the Humanisation of Prisons (Riksförbundet för Kriminalvårdens humanisering, KRUM), which was founded in 1966. The National Organisation for Mental Health (Riksorganisationen för mental hälsa), later renamed as the National Association for Social and Mental Health (Riksförbundet för social och mental hälsa, RSMH). Finally, the National Association for People with Alcohol Problems (Alkoholproblematikers riksorganisation, ALRO) was established in 1974. Each of the R-associations issued their own magazines for members, and in 1970 they joined forces to launch the Pocket magazine R. 110 In Sweden, the drug problem was primarily dealt with in the field of psychiatry, and the RFHL also took a critical stance on the care provided for alcoholics, which was regarded as inhuman and repressive. The aim was to find democratic and humane alternatives for dealing with questions of exclusion and drug abuse. In general there was a strong undercurrent of anti-authoritarianism, and a strong urge to introduce and test new methods, including milieu therapy, prison-visiting groups and other ways of establishing closer links between ordinary citizens and “social outcasts” (Nordegren 2004, 128). The object was to re-integrate drug abusers into society. The first treatment collective based on milieu therapy was set up in 1968, and within the space of a few years the number of such units had risen to around 25, with a total of almost 100 client places (Adamson 2004, 151). In most of these collectives, staff included both former addicts and others. Thomas Nordegren (2004), the then secretary for the association, has described some of the difficulties that were caused by the collision of former addicts’ and other people’s very different life experiences. He says the unlikely combination gave rise to organisational vulnerability as the “most downtrodden and criminal” members quickly moved into dominant positions within the organisation and took advantage, ”disappearing with the cash” (ibid., 139). In 1965–1967, an experiment was conducted with the legal prescription of drugs under authorisation by the Swedish Medical Agency. The RFHL was one of the many advocates of this project, which at one point was moved to its premises. Initially the project involved just below a dozen or so doctors, but in the end there remained just the one, Dr Åhström, who could not singlehandedly cope with the constant flux of drug addicts. One of the first persons employed at the RFHL, Wille Sannegård (2004), has described how “some of the patients were skid-row addicts, others were intoxicated, paranoid or outright aggressive, and others still were decent, respectable citizens who simply wanted to have their prescription” (ibid., 111). In due course the RFHL decided to withdraw its support, and the project was prematurely terminated. In the drug policy debate, this project has since served as a warning example of the catastrophic consequences of the legal prescription of drugs (Tops 2000). At the same time as the RFHL continued with its practical efforts in care and treatment, setting up family collectives and launching counselling programmes and contact centres, it also set about lobbying public and political opinion. The aim was to get people to understand the conditions in which drug addicts lived, to demonstrate the impacts of exclusion, unemployment and the way that society dealt with drugs and the consequences it had on drug users. The problem of drug abuse was seen and portrayed first and foremost as a political problem, and the association took a critical view on what is regarded as a tendency of individualisation within the public system of care, i.e. the tendency to focus on 111 the individual and to ignore the social and political aspects. Quitting drugs was regarded as a personal political statement (Stenius 1999). One key issue that was raised at a very early stage within the RFHL was the wholesale prescription of medical drugs, both in prisons, in mental health care and indeed in the population at large. The organisation went so far as to file a complaint with the state prosecutor against all 600 psychiatrists in the country, claiming that they were handing out prescriptions far too liberally (Adamson 2004, 149). The purpose was to draw attention to the economic interests of the pharmaceuticals industry: parallels were drawn between the legal prescription of drugs and illegal drug abuse, and it was argued that legal drug use was also causing passivity, dependence and social isolation. The only difference was that the drug dealers in this case were the state and pharmaceutical companies (Nordegren 2004). The organisation continued to grow and become more formalised. A national board was appointed and independent local associations created, with a network of contact persons set up to cover smaller localities. Both the national board and the boards of local associations were made up of former addicts, public authorities and radical contributors to public debate (Nordegren 2004). It also launched a member magazine, which had a circulation of a couple of thousand copies. As well as receiving subsidies from central and local government and other sources, the RFHL now gained public recognition and was consulted in an expert capacity for various state surveys, for example by the National Committee for the Treatment of Drug Addicts (Narkomanvårdskommittén) in 1969. In this way it gained an increasing say over matters of state policy. Striking a Balance Between Criticism and Search for Legitimacy The R-associations brought together large numbers of people under their umbrella. They were an integral part of the wave of radicalism that swept through Sweden in the 1960s and 1970s, driven by people who took a critical view on the established and the traditional and who were committed to finding alternatives. The strength of the movement derived from its broad composition, involving as it did both intellectual academics and people with personal experience of the downside of the welfare state as patients, clients or prisoners. This immediate contact between personal experience and the theoretical, analytical and verbal skills of the intellectuals involved in the movement as well as contacts within the mass media and the state apparatus provided a solid sounding board for social criticism and at the same time afforded legitimacy to the organisations. 112 For both of these parties, the movements opened up opportunities and even career paths, giving individuals a chance to rethink and reorganise their own experiences and to work out new understandings and meanings for those experiences. This, according to Asmussen & Jöhncke (2004), can even lead to a completely new image of oneself, one’s situation or one’s own subjective identity, as described among others by Strömstedt (2004). He provides an account of how he “learned he was oppressed” in prison and says that this awareness was what gave him the strength to change his life. The organisations created various meeting-places where clients, patients and inmates were able to get in touch with new social groups and in this way gain direct access to the public arena in society. The intellectuals, for their part, gained access to materials that could be turned into plays, documentaries, feature films, books, articles and television and radio programmes. This “double competence” was hugely influential not only in opinion formation, but also in the development of new treatment alternatives whereby the treatment of drug addicts emerged as a whole new area in Swedish society. In its capacity as representative of drug abusers, the RFHL was also in the position both to legitimise its criticism of the treatment system and to carve out a role for itself as an expert in the care of drug addicts. The 1970s also saw a marked increase in drug treatment activities coordinated and administered by foundations and associations (Stenius 1999). This provides an example of how the organisation sells and uses its knowledge for purposes of securing its own survival. The experiment with legal drug prescription in the late 1960s was taken to constitute a serious threat to the RFHL’s legitimacy, and many took the view that for reasons of self-preservation the organisation should dissociate itself from the project. Activists involved in the organisation at this time have argued that the experiment and the fact that it was so closely linked to the RFHL burdened the organisation for a long time, for it meant that it became labelled as an advocate of a drug liberal policy – which in the Swedish context is not good news. They say that the efforts by the RFHL to take critical distance from methadone treatment was effectively an effort to erase that label (Adamson et al. 2004). At the same time, the adoption of this stance meant that the RFHL landed on the same side of the drug policy debate as its main adversary, the Swedish National Association for a Drug-free Society (Riksförbundet för ett narkotikafritt samhälle, RNS). It was not until the late 1980s that the organisation revised its position and expressed its support for methadone substitution treatment. The anti-methadone stance adopted by the RFHL serves as an example of how the organisation through its involvement in the legal prescription project challenged the Swedish doxa on a drug-free society. This meant that if the organisation was to gain legitimacy in the first place, it would have to dissociate itself categorically from everything that was linked to harm reduction – and in this, the focus on the drug-free concept was crucial. 113 Apart from methadone, another major issue of contention in the Swedish debate on social and drug policy was the involuntary treatment of abusers, which remained firmly on the agenda from the late 1960s through to 1982 when legislation was adopted on involuntary treatment in certain cases. During this period the issue was addressed in several state surveys, but none of them managed to resolve the problem. The RFHL made clear its stance on involuntary treatment from very early on as it advocated the development of voluntary care that was based on the needs and wishes of drug addicts themselves while still aimed at the ultimate goal of freedom from drugs. The organisation also invested great effort in shaping public opinion against the toughening climate in society against drug abusers, engaging in debates and conducting surveys and providing its expert opinions to emphasise the importance of solidarity with drug abusers. The RFHL was at its prime in the late 1970s, and then began to slip down a slope of decline as the wave of radicalism ebbed away. In the latter half of the 1980s, its operations began to wind down and several treatment collectives were closed in the absence of a sufficient number of clients. In its search for legitimacy, the RFHL had to constantly work on activities that attracted drug users, such as its contact centres and alternative forms of treatment, but at the same time it had to distance itself from its client’s way of life. This balancing act between representation and distanciation was occasionally described as difficult, particularly during periods when the repressive forces gathered momentum (Wallbom 2004, 161). The Second Phase: The Self-help Movement Even though self-help movements are not primarily concerned to change or shape the social conditions that impact the life of drug addicts, for example, they still are a typical example of voluntary organisations of the “we-for-us” type (Meeuwisse & Sunesson 1998). In contrast to client movements that also involve people with no personal experience of drug use, the self-help movement is confined to members who have first-hand experience of drugs or who are indirectly involved as “co-dependents”. The first self-help groups in Sweden were active initially in the alcohol field.59 The first Narcotics Anonymous group (Anonyma Narkomaner, NA) started in 1987. NA is totally independent in its operation from both central and local government. As the name implies, participation is based on anonymity, and the meetings are structured around the same 12 steps that are familiar from the Minnesota movement. The starting-point is provided by each user’s own personal experiences and the need to share those experiences with other people 59 Länkarna, a Swedish version of Alcoholics Anonymous, was founded in the mid-1940s. The first AA group was launched in the mid-1950s. 114 who share the same kind of situation. The association accepts no subsidies, it provides no consultancy or expertise, and NA members do not participate in any organized collaboration with public authorities on a structural level. In addition to self-help groups, NA activities may include telephone helplines and sponsorships, with participants who have been off drugs for longer periods supporting those who have only just started. These members may also contact local alcohol clinics, hospitals, treatment homes, prisons and social welfare departments and offer their services as a rehabilitated abuser and share their experience of how they achieved abstinence. Local NA groups are divided into circles, which in turn make up geographical regions in which each local circle has its own representative. There is a national council and each year a national service conference is held. Among the council’s duties are to ensure that the local groups adhere to the tradition of 12 steps and that the decisions taken at the service conference are put into effect (Hammare & Stenbacka 2003). The self-help movement has grown enormously and spread all around the world. The reason for its success is usually thought to lie in its independence from the surrounding world, with the autonomous and self-directed group at its heart. Helmersson Bergmark (1998), however, takes a critical view of this assumption and maintains that it is its form that makes the movement a victim of its external circumstances. By way of an example, she describes the development of selfhelp groups in Sweden and shows that their considerable growth and expansion ties in closely with the launch of the Minnesota model in the Swedish system of abuser care. Even though the AA has been active in Sweden since the mid-1950s, the movement’s breakthrough only came with the need for aftercare for all those abusers who had been through the Minnesota programme. The number of self-help groups then increased several times over a period of ten years, from the mid-1980s to the 1990s. Unlike the RFHL which placed drug use in a social policy or societal context, the self-help movement and NA focus on the phenomenon of “abuse” and the abuser. The individual is thus isolated from the social context, and subjective identity formation starts out from and builds upon drug abuse. Through the 12step programme the abuser gains access to a comprehensive system of treatments and explanations, which provides the framework for interpreting and understanding one’s life. At the centre of it all is the process of identity formation. Steffen (1996) emphasises the total inclusiveness of the twelve-step model, suggesting that the programmes can only be viewed and assessed as a whole, where truth is juxtaposed with lies. The programme, she says, “offers members a new social identity from the vantage-point of a total experience of reality” (ibid., 16). 115 This focus on drug abuse is also reflected in the form of organisation. The main core consists of group meetings where the anonymous participants discuss the consequences of abuse against the background of their own personal life situation; they then split up and return to their everyday lives. This kind of community that is based on an exercise of individual reflexivity regardless of social position, is very much in line with the modern project of self-realization and is also thought to contribute to the popularity of the self-help movement (Mäkelä in Helmersson Bergmark 1998). In general both the self-help movement’s ideology and its concept apparatus have very much shaped and influenced the everyday terminology about questions of abuse. Substance Abuser Care in Sweden is Cut Back and Restructured Both the RFHL and the NA took shape in an environment of ever-expanding efforts to combat and contain substance abuse, whether by means of prevention, care and treatment or control. The care of substance abusers and drug policy have enjoyed high priority and attracted much debate and discussion in Swedish society. The point of culmination was reached in the mid-1980s with “Offensive Drug Abuse Care”, a government programme aimed at containing the spread of HIV in which drug addicts were to be picked up from the streets and prisons and other everyday environments and encouraged to receive care (Stenius 1999). Methadone substitution therapy was reluctantly accepted, and the maximum number of patients was doubled from 150 to 300 in 1988 (Johnson 2003). Needle and syringe exchange programmes were also launched in some areas, despite fierce objection and protests. The Swedish system of institutional care for substance abusers, which covers both alcoholics and drug abusers, was at its prime in the late 1980s, when the number of substance abusers receiving care on any one day peaked at around 5,000. It is estimated that in the 1970s and 1980s, the annual number of people admitted for some type of institutional treatment was between 14,000 and 18,000 (Blomqvist 1998). These figures were based on the number of institutional places; no data are available on the number of contacts in community care. The restructuration of the Swedish welfare state, and by the same token the system of abuser care, got under way in the late 1980s. Market-oriented models were introduced and tested, the heavily centralised state system began to take a more backseat role, central government transfers to substance abuser care were discontinued, and the provision of abuser care was increasingly delegated to local municipalities. Long-term institutional treatment decreased, whereas Minnesota programmes increased sharply so that by the end of the 1980s they accounted for almost 25 per cent of all institutional places (Stenius 1999). The crisis in central government finances in the early 1990s led to cutbacks in public 116 expenditure, which had the effect of dramatically reducing the provision of institutional care, increasing the number of private and voluntary organisations in the field, intensifying competition between different forms of care, and increasing the number of abusers whose options were limited to community care. According to the National Board of Health and Welfare (2005), the total costs of substance abuser care in Sweden have been cut by 20 per cent since 1995, in spite of the sharp increase in the demand for detoxification beds, treatments, psychiatric care and aftercare. The situation has been improving in the past few years, though. Calculations by the National Board of Health and Welfare show that within social services, substance abuser care had daily contact with more than 21,000 alcohol and drug abusers. The vast majority of these contacts had to do with community care, but also with housing benefits and institutional treatment. The number of people receiving institutional care on any one day totalled 3,600 (ibid.). As for drug abusers, it is estimated that among the 26,000 people identified in the 1998 census, some 10,000 were in contact with social welfare services and 13,000 with medical health care (ibid.). Apart from the earlier drive to cut back on service provision, another distinctive characteristic of the Swedish system of substance abuser care is the wide range of treatments and models it supports. The medical component has gained increasing prominence, both as a result of the illness model and the growth of substitution therapy using methadone and buprenorphine. Restrictions remain in place on the prescription of methadone, but the indications and rules have nonetheless been eased. Furthermore, the ceiling for the maximum total number of patients has now been removed. On the other hand, rules for the prescription of buprenorphine have been tightened, as only doctors working within the addiction field are now allowed to issue prescriptions (National Board of Health and Welfare 2004). There are currently some 2,000 people in Sweden today who are on methadone or buprenorphine substitution therapy (oral source). There are two cities that run needle exchange programmes, i.e. Malmö and Lund, which together have some 1,500 patients (pamphlet 2004, from needle and syringe exchange programme). The implications for the individual abuser are twofold: on the one hand it has become harder to gain access to care, on the other hand it has meant they have had to assume greater personal responsibility for their situation. A number of reports have come out talking about a Black Peter game where the authorities are trying in various ways to avoid the heavy costs of care provision and to promote more open and less expensive forms of treatment. The deregulation of the housing market has made it much harder for addicts to find a place to live, which has driven up the number of homeless people. All in all, there has been a marked deterioration in the social and economic circumstances for large numbers of heavy drug abusers, adding further to their marginalisation. Over the years a large proportion of them have also taken part in various treatment programmes 117 and are now showing signs of “treatment fatigue” (Kristiansen & Svensson 2004; Lander et al. 2002). The Third Phase: The State Withdraws At the same time as the state has withdrawn into a more backseat role, voluntary organisations have taken on an increasingly prominent role, both within the field of substance abuse and in other welfare sectors. The political rhetoric describes voluntary organisations as playing a key role in “deepening welfare”; they complement the official, public system and have a special competence that is clearly distinct from that of professionals. Indeed, the government has created a new policy field dedicated specifically to popular movements. User involvement is also a feature of several other state measures, the aim being to get welfare service users take a more active role in their own care. This is done by such means as study circles, user councils, user panels and conferences in order to give a voice to users (see e.g. Prinz 2003). It is noteworthy that several different types of organisations are active in the drug field. The RFHL, the oldest of these organisations, operates on both the central and local level. For a number of years now its membership has been around 3,000, some 2,000 of whom have personal experience of drugs and/or addictions to medicinal substances (Meeuwisse & Sunesson 1998). Most of its funding comes in the form of government subsidies, less than one-quarter comes from the sale of services. Around 60 per cent of the RFHL’s activities consist of support and treatment, 30 per cent of work to lobby public and political opinion and prevention, and the rest of counselling and education. The association also publishes a magazine called “Oberoende”, which features critical commentaries on the adverse effects to clients of cutbacks in care provision. The RFHL has also been involved in launching “Basta”, a work cooperative that provides rehabilitation but also runs businesses part-owned by former abusers. Measured in terms of the total numbers involved, the biggest movement of all is without doubt the self-help movement, as represented by the AA60 and the NA. According to the AA’s own estimates, it had in 1998 some 500 self-help groups that involved some 10,000 people (Hammare & Stenbacka 2003). The NA says on its website that it has just over 200 self-help groups. There are also many other voluntary organisations in Sweden today that have been set up and that are run by former drug addicts and that are partly funded from central or local government sources. These include Convictus, Basta, 60 Drug users are also welcome to attend AA meetings. There is some oral evidence that people on medically-assisted substitution therapy (methadone, Subutex) prefer to go to AA meetings instead of NA meetings. 118 Dianova and KRIS (Criminals’ Return Into Society / Kriminellas revansch i samhället). The purpose of these organisations is to provide peer support, which may be in the form of cafés, social activities, alternative housing, abuser treatment and work cooperatives. Indeed, it is a broad spectrum of activities that are covered. Some of these organisations’ activities have been upgraded into “services” that are sold as alternatives to those offered by social welfare services. Some organisations, including the RFHL, Basta and Dianova, have pooled their resources in a centre known as “Rainbow Sweden”. Yet another type of association is the Swedish Users Union (Svenska Brukarföreningen, SBF), which differs from the rest of the field by explicitly supporting a drug policy based on “harm reduction”. The text below offers a brief description of two of these organisations, i.e. KRIS and the Swedish Users Union. The choice of these two cases is based on their both being organisations for drug users and actively involved in the social debate, but at the same time they occupy opposite ideological poles. While the Swedish Users Union also represents active drug abusers, KRIS is a firm advocate of the Swedish drug policy ideal of total abstinence. As for their relationship to the authorities and other actors in the field, the Swedish Users Union takes a more critical stance than KRIS against official drug policy. It is particularly unhappy with care and treatment available for opiate addicts. Criminals’ Return Into Society / Kriminellas Revansch i Samhället (KRIS) KRIS was founded in Stockholm in the autumn of 1997 by four people with long histories of crime and substance abuse. They wanted to set up a peer association whose members would together provide a supportive network for others who wanted to leave their former life behind. KRIS was soon in the public eye following a TV documentary which showed a group of members standing outside the gates of a prison, waiting for a prisoner who was going to be released. This standing and waiting outside prisons became one of the association’s hallmarks, a manifestation of its ideological premise that quitting drugs and crime requires not only commitment, but also social support and a drug-free community. Many of the association’s members are also active in the NA and the AA, and indeed complete abstinence and freedom from drugs are among their main tenets. KRIS is strictly opposed to needle and syringe exchange as well as maintenance treatment with methadone or Subutex. KRIS consists of a national association and a number independent local departments (in autumn 2005 there were 28 such departments). It receives its funding from central and local government project appropriations, private business companies and the sale of services. The larger local departments usually have a few employees, whose wages are paid partly from central 119 government and municipal subsidies. In addition, there is a board and a membership who work on a voluntary and ideological basis (BRÅ 2003). According to the association’s website, it has 5,300 paying members who have personal experience of drug abuse and crime. The association mainly provides a source of peer support. Each local department has its own premises and meeting place for members, which will typically include a café, a pool table, magazines, games, and TV. The main focus is on social activities, excursions, sports, training sessions, football, and cinema, but there are also study circles for example on meeting techniques. KRIS also publishes its own member magazine, called “The Way Out” (”Vägen ut”). Furthermore, KRIS organises visits to prisons where members take charge of discussion groups, motivate inmates and hand out information about the association. This activity is supported by funds from criminal care services. In addition, KRIS runs various information campaigns, and its members frequently visit schools to give lectures. Based on its studies of KRIS, the Swedish National Council for Crime Prevention (BRÅ 2003) says that there is an element tension between the association’s professional members and its more ideologically minded members. The introduction of new services has created competition and disagreement, and attention is drawn to the difficulties of maintaining a balance between professional commitments and the simultaneous provision of peer support. According to BRÅ, the steady growth of professional ambitions has happened at the expense of social activities and community. It also make the critical point that the association’s insistence on absolute freedom from drugs and strict adherence to the law may lead to the exclusion of large numbers of members. Svenska Brukarföreningen / The Swedish Users Union61 Svenska Brukarföreningen, the Swedish Users Union was founded in October 2002 by people in medically-assisted maintenance treatment. The full name of the association is “The Swedish Users Union – help for opiate users and people who have or need methadone or Subutex”. The following text is based on the association’s website and newsletters.62 The association’s aim is to promote and defend the interests of “heroin addicts”, both within the field of substance abuse care and elsewhere in society. It is committed to changing Swedish drug policy so that it is based on the principle of harm reduction. The Swedish Users Union is in favour of needle and syringe 61 62 The Swedish Users Union is discussed in more detail in the article by Jessica Palm in this publication. Www.brukarforeningen.com, accessed 17 December 2005 120 exchange, which it considers important purely for reasons of health promotion. In its programme the association compares drug addiction to other diseases and says that treatment must be based upon “science and proven experience”: no professional, it continues, must be allowed to give preference to a certain treatment on ideological grounds. Furthermore, the Swedish Users Union wants to see waiting lists for care and treatment abandoned and replaced by a system which guarantees access to substitution therapy within 72 hours or to drug-free treatment within 14 days. Patients’ rights to maintenance treatment must also be guaranteed. The Swedish Users Union says it is still in the process of building up its operation. Initially the association had access to a room at RFHL’s offices, but it has now premises of its own. The association runs information campaigns to persuade public opinion, and it has helped to start up a user council at two addiction clinics in Stockholm. It also offers help to members in their contacts with the authorities. According to the same newsletter, the association has helped almost 100 members to file documents with the National Board of Health and Welfare, the Patients’ Committee and/or the Committee on Medical Responsibility. The issues addressed have ranged from the suspension of social benefits to cases where patients have been excluded from treatment programmes. The association is organised into one national department and six local departments. There is also an association for next of kin. In 2004 the association had a membership of almost 800. The Swedish Users Union is also a member of the international network for methadone patients (NAMA), and it works closely with its sister organisations in Copenhagen and Oslo. The Swedish Users Union is also an expert association whose opinion is consulted in state surveys. Discussion Ever since the mid-1960s when the drug issue began to emerge in Sweden, drug users have taken an active involvement in various kinds of organisations in order to take advantage of other users’ experiences and to share their own views. The Swedish “doxa”, which looks upon drugs as a serious social and individual problem, which regards drug abuse as a condition that requires care and treatment and which takes freedom from drugs as the ultimate goal – this doxa means that, according to the theoretical model proposed by McAdam, McCarthy & Zald (1996), there have been no political opportunity structures in Sweden for the organisation of drug users, other than for former users or users committed to quit drugs. One of the consequences of this doxa, which is described in more detail at the beginning of this article, is that all these organisations have been very much preoccupied with questions of care and treatment, indeed care and treatment have been central to the very formation of these organisations. As far 121 as users are concerned, access to strong and effective alternative forms of care provide a reason for mobilisation, and the provision of effective treatment for drug addicts enjoys not only political legitimacy, but it is also seen as an important social duty. The first organisation, the RFHL, was created as a critical reaction to the way that society dealt with drug issues, to the way that the authorities and the police dealt with drug addicts and to the lacking and repressive methods of care. The environment in which the RFHL was founded was pervaded by a sense of moral panic: the drug issue had been labelled as a social problem and drug abuse was seen to be spreading among the youth of the nation. There was a social and public demand for effective and appropriate methods for dealing with the problem, as there still existed no system for the care of drug addicts. Society was also at a loss with the protest movement that was rapidly evolving and that among other issues was drawing attention to processes of social exclusion. There were thus both political opportunities and mobilising structures in place, and in principle all that remained for the active, i.e. radical and progressive forces in society and users to do was to ride this crest and coordinate the unfolding activities. The forms of care launched by the RFHL, such as milieu therapy collectives and contact centres, were incorporated into this structure later on and eventually became part of the official care system. In addition to its efforts to develop alternative forms of care, the RFHL has continued to work to lobby public and political opinion by drawing attention to the conditions in which drug abusers live their lives. Over the years the organisation has both changed its form and revised its stance on methadone use, for example. Initially, the RFHL was opposed to methadone, but after years of vacillating debate, it eventually decided to change sides. If the RFHL can be described as an open and politicised movement geared to change, the self-help movement is its exact opposite. It is introverted, anonymous and conservative in the sense that there have been no major changes or shifts from its original setup. Instead, the reason for the dramatic increase in the number of self-help groups since the mid-1980s is thought to lie in the successful launch of the Minnesota model in Sweden (Helmersson Bergmark 1998). On the other hand, one may also presume that the large number of selfhelp groups was both as a prerequisite for and served to legitimise the Minnesota treatment model, which from a Swedish point of view was very short and brief. These groups provided a convenient way to reach those patients and to provide them with the aftercare they needed so that they could become “successful results”, i.e. abstinent abusers. Furthermore, self-help groups were extremely valuable to the official system which at times of budget constraints could send their clients/patients to receive care free of charge. 122 Today, organisation among drug users takes place in a society where the state has withdrawn into a back-seat role, where the nature of abuser care has changed, and alternative forms of community care have increased at the expense of institutional bed places. A space has opened up that can be filled by voluntary forces driven and stimulated by the state. Information campaigns aimed at shaping public opinion has been downscaled, with the possible exception of the Swedish Users Union which says it wants to highlight the interests of heroin addicts. However, the association has originally grown up out of a sense of dissatisfaction with existing substitution maintenance programmes (methadone and Subutex) and with the rights situation of many patients. Like other voluntary organisations, all of those mentioned here, with the single exception of the NA, work closely with and are heavily dependent on the state. This may have to do with economic and material resources and opportunities to participate in public debate. All this marks an extension to and continuation of the Swedish corporatist tradition, which is characterised by the absence of confrontational movements in the social policy field. In exchange for resources they receive, the organisations sell their expertise, their competence and access to different groups of citizens (Magnusson 2002; Meeuwisse & Sunesson 1998). However, in the present system of user organisation it seems that the nature of co-opting has changed. Increasingly, voluntary organisations appear to have given up their role as advocates and critics at the expense of the role of service provider. A successful example is provided by KRIS, which has gained broad public support and recognition for its work and commitment to the Swedish drug policy of complete freedom from drugs. All organisations started by users have grown up out of personal experiences of care. In some organisations, such as the Swedish Users Union for opiate addicts, the drug of choice is a key criterion for membership, in others members are drug users in general. Users have become experts on substance abuser care and they are using their experience and knowledge to help others with similar problems. The help they offer may vary both in terms of duration, form and content: it may consist of peer support, voluntary work, work as an employee or self-employed, and take up a larger or smaller part of one’s everyday life and own identity. In this way treatment practices, explanation models and knowledge production around drug use and quitting drugs are not the exclusive domain of professionals whose expertise is based on formal education. In the long term, this might have implications for expertise-building on issues of drug use and abuse. As yet, it is too early to say what exactly those implications might be. In several organisations user experiences have been transformed into services that are sold on the marketplace. Taking on the role of service provider creates various different tensions both for the individual user and for the organisation. 123 For the individual user, this may provide an opportunity to earn an income, gain social respect and even build a future career, but it may also necessitate various new roles that carry the potential of serious role conflicts. From the role of voluntary worker, one moves to become a salaried employee, in a position that involves certain responsibilities, at the same time as one may be involved in selfhelp groups with other users, sometimes close friends, who are also potential “clients”. Another problem may come from the difficulty of changing careers and transferring the capital and status one has built up in this expert role. There is the risk of becoming trapped in the role of user, albeit a professional one. As for the organisation, service provision may also give rise to tensions, as shown by the study of KRIS conducted by the Swedish National Council for Crime Prevention (BRÅ), if professional users want to present themselves as such and take up an expert role vis-à-vis other users. The user is placed up against another user, and it is the one who has been abstinent longer that will emerge as winner, gaining the rights of interpretation – a practice that is also common in the selfhelp movement, where there are rewards and special privileges for those who have been abstinent the longest. User participation today is probably dependent on a cluster of interwoven factors. The political opportunity structures are in place in so far as central and local government encourage active engagement and involvement. There are established forms of voluntary organisation that create the necessary mobilising structures, which can be taken into use by actors who represent a relatively limited, well-defined and permanent group of people with fairly similar problems. Drug abusers have become older, some of them have been through several treatment regimes, they have experience and knowledge of what is required in order to quit drugs that they can pass on to others. Some of them have succeeded, others haven’t. Together with this, the terminology advocated by the self-help movement has gained ground whereby abuse is understood as a special identity, as a problem that cannot be treated by means of medication – as is confirmed by substitution therapy. Here the users are presented as patients, a legitimate interest group who are capable of articulating their claims for care. However, this is a group of people who are defined as and who create a community on the basis of their position in the welfare state, as clients/patients or users of substance abuser care. The tendency of involving users of welfare services is seen not only in Sweden but other welfare states as well. Asmussen (2003) argues that user participation in this latter sense should be understood as a new technology regarding citizenship. She argues that this is not only about developing and improving welfare services with a view to adapting them to current target groups, but also about steering citizens’ behaviour towards the role of active citizen who assume responsibility for themselves. The question now is whether user organisations will find and content themselves with the place appointed to them by the state and work within mainstream 124 society to build “sheltered islands” in the shape of work collectives, day activities, leisure activities, etc. where they make use of their members’ personal experiences and where their situation is established. Alternatively, it is possible that users will consciously and strategically produce a shared view of their environment and themselves and in this way create “islands of meaning and opposition” that project into mainstream society and in the future come to challenge the prevailing doxa. 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Hedemora: Gidlund. 127 The Development of User Influence on Swedish Drug Policy 1965–2004 Björn Johnson Introduction The aim of this article is to investigate the degree to which Swedish drug users have been able to influence Swedish drug policy from the mid 1960s onwards, the time during which drug abuse was established as a social problem. I will also try to determine in which areas their influence manifests itself. Influence is meant in a political sense and the article does not shed any light on whether individual users have managed to exert an influence over their own situation. The focus is rather on the relationship between public drug policy and the opportunities of the users to carry clout as a collective. In the last decade, Scandinavia has experienced a mobilization of drug users. This mobilization was initiated in Denmark where the first Scandinavian association of drug users was founded in 1993. Since then user associations have sprung up also in Norway (1996) and Sweden (2002). It may perhaps seem natural to interpret this development in light of the increased interest in user influence and other forms of civic participation that followed on from the discussions about participatory democracy during the 1990s. However, in this study I show that such an interpretation would be insufficiently rigorous. Ever since the early 1980s, Swedish users have had little say when it comes to drug policy, and in later year this influence has diminished rather than increased. In this article, the term user carries a double meaning in the sense that it refers to both someone who uses drugs and to someone who is subjected to or benefits from public measures. The first definition of the term – the drug user – is relatively unproblematic in this context, but the second meaning merits a further discussion. In administrative science, and when discussing user influence in general, a distinction is normally made between four different definitions of the term user (Dalhberg & Vedung 2001). According to the most common interpretation a user is the recipient of various types of public benefits in the form of services or goods. This definition is sometimes qualified in the sense that a distinction is made between recipients who themselves are able to choose services or goods – the user is a public services ‘customer’ – and recipients 128 without any such options. According to the fourth and widest interpretation a user is the recipient of public measures in general, that is to say of both public benefits as well as public rules and regulations and exercises of public authority. I am using this broader definition. Consequently, the users in this article mainly constitute active drug users who are recipients of public benefits – such as treatment of their drug addiction – as well as subjected to public rules and regulations and exercises of public authority; such as drug-oriented control policies. Arguments in favor of user influence are usually associated with and motivated by some form of participatory democracy perspective. However, you do not need to be an adherent of participatory democracy to take the view that the opinions, interests and experiences of the drug users should in some way be taken into account and be allowed to influence Swedish drug policy. The various policy components – control policies, drug addiction treatment and preventive measures – all contain such a great measure of exercise of public authority that the importance of listening to the users can be argued, even from a parliamentarian or elitist-democracy point of view. Dahlberg and Vedung (2001, 43–65) discuss six different ideal-type arguments for user influence. The civic education argument aims at achieving civic instruction through user influence. The expressivity argument focuses on the users’ opportunities for self-fulfillment through the influence process. The legitimacy argument brings up the benefits in terms of legitimacy that decisionmakers and administrators can achieve through user influence. The point of the efficiency-oriented argument is that user influence can lead to better goal fulfillment and increased administrative efficiency. The power leveling argument claims that user influence can reduce the imbalance in power that exists between decision-makers and administrators on the one hand and the users on the other. The reasoning behind the service adaptation argument, finally, is that user influence can lead to the public measures being adapted to meet the users’ needs and requirements. In theory, all of these arguments could be used to motivate the users having an influence over Swedish drug policy. In most cases, organizations safeguarding the interests of users favor power leveling, service adaption, efficiency or expressivity arguments, i.e. mainly arguments aiming to increase the benefits to the users. The first question that has to be asked when discussing user influence is, ‘influence over what?’ The term ‘drug policy’ is too wide and needs to be qualified and delimited. One way of doing this is by making a distinction between different spheres of influence. Burns et al. (1994), for instance, identify an individual sphere which concerns public measures for separate individuals or households in their own environment, a program sphere for individual or collective contacts with public services (such as schools, health centers or treatment clinics), a municipal sphere where individuals and groups come into 129 contact with municipal politics and administration, and finally a governmental or public policy sphere for contacts between individuals and groups on the one hand and key political and administrative authorities on the other. The main topic of interest in this essay is how users’ interests and influence have been articulated in the fourth sphere – the Swedish public drug policy. By ‘public’ I am primarily referring to all centrally decided and administered laws, rules and regulations (i.e. by parliament, government and key government departments and agencies). User-oriented studies usually deal with one of the first three spheres, whereas decisions made in the fourth sphere are seldom discussed in a participatory context. This is somewhat remarkable considering the fact that this sphere is of great importance to the other three; decisions in the governmental (public policy) sphere essentially draw up the boundaries for decision-making in all other spheres. Michael Lipsky (1980, 14) has formulated this neatly and succinctly: The major dimensions of public policy – levels of benefits, categories of eligibility, nature of rules, regulations and services – are shaped by policy elites and political and administrative officials. Administrators and occupational and community norms also structure policy choices of street-level bureaucrats. These influences establish the major dimensions of street level policy and account for the degree of standardization that exists in public programs from place to place as well as in local programs. The second delimitation concerns the time period under study. The period under investigation more or less covers the entire history of the modern Swedish drug issue. I have studied user influence on drug policy all the way from narcotics emerging as a social problem in the mid 1960s through to the early 2000s. The reason for this relatively long time span is that it has given me an opportunity to paint a more comprehensive picture of user influence on public drug policy from a perspective of social change. The user influence discussion demands, apart from a clarification of what is meant by ‘drug policy’, a discussion of the term ‘user influence’. In this context I would like to make a distinction firstly between substantial influence and secondly processual influence. Substantial influence is the question of the contents of the policy, i.e. the degree to which a drug policy has managed to produce results that are in the users’ interest, while processual influence concerns the forms for the decision-making or, put another way, the degree and the way in which users have been allowed to participate in and influence the decision-making process. These terms will be discussed in more detail later. I will begin by discussing the processual influence of Swedish drug users on the public drug policy, and then move on to their substantial influence. The essay concludes with an integrated analysis of user influence, where I also discuss a couple of interesting points of principle about the results. 130 Processual Influence In processual terms user influence is also a question of the degree and the way in which users or representatives of user and client organizations are allowed to participate and influence the decision-making process. For the purposes of this study, I have regarded as such organizations that either organize drug users or explicitly claim to represent a user interest. In this study, the former type is represented by Svenska Brukarföreningen (The Swedish Users Union), and in the latter group, Riksförbundet för hjälp åt läkemedelsmissbrukare (RFHL, National Association for Aid to People Addictive to Drugs and Pharmaceuticals) stand out in particular, but here we also find some of the associations in the client movement that was founded in the 1960s and 1970s – such as Riksförbundet för kriminalvårdens humanisering (KRUM, The National Association for Humanizing the Treatment of Offenders) and Riksförbundet för social och mental hälsa (RSMH, National Association for Social and Mental Health).63 Henceforth, I will use the term ‘user organizations’, even when discussing organizations which more accurately should be termed client organizations. It should be noted that I have disregarded the self-help movement founded in the 1980s, in this context mainly represented by Anonyma Narkomaner (NA, Narcotics Anonymous). The reason is that NA have chosen not to participate in the drug policy debate and deliberately avoided taking a stance on drug-related issues such as criminality, legality, prostitution and harm reduction. Let me first of all point out that it is hardly reasonable to expect individual users to be able to influence the decision-making on public (i.e. within the framework of what I above termed the fourth sphere) drug policy. The most important decisions at that level are first and foremost taken by Riksdagen (the Parliament) and the government, and secondly within key government departments and agencies. Drug users are often socially marginalized with a weak position in society. In general, these people have neither the time, the interest nor the energy 63 RFHL, the most prominent organization, was founded in 1965 in reaction to the increased influence of the police and the judicial system on drug policy. The point of the RFHL message was that rather than persecuting them, drug users should be offered treatment. RFHL quickly became an important voice in the drug policy debate, and in the 1970s the association turned into the most influential of the so called ‘Rassociations’ (R as in Riksförbund, National Assocation), a number of client organizations working to provide support for and influencing public opinion in favor of drug addicts, alcoholics, mentally ill and criminals. The guiding principle for the Rassocations was that also the people subjected to the social policy should have their say. Consequently, in the 1970s the R-associations played a relatively important role for the development of treatment element in social policy (see also Leili Laanemet’s article in this publication). 131 to try to influence public policy-making, regardless of the impact such decisions may have on their own situation. It is therefore reasonable to assume that the processual influence of individual drug users will predominantly take place within the framework of the first two spheres – the individual and program spheres – for instance in their interaction with social workers, treatment clinic staff and the forces of law and order. However, individual participation is not strictly speaking a hard and fast requirement in order for us to be able to talk about processual influence. In Sweden, public inquiries, i.e. commissions appointed by the government, have long been an important and characteristic element in the consideration of issues decided by the authorities (Zetterberg 1990). Nearly all important reforms in society tend to be preceded by public inquiries (ibid.). Within the public inquiry framework various types of organizations are often given the opportunity to give their views on current political issues. The result of the inquires is generally presented in the form of one or more commission reports, which are then referred for comment. This means that a number of referral bodies – government agencies, organizations, sometimes also individuals – are given the opportunity to voice their opinion on the proposals of the commission. The public inquiry framework fill three important objectives in the Swedish political system: as a drafting body for the government (and sometimes also for political parties or other organizations); as a public arena for cooperation and confrontation between various interest groups in society; and finally, as an important conduit for collating and producing knowledge (Zetterberg 1990). The Swedish drug policy has been subject to comprehensive public inquiries several times. In so far as users and user organizations have been given the opportunity to participate in the decision-making process on public drug policy, it should be possible to trace this influence in the commission reports. A scrutiny of the more important drug policy inquiries should therefore serve as an indicator of the extent to which users and user organizations have been allowed to exert a processual influence over the fourth (the governmental) sphere of drug policy. The processual influence takes several forms within the Swedish public inquiry framework: Firstly, the processual influence of users may be an explicit purpose of the inquiry and will then normally be reflected already in the remit of the inquiry. Secondly, processual influence may be exerted by including representatives of user organizations on the panel of the inquiry, either as members of the commission, as secretaries, specialists or experts linked to the inquiry, or as members in one of the reference groups that are often connected to the inquiries. Thirdly, processual influence may also be exerted during the work of the inquiry, while the commission panel consults users or representatives of user organizations. User influence may, fourthly, take place during the 132 consultation process when users or user organizations are given an opportunity to voice their opinion of the commission report. Finally, a user perspective may be included in the commission report, regardless of whether users or user organizations have participated in the inquiry in any other way. For a user perspective to be considered to be present, I have put down as a criterion that drug users should figure as a subject in the text in the sense that their views, opinions or (subjectively experienced) interests and living conditions are explicitly discussed in the report. In those cases I have chosen to see the presence of the user perspective as an indication of a certain amount of indirect processual influence, regardless of whether any real involvement occurred or not. The Material The main body of material of my study of the processual influence comes from the three major drug policy inquiries that have been conducted in Sweden. Narkomanvårdskommittén (The Committee for the Treatment of Drug Addiction), the first public drug inquiry, was conducted 1966–1969. This inquiry was launched as a result of the mobilization that had taken place in the drug policy debate in the early 1960s. In 1967 two reports were published, SOU 1967:25 and SOU 1967:41, that were to gain great importance. Based on the proposals made by the commission in those reports, the Parliament opted for a drug policy which saw the judicial system tightening its grip on issues of drug use, while at the same time placing much of the responsibility for preventive measures and treatment in the hands of the social services. In 1969, another two reports were published, SOU 1969:52 and SOU 1969:53. All four reports of the commission is included in this study. 1982 års Narkotikakommission (The 1982 Drugs Commission) operated between 1981 and 1984. This inquiry was launched as a result of an increased consensus among the political parties for the need of a stricter public drug policy. The remit of the commission was to outline the basis for a coordinated and intensified war on drugs, with a particular focus on control policy measures. Issues regarding the treatment of drug addiction were not part of the remit, however. The main report of the commission, SOU 1984:13 is included in this study. 1998 års Narkotikakommission (The 1998 Drugs Commission) operated during the period 1998–2001. This inquiry was motivated by a desire for a comprehensive review of the Swedish public drug policy. The directives stressed that the overarching objective for the Swedish drug policy – the vision of the so called drug-free society – should remain in place. The main report of the inquiry, SOU 2000:126 have been studied for this article. 133 The above-mentioned inquiries all had a broad remit in order to allow a comprehensive view on the development of Swedish drug policy. Apart from this material, I also include commission reports concerning two central user issues, namely the issues of compulsory vs non-compulsory treatment of drug addiction and the criminalization of personal drug use.64 In 1980–97, Socialberedningen (The Social Commission) conducted an inquiry into the issue of compulsory treatment.65 Only one of the Social Commission’s many publications, namely the first commission report, SOU 1981:7 is included here. This report formed the basis for the LVM Act (Lagen om vård av missbrukare i vissa fall, The Treatment of Addicts in Specific Cases Act), which came into force in 1982. The Social Commission’s main report, SOU 1987:22 – which led to the LVM Act being revised and reinforced – have not been included in the study. The issue of criminalization of personal use entered the agenda in the mid 1970s and the debate intensified considerably towards the end of that decade. In the early 1980s the issue was taken up by the Drugs Commission, but the legislation was left unchanged at this point. The main reason for this was that the Social Democrats took a sceptical view of criminalization. Towards the mid 1980s, however, the party’s stance on this issued started to change, and in 1986 time was considered ripe for a criminalization. The issue was investigated internally at the Department of Justice, and in 1988 the Parliament passed a law on criminalization. Some years later the issue was once again the subject of an intradepartmental inquiry, leading to an increased penalty, from a fine to a fine or a custodial sentence up to six months. The two memoranda from the Department of Justice, Ds Ju 1986:8 and Ds 1992:19 are included in this study. Results The following table lists the results of the review on the evidence on processual influence of drug users in the five inquiries studied: 64 65 See the section on substantial influence for a more detailed discussion of the term ‘central user issues’. Please note that the work of the Social Commission did not exclusively concern drug policy issues, but also compulsory treatment of alcoholics. 134 Table 1. Overview of processual influence. The Committee for the Treatment of Drug Addiction (Narkomanvårdskommittén) The Social Commission’s Treatment of Addicts in Specific Cases Act (LVM Lagen om vård av missbrukare i vissa fall) 1982 Drugs Commission (Narkotikakommissionen) Dep. of Justice Criminalization Memoranda 1998 Drugs Commission (Narkotikakommissionen) Remit Commission Panel Yes Work of Commission Yes Yes Yes Commission Report Consultation Process Yes Yes Yes Yes Yes As indicated by the above table, the processual influence mainly occurred during the consultation process and in the work of the commissions. As far as the consultation process is concerned, in each and everyone of the inquiries examined at least one user organization was given the opportunity to voice an opinion on the commission reports. At first glance this seem all good and very well, but there are certain factors making such a conclusion less clear-cut. First of all the Swedish referral system contains a fairly substantial element of routinism and ritualism; commission reports are rather sent to too many than to too few consultation bodies. The fact that an organization or a government agency has been asked to supply a comment on a commission report does not mean that the authorities will listen to their opinions on the matter, or even had the intention to do so in the first place. Secondly, in the three latest inquiries covered by the study only one organization claiming to represent drug users – RFHL – was allowed to comment. This is rather paltry, and considering the fact that RFHL ever since its foundation in 1965 has been a very important organization in the debate about Swedish drug policy it would have raised more eyebrows if it had been passed over. 135 As for processual influence during the work of the commissions, this is in evidence in the three major drug policy inquiries. In each case, RFHL was the only user-oriented organization asked to participate, despite the fact that in general a great many organizations and government agencies were invited to these consultation rounds. Also in these instances, considering RFHL’s towering presence in the debate, it would have been more remarkable if the organization had not been invited to take part. The fact that the Social Commission did not ask RFHL to give their view can, in all likelihood, be explained by that they were working under intense time pressure. Another contributing factor was probably the fact that the government more or less had made up its mind at that stage and that they already knew what RFHL thought of compulsory treatment. This latter factor was even more strongly manifested by the memoranda on criminalization from the Department of Justice; they were ‘tailor-made’ and took the form of technically inclined judicial inquiries. Being a member of the inquiry commission – or one of its working parties – is arguably the most effective form of processual influence. User organizations definitely exerted this type of influence in one case, the Committee for the Treatment of Drug Addiction. Moreover, in this instance the influence probably was relatively great as representatives of RFHL filled several posts in the allimportant secretariat. But perhaps this was nothing to be surprised at; at the time, RFHL was by far the largest and most well organized NGO on the drug policy arena. Considering that RFHL also later has played an important role in this area it is all the more surprising that the association was never offered a regular place on any of the subsequent inquiries reviewed in this study. This may at least partly be explained by the fact that in recent decades we have seen a general shift in the inquiry system towards a more professional, but also downsized make-up of committees as well as secretariats. In two areas of influence – the remit of the inquiry and a user perspective in the commission report – there was no processual user influence at all. As for the remit this is not so surprising; inquiry remits tend to be very general in character, rarely spelling out which interest groups should be given a hearing. However, the lack of a user perspective in all commission reports investigated is all the more remarkable. The Committee for the Treatment of Drug Addiction was the only inquiry where at least an attempt was made at approaching the drug users. The reports of the commissions detail a number of investigations into more objective factors – such as gender, criminal record, substance preferences and usage patterns – but they contain no information about the users ‘as human beings’. In fact, the objectification of the drug user is well nigh universal in all reports that I have studied. When drug users are mentioned it is as subjects for measures or statistical categories, not as human beings with experiences, opinions and feelings. Even in cases where one would expect to be able to trace a user perspective – when it comes to care and treatment – there is scant little evidence 136 of it. The latest major commission report, “Vägvalet” (“At the Crossroads”), the final report of the 1998 Drugs Commission, discusses the importance of “ensuring that the analysis is based on the client’s individual needs and current situation” (p. 167) when choosing treatment methods. It is clear, however, that the term ‘needs’ should be interpreted as an objective client ‘condition’, not something that has got anything to do with the client’s own wishes or expectations. Thus the only conclusion that can reasonably be drawn from the empirical material is that users and user organizations have had a very limited processual influence over public drug policy, at least since the early 1980s (given obviously that a study of processual user influence on major public inquiries is a good indicator of processual influence in general). The only inquiry that stand out in the sense that the RFHL client organization actually exerted a real processual influence, is the Committee for the Treatment of Drug Addiction’s inquiry 1966– 1969. However, we have already touched on a possible explanation for this, i.e. that RFHL at the time basically was the only NGO extant in the field of drug policy. The fact that the users’ processual influence over public drug policy has been limited or non-existent does not necessarily mean, however, that the same can be said of their substantial influence as well. The question of the extent of the substantial influence of users and user organizations over policy can only be answered by empirical studies, which leads us on to our next section. Substantial Influence Initially I mentioned that the users’ substantial influence over public drug policy centers on their opportunity to influence the actual contents of the policy. Another way of putting this is that substantial influence is a question of the degree to which a drug policy produces results that reflect the interests of the users. Before we go on we need to clarify what those user interests are. In this context there are various conceivable interpretations of the concept of interest. First of all, a basic distinction can be made between objective and subjective interests. The term ‘objective interests’ is often used to indicate the needs and rights of individuals, or, the demands and wishes if they would have been more knowledgeable (see e.g. Lukes 1974). One obvious criticism of this perspective is that it is difficult to tell who should decide what those objective interests are (Benton 1981). Furthermore, an objective analysis of user interests would also lead to the conclusion that, first and foremost, it is in the interest of the user to stop taking drugs – something which is not necessarily what the users are 137 looking to do, and something that also goes against the grain of the whole idea of users being worth listening to in the first place. The subjective interests, in contrast, are governed by the actual demands or wishes of the individual, either now or in the future. The subjective interests are, in other words, self-experienced. There are several conceivable methodological strategies for clarifying the subjective interests of Swedish drug users. Firstly, one can investigate articulated user interests. However, drug users are seldom heard in the general debate in Sweden, which makes it hard to find examples of such explicit interests. In those cases where individual users do take part in the debate the problem crops up of whether they can be regarded as representative for the wider user collective. Secondly, we have organized user interests. Today there are branches of the Swedish Users Union in Stockholm and other towns and cities, as well as other associations working to organize drug users (at least as part of their activities). In a longer historical perspective, however, few organizations have aimed at mobilizing the users. Client organizations, such as RFHL and KRUM, can in certain respects be said to have represented the user collective, as discussed above.66 Thirdly, interests can be derived from international comparisons. This is, in my view, the most promising way of studying user influence. The point is that the interests of Swedish drug users can reasonably be expected to be similar or identical to those of organized users in other countries. The interests of Swedish users can thus be postulated by looking at user issues pursued by user organizations in other countries. I have primarily adopted the latter strategy for my analysis, complementing it with the second strategy. I started, in other words, by collating a catalog of issues and standpoints pursued by user organizations in a number of countries. Then I compared this catalog with the issues and standpoints pursued by Swedish user organizations. In the Swedish context I have mainly focused on the client organization RFHL and on the Swedish Users Union. In RFHL’s case this is due to the fact that this is the largest and, at least in a historical perspective, by far the most influential user oriented organization. In the second case the reason is that the Swedish Users Union was the first Swedish organization to explicitly work in the interest of active users. Based on this comparison I subsequently studied the development of Swedish drug policy – from the end of the 1960s to the early 2000s – from a user perspective. In this task I have primarily used secondary sources, such as sociological, criminological and political science literature on the Swedish drug issue and Swedish drug policy. User Issues and Standpoints 66 See the articles by Jessica Palm and Leili Laanemets in this publication for a more detailed discussion of the backgrounds of and ideologies behind i.e. SBF and RFHL. 138 The catalog below was compiled by searching the Internet for issues pursued by user organizations in nine countries: Australia, Canada, Denmark, Germany, Great Britain, The Netherlands, Norway, Sweden and USA.67 Some of the organizations are relatively young (such as the user associations in Norway and Sweden), but many of the others are of relatively long standing. The unanimity as regards issues and standpoints pursued by the various organizations have been comparatively comprehensive, both in terms of time and geography. In this fashion I was able to identify five issue complexes, commonly found on the agenda of many of these organizations. They will be discussed separately in the forthcoming sections: • One complex of issues concerns a user’s rights and position in society. All user organizations in the study are working to make visible drug users and their social plight. In connection with this the importance of creating new social networks for the users – often within the framework of the user organization – is often stressed, as well as a widening the interface and access to the social security network. • Another issue complex concerns drug addiction treatment and access to it. In this context, user organizations are working to ensure that places at detoxification and treatment clinics are available on demand, i.e. when the user him- or herself is motivated or ready to seek treatment. User organizations are also working to provide a broad spectrum of treatment options, and to ensure that the treatment is individually adapted and planned in consultation with the client. User organizations are by and large opposed to compulsory treatment • A third set of issues involves the degree of repression in the control system. In general, user organizations are of the opinion that the control system should be as humane as possible and that the criminalization of users should be avoided as far as possible. The specific issues vary from country to country, but concrete examples are opposition to criminalization of possession and personal use of classified substances, lowering various penalties for drug-related crime and issues regarding the incarceration systems. In some countries user organizations are active on whether cannabis should be legalized or not. 67 In total I reviewed eleven organizations: AIVL – The Australian Injecting and Illicit Drug Users’ League (Australia), UNDUN – Unified Networkers of Drug Users Nationally (Canada), VANDU – Vancouver Area Network of Drug Users (Canada), DDUU – Brugerforeningen (Denmark), Jes-Bielefeld e.V. (Germany), Junkie Bund (Germany), The Alliance (Great Britain), MDHG – Belangenvereniging voor Druggebruikers (The Netherlands), BrukerForeningen i Tønsberg (Norway), Svenska Brukarföreningen (Sweden), and Springfield Users’ Council (USA). The URLs to the home pages for these organizations can be found in the list of references. 139 • A fourth issue complex concerns harm reduction measures. All user organizations in my study are pressing one or more issues regarding harm reduction measures. Common issues are access to methadone maintenance treatment, needle exchange programs and access to public spaces where the users can congregate without fear of harassment. In connection with the latter issue, demands are sometimes heard for injection rooms or similar facilities. Less common issues are things like regular prescription of heroin. • The fifth set of issues, although closely connected to harm reduction, concerns health care and information. These issues are often about what help users can get to protect themselves against infectious diseases and overdosing. In this context demands are often voiced for public-service involvement, partly by widening the access to health care for users (for instance by extending health care resources to places where users can be found), and partly by financing or organizing information campaigns, the distribution of condoms and the like. The Rights and Position of Users in Swedish Society The issue of users’ rights and their position in society is on the agenda, directly or indirectly, of all user organizations in the international sample. However, the issue of rights is often connected to more drug policy-specific questions, such as the aim of control policies and access to treatment. In this section I will therefore limit myself to some general reflections on drug users as members of society. On a purely formal level there is no question of drug users not enjoying the same status as other citizens in Swedish society. With one notable exception there are no formal obstacles for users who want to exercise their civic rights. The exception is, of course, the fact that the use of classified substances has been illegal in Sweden since 1988, something which in practice means that the users themselves are criminalized to a certain extent. However, I will return to this issue in more detail when discussing the control system. Although there is no formal discrimination of drug users in Swedish society, it can be reasonably assumed that in practice a substantial amount of negative discrimination occurs in their contacts with social welfare institutions. For instance, known drug users tend to attract inordinate attention from the police, something which can be seen as a form of negative profiling (cf ‘racial profiling’). Furthermore, in many instances access to health care is in all likelihood more restricted for drug users, even when allowances are made for deficiencies caused by their own actions. 140 It is a well established fact that the public sector cutbacks of the 1990s hit many vulnerable groups in the Swedish society especially hard. There is every reason to believe that this was a major contributing factor behind the comparatively large increase in heavy drug use that took place during that decade (Olsson 2001; CAN 2004). Whether there is a connection between this increase and the development of public drug policy during the same period is, however, not easy to say. As Olsson (2001, 94) notes, drug policy has only a limited impact in the grander scheme of things when it comes to the drug situation. More important are things like poverty, youth unemployment, marginalization, global trends in youth culture and a number of other social conditions. The Swedish Drug Addiction Treatment Framework from a User Perspective Drug addiction treatment is a central issue complex for all user organizations in my study. These issues center around the extent and planning of treatment as well as access to it, but also the issue of compulsory treatment looms large. In the following section I discuss the development of Swedish drug addiction treatment from a user perspective, focusing specifically on the role of compulsion. However, I leave the important question of methadon for the section on harm reduction measures. The reason for this is that in my global user organization sample, methadone is usually discussed in the context of harm reduction. The Development of Drug Addiction Treatment68 Around 1970 the treatment of drug addiction was increasingly transferred away from psychiatric hospitals. This led to a distinctive drug addiction treatment framework, independent of the health care system, being established in Sweden. A comprehensive treatment apparatus consisting of treatment clinics, health centers and advice bureaus sprang up (Hilte 1990). The first half of the 1970s saw a steady increase in the resources earmarked for drug addiction treatment, while at the same time there was a shift from one system – psychiatric care – to a loosely organized and unwieldy treatment framework based on social authorities (Bergmark 1998). This development relaxed the grip of the medical profession over drug addiction treatment, allowing social workers, psychologists and other behavioural scientists to gain ground. The client organization RFHL took a very active part in this development by, amongst other things, initiating and running several new therapeutic communities. 68 See also Leili Laanemets’ article about the restructuring of the Swedish addiction treatment framework in this publication. 141 This expansion continued apace during the second half of the 1970s, at the same time as the so called Hassela principles attracted ever more attention in Sweden. The first Hassela community was founded in 1969. The idea behind Hassela was to treat young addicts aged between 15 and 20 years of age. The Hassela principles emphasize education and fostering social responsibility (Hilte 1990). The method is relatively authoritarian in character, often with elements of compulsion, something which RFHL took a very sceptical view of. The second half of the 1980s saw the expansion of the drug addiction treatment framework gaining new momentum as the authorities feared an HIV epidemic among the drug users. The government’s action plan for fighting Aids (prop. 1987/88:79) stressed the importance of tracking down drug users and offering them drug-free treatment. In practice this meant that Socialstyrelsen (The National Board of Health and Welfare), among others, during the latter part of 1980s supported the creation of a specialized open treatment framework at local and regional level. Institutional care also expanded during the same period (Socialstyrelsen 1993; Bergmark 1998). In the period 1986–1991 the total number of treatment places increased by some 50 per cent, with outpatient treatment taking the lion’s share of this increase (Socialstyrelsen 1999). The economic downturn in the 1990s resulted in a marked worsening of the financial situation for local and county councils. According to some analysts this also led to a drastic decline in the treatment of drug addicts. Judging from the statistical data presented by the National Board of Health and Welfare to Kommittén för välfärdsbokslut över 1990-talet (The Welfare Accounts Committee for the 1990s) in 1999, however, no general reduction in the resources set aside for drug addiction treatment seems to have taken place, although many individual local councils did cut back spending (Socialstyrelsen 1999). The institutional framework for drug addiction treatment has declined noticeably, but this has to some extent been offset by an increased access to outpatient treatment (SOU 2000:126). All in all, it seems that the resources for treatment of drug addiction were roughly the same in the early 2000s as they were in the early 1990s. But in light of the increase in the number of addicts during the 1990s the picture becomes more gloomy. Most available indicators show a steady increase in substance abuse throughout the 1990s. The number of heavy users, for instance, increased by nearly 40 per cent between 1992 and 1998 – from 19,000 to 26,000 people (CAN 2004). Such figures lead us to the obvious conclusion that the drug addiction treatment framework, which quantitatively speaking saw a positive development until the end of the 1980s, has undergone a significant decline in the last fifteen years.69 69 The quality of the treatment of drug addiction is, of course, also an important factor. A knowledge survey from SBU (SBU 2001) indicates that in many cases the quality of Swedish drug addiction treatment can be called into question. The lack of scientifically 142 Compulsory Treatment The issue of compulsory treatment turned into one of the major conflicts in the drug debate of the 1970s. On one side in this conflict stood the client movement, championed by RFHL and supported by the National Board of Health and Welfare for one. RFHL pressed for a treatment structure based on consent and were categorically opposed to the idea of compulsory treatment. The influence of RFHL had been a contributing factor when the Parliament in 1972 decided that voluntariness should be the guiding principle in the treatment of drug addiction. Across the divide stood some of the real drug policy hardliners, such as Föräldraföreningen mot narkotika (Parents Against Drugs) and the Hassela movement. Hassela’s treatment clinics had come to be regarded as highly successful towards the end of the 1970s, a contributing factor behind the more positive attitudes towards a compulsory element in addiction treatment. An important consequence was that RFHL gradually lost its role as the leading NGO in the drug policy field. In 1981, the LVM Act concerning treatment of addicts in specific cases was passed which widened the scope for compulsory treatment. The object of the LVM Act was first and foremost to encourage patients to seek voluntary treatment. The treatment period was initially restricted to two times two months. In 1989, many aspects of this act were reinforced, one of them being an increase of the maximum treatment period to six months. Of the organizations opposed to this, RFHL were one of the most negative. Their stance was based on research showing that long periods of compulsory treatment had no effect and could even be detrimental. The cutbacks during the 1990s led to a steady decrease in the number of LVM cases throughout almost the entire decade. Nevertheless, in 2000 over 1,100 people in Sweden were still to be found in compulsory treatment, most of them for alcohol addiction. At the same time, compulsory treatment was virtually unheard of in Denmark, Finland and Norway (Stenius 2001). Despite a reduction in the number of cases of compulsory treatment, the demands for budgetary restraints may have forced the local councils to set aside part of their acceptable reviews has been a constant problem; generally speaking, only the medication-based maintenance therapies for opiate addiction have been subjected to rigorous appraisals (see Johnson 2005). 143 institutional care resources for these LVM cases, rather than for those who had decided to seek voluntary treatment for their addiction (Ekendahl 2001, 29). The negative attitude of the Swedish client movement towards the compulsory treatment act has been moderated slightly in later years. RFHL have for instance suggested a shorter compulsory treatment option where the period of treatment is limited to a maximum of one month (Svensson 2003). It should also be pointed out that surveys and other scientific studies have shown that many of the users who have been committed under the compulsory treatment act have not rejected it out of hand. A great number of the LVM patients in Bengt Svensson’s (2003) study of the compulsory treatment system, for instance, took a mainly positive view of their committal and many of the others saw it as containing both positive and negative aspects. The Swedish Control System from a User Perspective As previously mentioned, user organizations in general are of the opinion that the drug control system should be as humane as possible and that a far-reaching criminalization of users should be avoided. In Sweden, ever since its foundation the client organization RFHL have voiced similar opinions, and the same can be said for other user oriented organizations, such as KRUM. So how to judge the development of the Swedish control system from a user perspective? In the Swedish drug policy debate it is often said that Sweden in the ten years from 1965 to 1975 had an unusually liberal drug policy in a global perspective. However, this is hardly consistent with reality. It is rather the case, as Börje Olsson notes, that Sweden ever since the end of the 1960s has had a “massive drug policy with strongly repressive elements alongside major – from an international point of view – information campaigns and preventive measures as well as treatment and rehabilitation on a broad scale” (Olsson 1994, 172, original italics). There is no denying that in terms of control policy we have seen a reinforcement on several levels since the 1970s, but this development was initiated as early as 1968, and ever since then legislation has gradually become more repressive (van Solinge 1997; Tham 1995; Tham 1998). The control policy report of the Committee for the Treatment of Drug Addiction in 1967 (SOU 1967:41) led to the Parliament adopting a specific drug penal code (1968:64) the following year. By drawing up a comprehensive piece of drug legislation the Parliament wanted to signal that society did not accept drugs and that drug abuse was taken seriously. At the same time, however, they wanted to make a distinction between sellers and distributors on the one hand and users on the other, the point being that the users as such should not be punished by the new law (Träskman 2003). 144 The first years of the 1970s saw a couple of increases in the penalties for serious drug crimes, but it was not until the second half of the decade that control policy issues started to dominate the drug debate in earnest. Drug abuse became an election issue in the run-up to the 1976 general election and after their victory, the right-wing government announced tougher measures against drugs. From an earlier situation where the efforts were mainly geared towards the drug trade, i.e. the supply side, control policy measures now increasingly took aim at the users themselves. Behind this change lay intense lobbying by drug policy hardliners. Since the users constitute the only irreplaceable link in the drugs chain that is the place to strike, the argument ran. In other words, the focus of the control policy shifted from the producers to the consumers (Tham 1998). Leif Lenke and Börje Olsson make the following analysis: By the end of the 1970s, it is reasonable to say that Swedish drug policy had shifted its profile. The focus had moved from international syndicates and the treatment of “drug victims” to a police-oriented strategy whose objective was to clear the streets of drug pushers. These were to be placed in compulsory treatment to stop this “contagious disease,” which is how drug use was portrayed to the public. (Lenke & Olsson 2002, 69) The early 1980s saw a further reinforcement of the penal code as well as a more rigorous application of it. But it did not stop there; the number of drug squad officers increased, as did the numbers sent to prison for drug-related crimes and the number of drug users in the prison population (Tham 2003). With these extra resources the police targeted drug dealers at the street level, and in only a few years the number of arrests doubled (Eriksson & Eriksson 1983; Tham 1998). This development continued apace when the Social Democrats returned to power in 1982; during their time in opposition they had moved ever closer to the drug policy of the right-wing parties. Although it is probably safe to say that drug abuse on the whole did not increase significantly in Sweden in the 1970s and 1980s, it was portrayed and seen as a growing problem (van Solinge 1997; Tham 1998; CAN 2004), leading to a form of control policy consensus in the second half of 1980s (Tham 1995). Characteristic of this consensus was the hard line being pursued at all levels (Träskman 2003). The most important example of this was the Parliament in 1988 with a large majority voting in favor of criminalizing personal use of classified substances. During 1970s there had been an overwhelming opposition to a criminalization, but in only a few year this resistance had virtually melted away. RFHL were one of the few voices who opposed the decision to criminalize possession. Five years later the maximum penalty for personal use was increased from a fine to a prison sentence of up to six months. The primary reason for this increase, 145 however, was not a particular wish to mete out prison sentences, but rather to ensure a strict and consistent penal code while at the same having the opportunity to use urine samples and blood tests in order to control whether drug use had occurred (impossible as long as the maximum penalty was a fine). The 1990s saw the control policy development level out; for example, there were no further penalty increases. However, the graph charting the number of drug squad officers continued its steep incline during the first half of the decade and leveled out only in the latter half of the 1990s. Likewise, the number of prison sentences for drug crime and the number of drug users in the prison population continued to increase (Tham 2003). Harm Reduction Measures in Sweden As already mentioned, all user organizations in my international review pursue one or more issues regarding harm reduction measures. In the Swedish context, harm reduction has been an extremely controversial issue ever since it entered the international debate in the 1980s. In Sweden the discussion has primarily centered around two types of measures, maintenance treatment and needle exchange programs.70 Maintenance Treatment in Sweden The methadone maintenance treatment (MMT) concept reached Sweden as early as 1966, but throughout the 1970s it was no more than a relatively small scale trial, although this was belied by its high political profile. A few years into the 1970s, the Uppsala-based MMT project became embroiled in an increasingly bitter political battle. The general opinion saw this as a risky and politically suspect form of treatment (Johnson 2005). Curiously enough, the resistance was led by RFHL, a client organization. In this case the organization took an unusual – not to say deviant – stance from a user perspective. The association’s standpoint can partly be explained by the negative experience of a previous trial with legal prescription of drugs in the 1960s (see Lenke & Olsson 1998). This trial had taken on great symbolic significance for RFHL, serving as a cautionary tale of what may happen when working with less ambitious goals than complete abstinence (Johnson 2005). 70 In an international perspective these measures tend to be classified as harm-reducing. However, in Sweden both maintenance treatment and needle exchange programs have always been tightly controlled programs with markedly social curative ambitions. One principally important difference that should be highlighted though is that needle exchange programs, as opposed to maintenance treatment, can not be regarded as a treatment or rehabilitation measure. 146 The resistance to MMT led to the National Board of Health and Welfare, the government agency in charge, not approving the treatment method until 1983. From then on this treatment form became a regular health care component, although confined to Uppsala. In the mid 1980s the previously hostile opinion of MMT started to abate. At the same time RFHL also gradually began changing their view on the issue, and today the association takes a more user-typical view of this treatment method. One strong contributing factor to this change was the fear of a major Aids epidemic in Sweden. In fact, the Aids issue constitutes a watershed in the Swedish methadone debate and can hardly be underestimated as the reason why MMT was finally accepted and subsequently started spreading throughout the country (Johnson 2005). In 1987 the National Board of Health and Welfare allowed new MMT programs to start, and the following year a second program was initiated in Stockholm. Another two were quickly initiated in Lund (1990) and Malmö (1992), and in March 2004 a fifth MMT program was launched in Gothenburg. The general view among the foreign user organizations in my review is that – as previously mentioned – MMT and other types of maintenance treatment should be made available for those who wish to avail themselves of it. Ever since the early 1970s, however, Sweden has had a centrally decided cap on the number of patients who are simultaneously receiving MMT. In absolute numbers this ceiling has gradually been increased, from 100 (1972) to 150 (1983) and so on, up to 300 (1988) and 450 (1990). The 1990s saw a continuation of this development, and in 2004 the ceiling was raised from 850 to 1,200 patients. In relative terms this expansion has been more modest, however. According to estimates of drug abuse, in 1979 just under 5 per cent of the opiate users were given a place on this treatment program. In 1992 this figure was 9 per cent, and in 1998 it had risen to just under 11 per cent (Johnson 2005). The expansion has, in other words, been fairly slow, and in an international perspective this is a fairly low percentage of the opiate users. From a user perspective, however, the picture is not quite as gloomy if we also count the users receiving buprenorphine (Subutex). This drug was approved by Läkemedelsverket (The Swedish Medical Products Agency) in 1999, and has become widespread, particularly at health centers. According to estimates by the National Board of Health and Welfare, some 1,300 people received Subutex in Sweden in 2003. On 1 January 2005 new guidelines from the National Board of Health and Welfare came into force regarding both methadone and Subutex (SOSFS 2004:8 M). The point of the new guidelines is to put methadone and Subutex on an equal footing in a regulatory sense. The regulations for Subutex prescription has consequently become clearer and stricter, while the MMT ceiling has finally 147 been lifted – changes long overdue from a user perspective. It still remains to be seen, however, what consequences the new guidelines will have in terms of access to these treatment programs. Finally, it is worth noting that the Swedish MMT program has been the focal point for much of the user mobilization that has taken place in Sweden in recent years. The Swedish Users Union, for instance, was founded as a pressure group for methadone patients. Swedish Needle Exchange Programs One of the main arguments against MMT in the 1970s and 1980s was that it ran the risk of sending a ‘conflicting message’ to the users about society’s views on drugs. The same argument has been the most important one for the opponents of needle exchange programs ever since the start in 1986–87. These programs, based in Malmö and Lund, came about as an emergency measure in order to stop the HIV virus from spreading among the users. Ever since the start the programs have been tolerated, but only just, and are seen as limited trials. They have enjoyed strong local support throughout, but in the national debate the negative views have dominated. Since the early 1990s RFHL have been one of the supporters of needle exchanges, although the internal decision to speak out in favor of it was not unanimous. For a long time the future of these programs were in doubt, but in recent times public opinion has started to change also on the needle exchange issue. At the time of writing the Swedish Parliament has just decided to make the existing needle exchange programs permanent and integrate them in the regular treatment framework for infectious diseases, and to allow new programs. However, according to this decision any new programs should be subject to permission from the National Board of Health and Welfare, and in the evaluation process access to detoxification and other areas of the addiction treatment be taken into account.71 Health Care and Information Issues – Swedish Experiences from a User Perspective 71 This requirement – which must be seen as a way of allaying the fears of opponents of needle exchanges that society would prioritize cheaper harm reduction measures at the expense of more resource intensive forms of drug addiction treatment – has been criticized by the users. In their comment on a preparatory report, RFHL expressed the opinion that the proposal runs the risk of giving users in local councils with poorly developed treatment facilities a double whammy by denying them access both to regular treatment and needle exchange programs. 148 When it comes to treatment and information issues, since the 1980s public drug policy measures in Sweden have almost exclusively centered around the infectious diseases HIV and, to a lesser extent, hepatitis. In the mid 1980s the government agency Aidsdelegationen (The Aids Delegation) instigated a campaign whereby social workers were encouraged to seek out users and inform them about the risks of HIV/Aids and induce them to seek treatment (Johnson 2005). The primary responsibility for this practice, however, rested – here, as in later campaigns of this type – with local and county councils. When it was clear that the risk for a widespread Aids epidemic among Swedish drug users had been fended off, the 1990s saw a reduction in the resources alloted for information campaigns. In Sweden the debate about access to health care often has centered on the fact that many users have an insufficient interface to civic society. The debate often resurfaces in connection with the needle exchange programs in Malmö and Lund in the south of Sweden, with the supporters pointing to these programs as a unique resource for upholding the contacts with the users. They have given users in need better access to other health care institutions as well as the social services. The RFHL position on the needle exchanges for a long time has been wholly positive, and the same can be said for the Swedish Users Union since its foundation in 2002. The view of the authorities on these programs was discussed in the previous section. Prominent issues in the international user debate, such as the opportunities for spreading information on safer drug use and how users can protect themselves against overdoses and the like, are filed under ‘harm reduction measures’ in Sweden and thus actively discouraged. Some attempts at moving such issues onto the agenda have been made by users, but to hardly any avail. Substantial Influence – Concluding Remarks In conclusion it must be said that the Swedish drug policy in the 1970s was relatively user oriented. A major expansion of the drug addiction framework had been initiated, the control policy was restrained in relation to the users and on both the compulsory treatment issue and the methadone issue the official line coincided with the opinion of the users, at least as manifested by the client organization RFHL. The RFHL view on the methadone issue, however, was not representative or typical of users in an international perspective. From the users’ point of view, the positive development in drug addiction treatment – except for the issue of compulsory treatment – continued in the 1980s. The expansion continued throughout almost the entire decade, from 1985 onwards fueled by the great fear of an Aids epidemic among the users. The Aids issue meant that, on the whole, traditional user interests were accommodated to an 149 increasing degree, although for reasons other than specific user interests. The general view of methadone maintenance treatment (MMT) turned more positive and two needle exchange trials were launched in southern Sweden. Towards the end of the 1980s RFHL too began changing their position on these issues, and in the 1990s they totally embraced the conventional user view. The control policy, however, turned ever less user friendly. On the whole the repressive development from around 1980 until the criminalization acts of 1988 and 1993 can only be seen as devastating from the users’ point of view. In an international perspective, however, the Swedish control policy can not be considered out and out extreme, even though many European countries have a more liberal legislation (Lenke & Olsson 2002). The 1990s saw a further reinforcement of the control policy measures, albeit at a more modest pace than in the period from 1980 to 1993. The greatest change during this period instead took place in the treatment sector, where the economic hardships caused a drastic decline. Treatment resources remained at the same level or decreased slightly, while drug use increased dramatically. Even without adopting a pronounced user perspective this development can not be considered anything but sad. It should be pointed out though that in recent years at least one positive sign can be discerned: access to methadone- and Subutex-based maintenance treatment programs have increased slightly while the rules and regulations surrounding these programs have become more flexible. If we turn to the needle exchange issue, the future has brightened considerably here as well. Good news for the users, but whether these positive developments prove to be the turning of tide or just a passing whim remains to be seen, however. User Influence on Swedish Drug Policy In this study I have investigated the influence of Swedish drug users over public drug policy in the period 1965–2004. I have been able to establish that their influence has been extremely limited in recent decades, and, as far as can be judged, this influence seems to have diminished over time. The picture of the development of user influence is similar both in terms of processual influence (the degree and the way in which users have been allowed to participate and influence drug policy making), and in terms of substantial influence (the degree to which the drug policy has managed to produce results that are in the users own interests). In order to study the processual influence I have reviewed the influence users exerted over public drug policy inquiries. Assuming that participation in such 150 inquiries is an acceptable measure of processual influence, the only possible conclusion is that the users, since the inquiry by the Committee for the Treatment of Drug Addiction, have had a very limited processual influence over drug policy. What influence can be traced has taken the form of participation in the consultation and referral process, two forms of influence that often take on a more or less ritual character without guaranteeing any real influence. In terms of substance the public drug policy was relatively user oriented in the 1970s. The control policy focused on the drug trade, and kept a low profile in connection with individual users. A major expansion of the drug addiction treatment framework had been initiated, and on important user issues – such as compulsory treatment, criminalization of personal use and methadone maintenance treatment (MMT) – the drug policy on the whole coincided with the general user opinion, at least as expressed by RFHL. During the 1980s the policy gradually turned less user oriented as the control policy was reinforced, the powers to order compulsory treatment were increased and personal drug use was criminalized. In the 1990s public cutbacks hit the treatment framework, while the number of users rose rapidly. This leads us to conclude that the public drug policy in Sweden has become less user oriented over time also in terms of substance. In light of this, the mobilization of drug users in an organization such as the Swedish Users Union does not appear to be a result of the authorities requesting their participation, but rather a symptom of the users feeling forgotten or neglected. Causal connections are not directly observable in the social sciences, and in any event it is not possible from a study like this to draw any definite conclusions as to the connection between processual and substantial influence. However, a reasonable hypothesis appears to be that a high degree of processual influence tends to lead to greater substantial influence. This study does not provide any reasons to reject this hypothesis. Consequently it can not be ruled out that the relatively high degree of user orientation in the public drug policy at the end of the 1960s and in the first half of 1970s actually was a result of the influence exerted by RFHL within the important inquiry by the Committee for the Treatment of Drug Addiction and in other ways. The right of drug users to exert an influence over public drug policy has never been formally expressed in Sweden. From time to time, especially in the 1970s, RFHL have been regarded as an important party to the discussions worth listening to, but only in the capacity of client organization, not as an organization for drug users. Correspondingly, the fact that SBF nowadays is an official referral body should be interpreted as recognition of the organization functioning as a patient organization for maintenance treatment patients. In conclusion, the result of this study must be regarded as pretty dismal for anyone arguing for a more user oriented drug policy. Nonetheless, a small degree 151 of user influence over public drug policy does not necessarily mean that the user influence has been limited in other spheres of influence. It does not seem unreasonable to think that individual users could exert a certain amount of influence over the day-to-day runnings in the drug addiction treatment framework, for instance at local council level. That, however, will have to be the subject for another study! Translation: Ola Winfridsson References Benton, Ted (1981): Objective Interests and the Sociology of Power. Sociology, 15 (2): 161–184. Bergmark, Anders (1998): Expansion and Implosion – The Story of Drug Treatment in Sweden. In: Klingemann, Harald & Hunt, Geoffrey (Ed.): Drug Treatment in an International Perspective. Thousands Oaks: Sage. Burns, Danny; Hambleton, Robin & Hoggett, Paul (1994): The Politics of Decentralisation. London: MacMillan. CAN (2004): Drogutvecklingen i Sverige – Rapport 2004 [The development of drug use in Sweden – Report 2004]. Stockholm: Swedish Council for Information on Alcohol and Other Drugs (CAN). Dahlberg, Magnus & Vedung, Evert (2001): Demokrati och brukarutvärdering [Democracy and user evaluation]. Lund: Studentlitteratur. Ds Ju 1986:8. Förslag till ändringar i narkotikastrafflagen (1968:64) [Proposed changes to the Drugs Offences Act]. Stockholm: Liber/Allmänna förlaget. Ds 1992:19. 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Tham, Henrik (1995): Drug Control as a National Project: The Case of Sweden.The Journal of Drug Issues, 25 (1): 113–128. 153 Tham, Henrik (1998): Swedish Drug Policy: A Successful Model? European Journal of Criminal Policy and Research, 6 (3): 395–414. Tham, Henrik (2003): Narkotikapolitiken och missbrukets utveckling [Drug policy and the development of drug abuse]. In: Tham, Henrik (Ed.): Forskare om narkotikapolitiken. Stockholm: Kriminologiska institutionen. Träskman, Per Ole (2003): Narkotikapolitik och brottskontroll [Drug policy and crime control]. In: Tham, Henrik (Ed.): Forskare om narkotikapolitiken. Stockholm: Kriminologiska institutionen. Zetterberg, Kent (1990): Det statliga kommittéväsendet [The public inquiry system]. In: Departementshistoriekommittén, Att styra riket [The departmental history committee, Governing the realm]. Stockholm: Allmänna förlaget. URLs to User Organizations: AVIL (Australia) http://www.aivl.org.au/default.asp Brugerforeningen (Denmark) http://www.brugerforeningen.dk/bfny.nsf Brukerforeningen Tønsberg (Norway) http://www.brukerforeningen.no/ Jes-Bielefeld e.V. (Germany) http://www.junkienetz.de/ Junkie Bund (Germany) http://www.junkiebund.de/index.htm MDHG (The Netherlands) http://www.mdhg.nl/ Springfield Users’ Council (USA) http://springfielduserscouncil.org/ Svenska Brukarföreningen (Sweden) http://www.brukarforeningen.com/ The Alliance (Great Britain) http://www.m-alliance.org.uk/ UNDUN (Canada) http://www.freewebs.com/undun/index.htm VANDU (Canada) http://www.vandu.org/ 154 The Consumer, the Weak, the Sick, and the Innocent – Constructions of ‘the User’ by the Swedish Users Union72 Jessica Palm Introduction Drug users are often described as a socially marginalised group in Swedish society (Lander et al. 2002; Svensson & Kristiansen 2004, Fondén et al. 2003). This condition is sometimes blamed on the country’s restrictive drug policy (Lander et al. 2002). Although there are large number of associations and nongovernmental organisations in Sweden, only very few organisations have been primarily aimed at drug users (see the article by Laanemets in this publication). There are, however, several associations for former drug users and parents of drug users, many of which have been influential in the drug policy debate and some of which claim to advocate the interests of drug users. The focus of this paper is on a relatively new association, i.e. the Swedish Users Union (Svenska Brukarföreningen – SBF). The SBF was founded in 2002 in Stockholm as an interest organisation for opiate users with or without substitution treatment (methadone or buprenorphine, which in Sweden is called Subutex73). It is the first and only association in Sweden whose board consists of active users of opiates (including methadone and Subutex). Before the SBF, drug users in Sweden had lacked a public voice. The SBF is committed to defending the interests of drug users among others in relation to the caregivers in charge of substitution treatment. According to Berne Stålenkrantz74, head of the union since it was founded, the main background and motivation for the establishment of the SBF came from the difficulties in obtaining methadone and the problems in the Stockholm methadone programme: its high levels of control, strict demands on users, and punitive actions. Furthermore, no one was available to advocate the patients’ interests. 72 73 74 The article has been reviewed by two referees. Subutex is the term used by the SBF for buprenorphine and therefore used in this article. Chairman of the SBF board, Berne Stålenkrantz, was interviewed on 4 February 2005 to gain an overview of the union’s history so far. 155 The first discussions on organising drug users were held between Stålenkrantz and Björn Hjerdin from the Stockholm section of the National Association for Aid to People Addictive to Drugs and Pharmaceuticals (RFHL)75 in the spring of 2002. The RFHL made office facilities available to Stålenkrantz and in October 2002 a board was appointed and statuses formulated at a meeting with 15 users of heroin or substitution treatment. According to these statutes all decisionmaking was restricted to drug users on the board, which consisted of 12 persons appointed at an annual meeting. The SBF’s mission is to advocate the interests of patients within the treatment system. It wants to see a policy shift from zero tolerance (including substitutes) to harm reduction, primarily to reduce drugrelated deaths. Another aim of the union is to counter stigmatisation: There is a lot of prejudice against our members, and the association will be working to eliminate that prejudice. (Application to the National Board of Health and Welfare 2005) Within just 10 months, the association had attracted 500 members. Some problems arose early on, partly of a financial character, but there were also internal conflicts regarding the SBF’s political direction 76. By early 2006, the union had around 1,000 user members and local associations had been established in Malmö, Lund, Sörmland, Örebro, Stockholm and Sundsvall. Moreover, there are local user representatives in Umeå, Borlänge and Kalmar. There is also a section for relatives, with around 300 members. The SBF is no longer attached to RFHL and it has moved out of the RFHL’s premises. The SBF is an interesting association, for several reasons. Prior to the founding of the SBF, most actors on the Swedish drug policy arena were non-users and exusers. Furthermore, the union has grown very rapidly and there are early indications that it has been recognized as an actor within the drug policy debate77 and among caregivers78. The SBF can be seen as both a product of contemporary discourses and an actor that could come to influence the dominant drug policy discourse. This article uses discourse analysis to explore how the SBF constructs the ‘user’ in its official texts, as seen in the light of the official Swedish drug policy discourse. Swedish drug policy has been described as highly restrictive and 75 76 77 78 The most prominent client organisation for drug users to date, the RFHL, was founded in 1965. The organisation emerged as a reaction to the repressive and restrictive measures imposed in society against drug users. See also the articles by Leili Laanemets and Björn Johnson in this publication for more information on the RFHL’s ideology and establishment. Views differed mainly on how liberal a stance the SBF should/could take in the public drug policy debate. The Ministry of Health and Social Affairs and the National Board of Health and Welfare have asked the SBF to give its opinion on public reports on drug policy issues. For purposes of quality control a council was set up with representatives of both the SBF and caregivers. 156 moralising in its attitude towards drug users, and the SBF may be understood as a reaction against this approach. The SBF’s construction of the ‘user’ is central in this respect. The SBF combines different constructions in a novel way, and this new combination can be seen as representing an “official SBF discourse”. The strategy chosen is interesting in that it sheds light both on the perspective of the dominant Swedish drug policy discourse and on what other discourses are available, what can (and cannot) be expressed within the dominant drug debate and how a reaction on the part of users can be formed. Swedish Drug Policy To gain an understanding of the context within which the SBF has emerged, we need to begin by looking briefly at official Swedish drug policy and its construction of the ‘user’.79 Swedish drug policy is traditionally characterised by a restrictive attitude, the ultimate goal being to completely eradicate drug use (SOU 2000). The three cornerstones of this policy have been treatment, prevention and control. However, it was not until the 1960s that drug use was established as a social problem, in what Johnson (2003) calls a collective definition process. Over the years, right-wing and left-wing parties in Sweden have been competing with one another over who is the toughest on drugs – and consequently the controls and restrictions have continued to expand and deepen (Laursen 2001; Tham 2003). On the other hand since the turn of the century there have been growing signs of some movement towards harm reduction measures. This softer approach is reflected in new nationwide guidelines for needle exchange80, the spread of substitution treatment with Subutex, increased availability of methadone treatment and a rather more critical debate about “the Swedish approach”.81 However, this tendency should not be overestimated. Swedish drug policy and its goals still stand (SOU 2000), and it appears unlikely that the existing control measures will be relaxed. Tham (2005) thus interprets the proposal for a national syringe exchange programme as part of a public health perspective rather than a human rights perspective. Further, maintenance treatment is still seen as a temporary solution which ultimately should lead to complete rehabilitation and abstinence (Tham 2005). A long-standing argument against methadone treatment is that the “patient” still remains a drug user (Johnson 2003). Recent research has described the public health approach as less 79 80 81 See the articles by Leili Laanemets and Björn Johnson in this publication for a historical description of Swedish drug policy. Needle exchange programmes have only been available in Malmö/Lund, and even here their operation has been disputed. A critical investigative TV programme on substitution treatment, for example, was aired on Swedish television on 17 October 2005. 157 ideological and more pragmatic than the human rights approach, thus facilitating a combination of harm reduction measures with a restrictive policy (Hurme 2002; Hakkarainen & Tigerstedt 2003). Here a distinction needs to be made between harm reduction measures and human rights ideology (Hurme 2002). The reluctance to use the term harm reduction in Swedish drug policy is probably due to the ideological resistance against drug use and regarding drug users and their civil rights as accepted parts of society. Nonetheless it is a reasonable interpretation of the growing reliance on harm reduction measures that a public health approach as a pragmatic solution to problems due to drug use is being combined with a restrictive policy still aiming at a drug-free society. In 2002, the Ministry of Health and Social Affairs set up a new agency called Mobilizing against Drugs (MOB) in a bid to intensify the struggle against drugs. MOB’s action plan includes steps to cut the supply of drugs, reduce the number of youths experimenting with drugs, and to increase the number of people receiving help with quitting drugs (MOB 2004). The launch of MOB was effectively a way of demonstrating the government’s determination in the face of the drug problem at a time when research pointed at an increase in drug-related deaths (Olsson 2001) and more widespread drug use among young people (CAN & FHI 2000). This effort has also shown some interest in the perspectives of drug users.82 Furthermore, the National Board of Health and Welfare has on various occasions taken notice of the users of health services. User organisations have been invited to take part in reference groups and give their views on current treatment practices. Indeed such expressions as “user influence” and “user interests” are now being heard more and more often. Method and Material Theoretical Point of Departure In this section my intention is to sketch the background against which the results of this study will be analysed. This study is a discourse analysis. Winther Jørgensen and Phillips (2000) provide the following useful description of discourse as defined by Laclau and Mouffe, whose poststructuralist perspective 83 is at the core of my theoretical point of departure: 82 83 MOB and the National Board of Health and Welfare have commissioned a study on drug users’ experiences of the drug treatment system (Svensson & Kristiansen 2004), and there have been discussions on the subject between the SBF and MOB. Laclau and Mouffe can be seen as poststructuralists in the sense that they consider everything to be language and thus discourse. It follows that there is always more than one truth that can be described. 158 A discourse is conceived as a fixation of meaning within a specific domain. All signs in a discourse are moments; knots in a fishing net, and their meaning is fixed through their specific way of being different from each other (differential positions). According to the theory of Laclau and Mouffe (1985), nodal positions are the central signs or “privileged discursive points” of a discourse around which other signs are organised and given meaning. Alternative meanings are constantly threatening to destabilise the fixation of the fishing net in the discourse, and these alternative meanings are relegated to what Laclau and Mouffe call the field of discursivity. This field holds all the alternative meanings that a discourse is doing its best to keep at bay. In the Swedish official position on drugs, for example, “stimulant” in the sense of “drug” is referred to the field of discursivity to prevent any positive associations being connected to the word. At the same time, “stimulant” is constantly threatening to destabilise the closure/net fixation, or the view of drugs as something dangerous and threatening (could be seen as a nodal position). All moments are potentially ambiguous. Concrete articulations reproduce or question the prevailing discourses by fixating meanings in a particular way. According to Laclau and Mouffe (1985), a constant battle is going on within the field about how the structure should be organised (in the fishing net/fixation), which discourses should rule and which meaning should be given to particular signs. One of the key concepts in the theory of Laclau and Mouffe (1985) is that of ‘hegemony’, which they adopt from Antonio Gramsci. Hegemony consists of the processes that create people’s consciousness, a kind of disciplining where the power tool is meaning-making. Hegemony implies that power structures are neutralised and taken for granted. A kind of consensus is in place that hides any alternative meanings. The processes are not guided solely by economic power or economic struggles, but they can also be influenced by opinion-forming strategies and resistance to existing conditions. In the same vein, Foucault (1982) states that power is not something that is imposed on us from above, but rather it is constantly reproduced by each and every one of us. Official Swedish drug policy discourse, with its scarcity of opposition and alternative understandings, is a good example of hegemony. Starting from the theory of Laclau and Mouffe, the following questions can be posed in order to try and understand how the SBF constructs the user and the drug policy discourse that they use: How does the users union threaten the structure of other, dominant discourses? What meanings do they establish, what meanings are withheld? On what discourses are the SBF’s articulations built, what discourses do they reproduce? How does the SBF rephrase and question a discourse by redefining its moments? What signs have a privileged status (i.e., are nodal positions) and how are they defined in relation to other signs? What construction of meaning is the struggle about? These questions should be understood not so much as research questions, but instead as tools of analysis. 159 Material The discursive practices that I want to study here are those expressed in written text, even though the SBF obviously also uses other discursive practices such as oral communication. These texts have the benefit of being limited to what the SBF wants to communicate publicly. For reasons of research ethics, the association’s internal communication is excluded from the analysis. Included are all the public texts produced by the SBF since its establishment in 2002 until the beginning of 2005. Most of these texts have been written by a handful of persons. All texts published in the name of the SBF are read by at least the chair and one other person. The board also has active discussions about articles, other texts, as well as the association’s political agenda. All these texts analysed are listed in Appendix 1, and they can be divided into five categories: ■ Debate articles and press releases ■ Newsletters84 ■ Informative texts (folders and website) ■ Responses to political queries ■ Applications for funding These texts were all treated in the same way in the analysis. SBF newsletters and texts on the SBF website include personal accounts of life events, mostly maltreatment, written by individual members. Even though they might shed useful light on treatment, I have chosen to exclude these stories from the analysis since they do not represent the SBF’s views or their way of expressing themselves. The same goes for information about medication and treatment provided for SBF members on the association’s website; these texts do not contribute to the attainment of the aim of the study. Texts about views on treatment and medication written in the name of the SBF are, however, included in the study. Procedure The research was carried out in several steps. To begin with, the texts were read with the aim of finding different descriptions of the “user”. These descriptions were classified initially into three categories/themes/positions: “the consumer”, 84 According to the SBF, its first newsletter (which was no more than a few sentences) has disappeared; it is therefore excluded from the analysis. Newsletter 5 is also missing because it was never written. What is now newsletter 6 should have been newsletter 5 – a mislabelling. 160 “the weak” and “the sick”. The texts were then re-examined in closer detail against the background of this run-through and the aim of the study in order to form a picture of what was written on these central variations of “the user”. “The weak” and “the sick” were particularly prominent representations to me in many of the texts, especially in debate articles and press releases, and “the consumer” was central in my search for different positions because of my expectations regarding the name of the organisation. Later, a fourth theme was added under the heading of “the innocent” as I found that it could be distinguished from “the weak” and that it was central to the SBF’s opposition to the dominant drug policy, which in itself is essential in the SBF’s texts. Parallels are also drawn to the first three of four possible perspectives (human rights, diseases, public health, criminal) on harm reduction outlined by Hurme (2002). When it comes to studying perceptions of what is conceived as “normal”, it is sometimes easier to define what a term does not mean (see Mattsson 2005), and what “the user” is not is clear in the opposition to the dominant drug policy. Finally, quotes were chosen to reflect what is expressed in the texts within each theme, even though the concern in some cases is with specific choices of wordings. It is obviously not possible to clearly separate the different themes from one another, and what is said on one theme can also tell us something about another theme. Since some phenomena are not directly expressed in the texts, I also use certain linguistic tools to try and understand the SBF’s viewpoint regarding a certain topic. Roger Fowler (1991) provides a useful description of analytical tools used within critical linguistics. Here, I concentrate on how “the user” is described in terms of active and passive, and on whether agents are visible or of no interest. Finally, I examine Swedish drug policy to discuss possible descriptions of “the user” that are not expressed in the SBF’s texts. Huckin (2002) brings up different forms of textual silence, concentrating most particularly on manipulative silence. Sometimes what is not said is more important than what is said for achieving one’s goals. Manipulative silence is about the encoder of a message consciously withholding questions that are important for the issue at stake, in order to mislead and gain an advantage (Huckin 2002). My interest is in the possible ways of describing “the user” that are missing in the SBF’s texts. In the excerpts below, issues of particular interest are marked in italics – these italics did not appear in the original texts. All original SBF texts are in Swedish and have been translated by the author. Inevitably, some nuances will have been lost in the translation process since two languages might not have the exact same word for the same meaning. Further, I use double quotation marks for quotes and for indicating the meaning of a term (a definition or a concept), and single quotation marks for referring to a word/term (also called a ‘sign’) (see Bergström & Boreus 2000, 7–8). Having said that, it is in practice difficult to separate a sign from its meaning. Meanings are interwoven in signs (see the discussion by Spivak on the deconstruction of the dualism signifier/signified by Derrida 1998). 161 Results “The Consumer” The first point I want to raise is the term ‘user’, which is used both by the SBF and by other drug policy actors such as the National Board of Health and Welfare and Mobilizing against Drugs. In the case of the SBF, it is clear that it refers to “consumers of drugs”, and mainly of opiates, while in other contexts ‘user’ is understood as “treatment consumer”. In the case of “consumer of drugs”, the use of the term ‘user’ can be understood as a reaction to the term ‘misuser’ or abuser, which is often used to refer to all users of drugs (see above). In Swedish, the most common word for ‘user’ is ‘användare’, but the word for ‘misuser’ is ‘missbrukare’, incorporating the less frequently used term ‘brukare’, which also means ‘user’. By using the word ‘brukare’ instead of ‘användare’, the SBF position themselves against those who wish to characterise all use of drugs as “misuse”. It is also clear from the following quote that the SBF sees the concept of ‘misuser’ as problematic: … the objectifying and grossly generalising categorisation “misuser”. (Response to political query on compulsory treatment 27 June 2004) The use of the term ‘user’ in association with treatment, as in the rhetoric of official agencies, is a relatively new phenomenon. Previously the terms ‘client’ (in social services) or ‘patient’ (in health care) were used to denote individuals receiving care or treatment for substance problems. As opposed to ‘client/patient’, the term ‘user’ emanates from a verb, ‘to use’, and thus it conjures up connotations of a more active subject than ‘client/patient’, who is thought of as a passive object of interventions by others around them, such as doctors or social workers (see Asmussen 2003). The following quote is an example of the SBF’s view of ‘the user’ as someone who is capable of assessing her/his own needs of treatment and thus of being an active “treatment consumer”: The law on compulsory treatment seems to be premised on the assumption that persons who are drug dependent do not understand what is in their best interests and are unable to assess their own needs. We at the Users Union speak from our own experience and can assure that this (assumption) is not true. We are fullfledged experts on our own problems. (Response to political query on compulsory treatment 27 June 2004) The more frequent use of both ‘user’ and ‘consumer’ to refer to individuals in treatment can be understood with the help of Fairclough’s expression 162 “marketization of discourse” (1992). Fairclough is implying that a market discourse is colonialising other discourses. This can be interpreted as a move away from a welfare discourse where services are offered to citizens/patients/clients towards a new liberal consumption discourse where commodities are chosen/consumed by/sold to consumers/users.85 ‘The user’ is implicitly expected to be more active and to assume greater responsibility for her/his care, which can be interpreted as individualisation. Instead of the collective looking out for the individual, the individual has to take personal responsibility and look out for her/himself. If things do not work out well for the individual, s/he has only her/himself to blame. The SBF’s comments on competition within the treatment system can also be seen as part of a consumption discourse. Competition, the SBF says, would give “the opiate dependent person better access to individually adapted treatment” (Press release 30 April 2004). We hope that the new guidelines will make it easier for private care providers to enter this treatment area, which today is heavily politicised. (Response to political query on Subutex-methadone 27 May 2004) The SBF also admits the difficulty of defining its target group of “heroin addicts”, and instead locates the definition in the common interests of users that it wants to make visible (SBF website, text written 11 June 2003). The common interests brought up in the text concern pharmacological treatment alternatives, methadone and Subutex; placing important decisions about oneself in the hands of others; failed attempts to gain influence over personal treatment; and the experience of being subjected to arbitrary and repressive measures. On several occasions, however, expressions such as ‘user’, ‘user part’ and ‘user perspective’ (Application 26 June to the County Council (Landstinget), Appendix 1) are used without further definitions of these parts, perspectives and interests. The silence surrounding a given subject may be equally as interesting to explore as the explicit (see Huckin 2002). One meaning absent in the texts that is relevant to understanding the limits of the construction of ‘the user’ as “the consumer”, is that of individuals who are not interested in quitting drugs – individuals who say they are doing drugs out of their own free choice because they feel they get something out of it. Drug users who are not interested in treatment, no matter how it is framed, are given no attention. The views that this group might have – that they should be allowed to do drugs if they want to – are therefore absent. The image of a strong, actively choosing “user” that one might have expected to find, considering the use of the term ‘user’ as a reaction against the use of ‘misuser’, is thus missing. I interpret this absence as an expression of a manipulative silence, since this image of “the user” could potentially destroy the 85 Järvinen & Mik-Meyer (2003) consider this an illusion, since the views of staff members are nevertheless always superior to the client’s. 163 chances of the SBF taking part in the Swedish debate where the dominant understanding is that any type of drug use is a problem that should be dealt with. In sum, ‘the user’ as “the consumer” is visible in the texts mainly as a capable, choosing consumer of treatment, but this is not among the most dominant userpositions. ‘The user’ as “the consumer” can be considered equivalent to the subject position focused on human rights and the equality of drug users in Hurme’s (2002) four perspectives on harm reduction, referring to an active and equal subject that should be treated with the same respect as any other citizen. “The Weak” It is difficult to find more elaborated descriptions of ‘the user’. In fact, the term ‘user’ is not used particularly frequently. Instead, the texts prefer to use words like ‘drug dependent’, ‘junky’, ‘heroinist’, ‘patient’, ‘persons with drug problems’ (target group according to the Application to the National Board of Health and Welfare 2005) and even ‘misuser’ (see e.g. Response to political query on knowledge overview concerning substitution treatment from the National Board of Health and Welfare, November 2002). The absence of ‘the user’ may well be a tactic to appeal to those recipients of the texts who might be more familiar with these expressions and who themselves use them frequently, but it may also be understood as a means to serve the SBF’s own purposes. Interestingly, the most common description of ‘the user’ is one of a deprived, marginalised, sick and exposed person “on the bottom of society”. On some occasions there are even faint suggestions that ‘the user’ is not really alive at all, or rather needs to “come back to life again” (Response to political query on knowledge overview concerning substitution treatment from the National Board of Health and Welfare, November 2002). For “weak” individuals, descriptions such as ‘drug dependent’, ‘misuser’ and ‘patient’ are better suited than ‘user’, which, as mentioned above, is a term more associated with the image of actively choosing individuals. At the same time, the description of ‘the user’ as “weak” is coupled with the failure of others, even though these “others” are largely kept invisible. For instance, in the third quote below, it is unclear who is placing the weak outside, and expressions such as ‘society’ and ‘the public’ are not defined further. This absence of a defined agent could be interpreted as a conscious strategy, a kind of manipulative silence (Huckin 2002) in order to relieve “the user” from responsibility (see “The Innocent” below). However, it could also be seen as a presuppositional silence, where the sender of the message takes for granted that the receiver understands what is meant. … the fear and insecurity of the public contributes to our isolation. (SBF website, text written 11 June 2003) … many of the weakest are being left outside.” (Newsletter 6) 164 In reality we are talking about social and psychological problems that cannot be punished away. On the contrary, this punitive approach only intensifies the social and psychological problems. Without the solidarity and understanding of society, it is almost impossible to break out of the problematic use of drugs. (Newsletter 6) We find an opposite to the view of ‘the users’ as weak if we look at how the SBF describes its organisation, which consists of “users”. In the quote below, there is nothing to imply that the SBF is weak. Instead, the SBF is described as active and supportive. However, the description offered of the SBF also strengthens the view of ‘the user’ as weak. The Swedish Users Union sees, hears & acts! (Newsletter 6) In the next quote, the distinction between “the users” or “the comrades” and the SBF is clear.86 “The users” are portrayed as weak and the SBF as strong. The use of ‘we’ in the texts sometimes refers to “us the users”, sometimes to “us active in the SBF”. The quote below is an example of ‘we’ referring to the SBF. Many of our comrades have difficulties making themselves heard in their contacts with the authorities, social services, the justice system, care providers and others and need assistance and knowledge, and in this we have been able to help. (SBF website, text written 11 June 2003) The following quote, then, is an example of ’we’ referring to “we, the users”. It portrays the SBF as activists (a term that is also used by the SBF, Newsletter 2) fighting against the power structure. Remember that together we are strong, alone we are weak against the system. (Newsletter 2) Descriptions of ‘the user’ as weak and in need of help from the authorities are relatively frequent in the texts. The position is in line with the public health perspective on harm reduction as presented by Hurme (2002). In the public health perspective, the drug user is mostly visible as a recipient of services. “The Sick” The terms ‘heroin dependence’ and ‘heroinism’ appear in several texts, implying a disease perspective. ‘Dependence’ is a medical term, and within the medical profession various tools have been developed for the measurement of addictions to substances and activities (i.e. gambling) (Janca et al. 1994). Impairment or loss of control is a significant feature of these medical characterisations of 86 It is, however, also stated that those active in the union should not be specialists, but rather communicate the members’ views (Covering letter for Application to the Social Services Administration, 10 November 2004). 165 “dependence”. In the medical literature, dependence also refers to biological processes and certain conditions in the brain. This is not, however, what is usually measured when someone is screened for ‘dependence’, and social scientists have criticised the medical discourse for creating a category which is not easy to distinguish and which risks stigmatising those categorised as dependent (Blackwell 1988). ‘Heroinism’, on the other hand, a term that is not frequently used in Sweden, sounds equivalent to ‘alcoholism’, which is an older term than ‘dependence’ in Swedish and nowadays associated with the alcoholism movement87 (AA ideology) 88. The AA ideology is also a kind of disease perspective. Alcoholism is described as an incurable disease where the sufferer needs to realize she/he will always be sick and has to abstain from alcohol. The difference is that the AA sees other than medical solutions to the problem (Gusfield 1996). There are also other similarities between the alcoholism movement and the SBF. In its early days the alcoholism movement considered it important to construct the alcohol problem as a disease; this was necessary in order to distance itself from the prevailing moral discourse where the drinker was seen as bad and weak-willed and should be punished rather than treated (Levine 1978; Blackwell 1988). The disease concept meant that responsibility for the problem could no longer be placed on the individual, since it was not the individuals’ fault that she/he had caught the disease. 89 Similarly, I interpret the SBF’s construction of the user as sick as a means of opposing the moralisation to which drug users are confronted (see also “The Innocent” below). Drug treatment should be guided by the same ethical rules that are applied to the treatment of all other kinds of diseases. (SBF website) Patients with substitution treatment – methadone or Subutex – are dependent on a prescribed medication for the sake of their health. (Article in Södermanlands Nyheter 22 May 2003) Needle exchange is a recurring theme in several debate articles, press releases and newsletters. The SBF apparently takes a positive stance on needle exchange, but it is critical of the proposal put forward by the National Board of Health and Welfare which according to the SBF places too high demands on municipalities and counties, effectively making exchange programmes impossible. In its texts, the SBF reconstructs the meaning of needle exchange: 87 88 89 In the United States where the AA originated, it was the alcoholism movement that spread the term and the word about alcoholism, whereas AA members, anonymous as they were, were less active in the debate (Room 1983). The term “alcoholism” was introduced in Sweden by a doctor, Magnus Huss, in 1849. At that time, though, it referred mostly to the chronic physical effects of alcohol consumption. According to Levine (1978) and Blackwell (1988), the disease perspective just meant a new way of controlling people with roots in the temperance movement. 166 Clean needles for injecting misusers are solely a health matter. (Newsletter 6) It is sick people who are being refused access to detoxification because the social services say no to aftercare, and who often lack the capacities to take part in ambitious programmes. The government’s suggestion for needle exchange is designed for an elite among the drug dependent. (Newsletter 6) Substitution treatment seems to be the main focal theme for the SBF. The SBF also sees treatment as moralising and wishes to construct methadone and Subutex as medication, which means taking up a position against those who define these substances as drugs comparable to heroin, and think that substitution treatment is just about exchanging one drug for another. The above-mentioned juxtaposition between a social and a medical understanding of the drug problem continues to persist in many places. It is often social workers who put up obstacles to people who want to get into methadone or Subutex treatment. (Newsletter 6) To have or to achieve more control over the prescription of these substances (Subutex) seems far more important than giving adequate and real help to the persons dependent on drugs. (Press release 4 March 2004, following an MOB conference on over-prescription90) The first of the two quotes above indicates that the SBF prefers a medical understanding over a social one, even though the quote below (and the third quote in the section “The Weak”) shows that it also adopts a social perspective − although it is not clear in what specific way the problem is seen as social. Further, the last quote in this section shows that an individual-oriented approach is preferred to a collective one. To decriminalise personal use. Argument: by criminalising drug use, society is saying that it is mainly the responsibility of the police, the criminal justice and the prison systems and not a social problem. (Newsletter 6) We turn against the collective perspective that is applied when the treatment system describes our problems and needs. (Newsletter 6) ‘The user’ as sick is a common position and corresponds to the disease perspective of harm reduction outlined by Hurme (2002). This perspective views drug dependence as a disease of the individual and is aimed at curing the “misuser from dependency and making his life as normal as possible” (Hurme 2002). “The Innocent” 90 “Over-prescription” means that too much medication is prescribed and that there is a “black market” for prescribed substances. 167 Another construction of ‘the user’ that is not far removed from notions of ‘the user’ as weak and sick is the construction of “the innocent”. It does , however, need to be separated from the two others since it appears as a reaction to the description in the dominant drug policy discourse of ‘the user’ as “the guilty” or “responsible” The texts do not say very much about how individuals started using drugs, but the construction of ”the user” as ”innocent” is reinforced with the repeated use of such expressions as “end up in”, “got stuck in”, “driven/forced into” or “fell upon” (see my italics in the quotes below). These expressions imply random courses of events for which the individual cannot be held responsible. On the contrary, someone who ended up in or got stuck in a situation appears as a passive victim, driven by active forces outside the individual (see Fowler 1991). The SBF seems to take a victim perspective on ‘the user’; in Sahlin’s (1994) words, they are just “poor wretches” (“stackare” in Swedish) who have not made an active choice to start using drugs. Sahlin (1994) puts forward the concept of “wretch” in relation to that of “scoundrel” (“usling” in Swedish), by which she means individuals described as unmotivated and incorrigible failures. And how should one value an ideology that in practice leads to a forcing down into ever deeper misery of those already excluded. (Press release, early 2003) …those who have yet not fallen into the hell of drug use. (Press release, early 2003) To say that someone ended up in drug dependence through a conscious decision is nonsense. (Press release, early 2003) The opposition against the dominant Swedish drug policy and treatment discourse is central to the SBF’s argumentation. “The Swedish model” is described as “moralising, judgemental and punitive”; it “harms those it has been designed to help” and, according to researcher Peter Cohen, cited by the SBF, it is based on moralism rather than on medical experience and scientific knowledge (Newsletter 3). The opposition appears mainly in debate pieces and press releases, in response to opinions expressed by other actors. This opposition to laying the blame on the individual carries the SBF’s opposite construction – the construction of “the innocent” user who is not blameworthy. I interpret the first of the examples below as “one should not send out the signal that ‘it is your own fault’ ”: Everybody who smokes, drinks or injects knows that this is punishable. However the signal that we send presently is that “it is your own fault if you are infected by hepatitis or HIV”. (Article in Oberoende, No. 4/1, 2003) We all want to see those who have become dependent get “well”, but the current drug policy has driven people into a more and more difficult outsider position, a position that makes it difficult for them to return to a life within the frames of society. (ibid.) 168 Many of the texts have descriptions of ’the users’ in terms of “powerlessness”, “isolation” and “helplessness” (see e.g. Application 2 March 2004 to the Social Services Administration). The following quote shows that the SBF wants to shift the responsibility for failure from ”the client” (who they imply is thought to be responsible in the eyes of others – exactly whose eyes remains unclear) to a particular set of actors – the treatment staff. If someone’s medication is withdrawn because it is thought they have not satisfactorily followed through with their treatment or for some other reason, in many cases we know that continued treatment would be preferable. That makes us believe that it is the doctor and the staff who did not succeed with their work with the client, and not the other way round. (Annual report 15 October 15 October 2002) The Swedish situation is described as chaotic, largely because of the country’s zero-tolerance policy and goal of a drug-free society. At the same time, the SBF seems optimistic about the future and expects to see positive changes, even though there still remain some enemies, such as the Hassela Nordic Network, the National Swedish Parents Anti-Narcotics Association (FMN) and the National Association for a Drug Free Society (RNS), who continue to put the blame on the user. The SBF is opposed to the criminalisation of personal drug use, which it considers as a sign of moralising. The police are portrayed as “disturbing and harassing” drug users and as consciously interfering with their personal integrity rather than working to maintain order and enforce the law. “The user” should not be seen or treated as a criminal, and thus as responsible/guilty. The Swedish Users Union is tired of the war that is being waged against people with the wrong kind of dependence. … If we receive adequate care, the right treatment and if we are not labelled as “criminals”, amazing forces can be released. In the future our dependence should be no more remarkable than sugar dependence. Decriminalisation could be the first step. (Press release 27 April 2004) Police violence and coercion, including urine samples, blood samples and other coercive measures against drug users, have to end. (Newsletter 6) Criticisms of treatment in the texts are also opposed to the view of users as guilty; examples include the critique of closing down detoxification beds, of difficulties in gaining access to substitution treatment, and of the use of collective punishment in substitution programmes. In general, these critiques focus on the tendency of municipalities, health care services and substitution programmes to moralise about “the user”, which makes it harder for “the user” to get access to the treatment s/he needs. But what is most upsetting of all is the death rate for those “discharged” from methadone and Subutex programmes: “Discharged” is new-Swedish for being thrown out against one’s will. The most common reason for such involuntary discharge is relapse into misuse. In other words, relapse into the disease and 169 dependence for which the patient has been prescribed medication is punished by withdrawing that medication. (Press release 11 May 2004) Among other things, the threat of compulsory treatment has often been part of the so-called “voluntary agreements” in which we have been involved. (Response to political query on compulsory treatment 27 June 2004) The two quotes above also serve as examples of the attempts by the SBF to redefine the meanings of expressions used by others, such as “discharge” and “voluntary agreements”. Another example of this kind of redefinition is the reaction to a debate article where the author emphasises the need for greater “clarity” in relation to drug users. In the SBF’s view, “clarity” equals punishment (Article in Dagens Nyheter 20 August 2003). It seems that the SBF does not want to construct ‘the user’ as “culpable”, except in their confirmation of the existence of this construction when they react against a moral perspective. “Misbehaving users in treatment”, another theme of the dominant Swedish drug policy discourse, does not show up either. In so far as the SBF uses this meaning, it is connected to the harsh control and strict rules of treatment providers (see the sixth quote in the section “The Innocent”). The users that want treatment and want their drug use to be strictly controlled are also absent from the SBF’s texts. “The innocent” is a common position of ‘the user’ in the texts and the opposite of the subject position of the drug user in the criminality perspective of harm reduction – “the criminal subject” (Hurme 2002). This subject is a morally corrupt and dangerous individual who should be held responsible for her or his actions. Discussion In my search for descriptions of ‘the user’ in the SBF’s texts, I found four distinguishable themes – “the consumer”, “the weak”, “the sick” and “the innocent”. These themes happened to correspond to the subject positions of drug users identified by Hurme (2002) in four perspectives on harm reduction – the human rights perspective, the public health perspective, the disease perspective and the criminal perspective. “The innocent”, however, can be regarded as the inverted version of the subject in the criminal perspective. The SBF’s texts clearly highlight the moralising nature of the dominant Swedish drug policy discourse, in which criminalisation, control and marginalisation are key features. According to the texts, this dominant discourse has also influenced the treatment of drug users. Substitution programmes have applied very strict inclusion criteria91 and a lot of effort has been invested in preventing “leakage” 91 These criteria have been relaxed for methadone, however, although tightened for Subutex during 2005. 170 of methadone and Subutex into the illegal market with the help of urine tests. The SBF draws attention to the use of collective punishments within these programmes. Furthermore, the dominant drug policy discourse has prevented intravenous drug users from gaining access to clean needles. Nodal positions (see Laclau & Mouffe 1985) in the construction of the user seem to be “morally responsible”, “incapable of making good decisions” and “criminal”. The Swedish Users Union was founded in a situation where alternative perspectives on drugs and their users had begun to destabilise the hegemony of this restrictive drug policy. This might have been due to increased drug use, policy changes in neighbouring countries and a weakening of voluntary organisations against drugs. An alternative explanation for the space that “suddenly” appeared for a user organisation is the trend towards increasingly individualised treatment, with individuals expected to take greater responsibility for their situation. In order for individual responsibility to be possible, individuals have to be seen and treated as strong. Perhaps strong groups are also better heard? By claiming that users are involved in decision-making or asked about their opinion, decision-makers can legitimate a particular policy even if users’ opinions are not in fact taken into account. In this sense the dominant actors need user organisations, as is also discussed in this publication by Willersrud & Olsen in relation to the emergence of Norwegian user organisations. The question is whether the SBF can in return manage to influence the dominant drug policy from within the space available to them, or whether they will be “co-opted” (see e.g. the article by Tops in this publication). The SBF could further be seen as dependent on a few individuals who are strong enough to take on this difficult task. The SBF’s position is that users’ interests have not been taken into account in the current restrictive policy and therefore they are opposed to it. It is clear from the texts quoted here that the SBF feels that the users union and its members are part of the out-group, but it would like to be in the in-group. Below is yet another example which points at the presence of the human rights perspective in the SBF discourse. Where union representatives are involved in the discussion it becomes impossible to talk about drug users, in an objectifying manner, as “those” – “the other”. We want to be part of society and be able to take part in what society has to offer to all its citizens. (Application 2 March 2004 to the Social Services Administration) Like the alcoholism movement, whose discourse was opposed to the dominant moralising discourse regarding alcohol, the SBF borrows its view of “the user” from a medical discourse. This seems to be one way in which the SBF wants to destabilise the closure or fixation of meaning in the dominant Swedish drug policy discourse. “The user” is described by the SBF as a sick person who is in need of medication. It wants to normalise “heroinism” or “drug dependence” by 171 comparing it to diseases that are not the subject of moralising and for which necessary treatment/ medication is readily provided (e.g. insulin for diabetes). Methadone and Subutex are thus constructed as medications. Curiously, though, methadone and Subutex are also treated as “drugs” in the SBF’s insistence that its board members should be “drug users”, and users of methadone and Subutex are included in this category. The focus on medical treatment implies an even greater reliance a medical discourse than the alcoholism movement’s, where medical solutions were not part of the discourse. Interestingly enough, restrictive drug policy was also grounded in a view of “the misuser” as a “disease carrier” spreading an “epidemic”. It was from that perspective that measures, partly police based, were to be focused on the users rather than the dealers. Perhaps it is to avoid confusing their perspective with the kind of ‘medical perspective’ described above that the SBF is keen to combine the “disease perspective” with the view of the user as “weak” and “innocent”. SBF’s texts include a construction of the user as passive, with other forces outside the user placing her/him in a marginalised position – “weak”. The constructions of ‘the user’ as “weak”, “sick” and “innocent” are not all that different – sick individuals are often seen as weak and not to be blamed, but with the dominant drug policy discourse connecting “the sick user” to “the morally responsible”, there is certainly a point in separating them. The “innocent” construction further facilitates the positioning of the SBF in relation to the dominant drug policy discourse. The construction of the user as weak and innocent has its roots in the leftist movement that in the 1970s regarded the problems of drug users as social and stated it was the fault of ‘capitalist society’ that certain individuals had a problem with drugs (see Modig 2004 for examples of the reasoning of the Rassociations92). Although “the weak” are often seen as “innocent”, one could imagine a user that is weak now, but culpable for having put her- or himself in this weak position. Equally, the reverse is thinkable – a “strong” person that is not to be blamed for his/her position. I therefore distinguish between the two. The SBF texts include many traces of a social perspective (or in the words of Lindgren 1993, of the treatment and reform strategy). The SBF writes about the problems as social and seems to view the individual as a victim of circumstances in the critique of the punitive policy and build-down of treatment, as well as in their quest for societal responsibility, in the defence of the weak and in their wish for solidarity (many texts end with “warmth & solidarity”). The use of the term “comrades” for SBF members can also be traced to 1970s left-wing groups. At the same time, the SBF views are clearly distinguishable from leftist movements such as the R-associations. In some texts the SBF seems to relate a social view to a moralising perspective, against which it takes a stand by preferring a medical perspective. Addressing problems with individually based measures such as medication was not part of the solutions adopted by the leftist 92 The group of so-called R-associations was a gathering of socio-political organisations founded during the 1960s and 1970s. 172 movement (as portrayed by the R-associations), which was rather concerned to change society (Modig 2004). Another difference is that the SBF borrows terms from a market discourse, including competition, private treatment and individuality before collectivism. Since the heyday of the R-associations there has been a general shift towards the right in politics (Boreus 1994). However, Tham (2005) argues that the reason for Sweden’s persistent restrictive policy lies in a “utopian left” who wants to see responsible individuals working together for a better society, which is why no one should be given up on and why the goal is total rehabilitation. This “utopian left” might also be what the SBF is opposing with its more individualistic approach. On the other hand, it should be pointed out that left- and right-wing parties in Sweden have agreed on the directions of drug policy. As regards the social/medical, the SBF seems to view the user as a victim and weak at the same time. It wants to see “the user” as comparable to any other patient who can make sound choices between treatment options as an expert in her/his own situation (see the analysis by Asmussen 2003 of “empowerment” strategies where clients are constructed as experts entering into partnerships with professionals). On the one hand, the SBF seems to offer external explanations for the problems – society has marginalised the user; on the other hand, its solutions are mostly individually based. Individually based solutions do not preclude societal solutions and a construction of external explanations to the problems. However, it is not quite clear to what extent the individual is regarded as responsible for the solution of her/his problem, although the SBF clearly thinks that society needs to provide better treatment and a better general situation for the user. My interpretation then is that the SBF sees itself as a spokesperson for “users” in treatment, or for users who want to gain access to treatment and who regard the treatment organisation as problematic. Other meanings of ‘the user’ that do not fall within the frames of questioning or wanting treatment have been pushed out to the field of discursivity, in the terms of Laclau and Mouffe (1985). In an outline for a programme by the SBF, seven out of eight issues concern the ways in which substitution treatment should be improved and made more readily available (Newsletter 6).93 In this regard the SBF shares many features in common with a patient’s organisation. It mainly discusses issues concerning treatment and needle exchange. A more pronounced user organisation might have been thought to focus more on individuals’ rights to use drugs and their strength and ability to make their own choices – a type of organisation that seems to exist in Holland, but which is unlikely to gain space within the confines of Swedish drug policy. One difference between the SBF and Dutch organisations (and to some extent Danish organisations) is that the Swedish union, even though it is also arguing (albeit not very emphatically) for a 93 The eighth and last point is a suggestion to decriminalise the personal use of drugs. 173 decriminalisation of personal use, does not take a stand for (or against) legalisation. This can be understood as either a conscious or unconscious survival strategy: if it were to adopt a stance that departs too radically from the dominant drug policy discourse, that might well preclude it from any further involvement in negotiating meanings and influencing drug policy and treatment. The SBF texts reveal something about the boundaries of what can and cannot be expressed in the Swedish drug policy debate at the beginning of the 21 st century.94 This implies that drug users who do not want to belong to the category of “poor creatures” still lack a “voice”; it also explains why the user is portrayed as weak rather than strong. The SBF’s position can be understood as a balancing act to challenge established beliefs and still to be taken seriously in a restrictive climate of debate. To sum up, ‘the user’, as well as the SBF, is fragmented, i.e. has multiple positions. ‘The user’ has no single identity, but rather several meanings that are used depending on the discourse concerned. The meaning is dependent on contemporary constructions of ‘the user’. I interpret the SBF discourse as a reaction against constructions of ‘the user’ as morally corrupt in the dominant Swedish drug policy discourse, and as having the aim of destabilising its hegemony through deconstructions, such as the ones of “voluntary agreements” and “clarity” mentioned above. In themselves, the deconstructions aim at changing the actions and measures taken by society vis-à-vis users and at increasing their right to be treated in the same way as other patients. In this work the SBF discourse reproduces a medical discourse, a closely linked individualistic discourse (and thereby a liberal discourse focusing on human rights) and a consumption discourse (also linked to the individualistic and liberal discourses), as well as a leftist solidarity or human rights discourse, which together form the SBF discourse on ‘the user’. References Asmussen, V. (2003): User participation: possibilities and limitations in Danish social services directed towards drug users. 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SOU [Government Official Reports] (2000): Vägvalet – den narkotikapolitiska utmaningen [At the crossroads – a challenge to drug policy]. SOU 2000:126. Stockholm: Fritzes. Spivak, G. C. (1998): Translator’s Preface. In: Derrida, J. Of Grammatology. Baltimore: The John Hopkins University Press. Svensson, B. & Kristiansen, A. (2004): ”Byråkrati och narkomani går inte ihop…” Livsvillkor och vårderfarenheter hos kvinnor och män som använder narkotika [”Bureaucracy and drug taking don’t mix...” Living conditions and treatment experiences among women and men who use drugs]. Rapport 1. Stockholm: Mobilisering mot narkotika. Tham, H. (2003): Narkotikapolitiken och missbrukets utveckling [Drug policy and the development of misuse]. In: Tham, H. (Ed.): Forskare om narkotikapolitiken [Researchers on drug policy]. Stockholm: Kriminologiska institutionen, Stockholms universitet. 176 Tham, H. (2005): Swedish drug policy and the vision of the good society. Journal of Scandinavian Studies in Criminology and Crime Prevention, 6 (1): 57–73. Winther Jørgensen, M. & Phillips, L. (2000): Diskursanalys som teori och metod [Discourse analysis as theory and method]. Lund: Studentlitteratur. Appendix 1. Material used in analysis Press releases: Press release 11 May 2004 Press release 6 May 2004 concerning article in Dagens Nyheter 4/5 about misuse of Subutex. Press release 30 April 2004 Market competition for methadone and Subutex; individual treatment possible at last! Press release 27 April 2004 concerning editorial in Expressen on 9 April about a woman who was locked up, beaten and raped and thereafter refused damages because she was under the influence of amphetamine. Press release 22 March 2004 concerning the suggestion for new guidelines in substitution treatment with methadone and Subutex from the National Board of Health and Welfare. Press release 21 March 2004 concerning the suggestion that all counties should be given the opportunity to apply for permission to treat heroin dependence with methadone and Subutex from the National Board of Health and Welfare. Press release 4 March 2004 in connection with the conference arranged by MOBilisering mot narkotika in the Rosenbad Conference centre about over-prescription of medication classified as narcotics. Press release concerning the suggestion from drug co-ordinator Björn Fries on how the needle exchange programme should be arranged 27 February 2004. Press release concerning a petition against the closing down of M:48 and the delivery of it to Birgitta Sevefjord 24 April 2003. Notes on the discussion about whether there should be a needle exchange programme in Stockholm 177 Articles/debate: 20 August 2003: Dagens Nyheter: Free needles save lives and suffering. 16 August 2003: Expressen: Clean needles save lives. 22 May 2003: Södermanlands Nyheter: About mistreatment in the Subutex programme in Nyköping. 22 May 2003: Will there ever be a needle exchange programme in Stockholm? April 2003: Oberoende no. 4/1-2002-2003 by Hjerdin, Björn: Free needles and treatment do not exclude each other. Response to debate article in Stockholm City 20 March 2003. Newsletter: Newsletter 2. Newsletter 3. Newsletter 4. Newsletter 6. Website: www.brukarforeningen.com Responses to political queries: Knowledge overview concerning substitution treatment from the National Board of Health and Welfare, November 2002. Compulsory treatment 27 June 2004. Subutex-methadone 27 May 2004. Needle exchange 24 May 2004. Applications for funding: Application 26 June 2003 to the County Council (Landstinget). Application 2 March (socialtjänstförvaltningen). 178 2004 to the Social Services Administration Annual report 15 October 2002, Social Services Administration. Application 31 May 2004 to the County Council (Landstinget). Covering letter for Application to the Social Services Administration (socialtjänstförvaltningen) 10 November 2004. Application to the National Board of Health and Welfare, 2005. 179 A Happy Compromise? Public Injection Rooms in Norway – Admission Criteria and Client Responses Hilgunn Olsen Sited in the centre of Oslo, Norway’s first supervised drug injection facility opened on February 1, 2005. This article reviews early operations, admission criteria and the response of clients to both. What was the thinking behind the criteria put in place by the authorities? How appropriate in the opinion of drug users are these criteria? The article addresses some of the issues related to the facility’s establishment and operation. Noting that public injection rooms can not solve the problems of the city centre’s drug using population completely, I round off with an examination of the measure’s limitations in light of its initial phase. Oslo’s public injection room is basically a place where drugs can be injected safely and in hygienic surroundings, under the supervision of health workers and social workers. Clients get a syringe, needle, an Alkotip disinfection swab, sterilised water, filter, ascorbic acid and heating utensil. 95 Users bring their own heroin dose which is shown to the staff on arrival. The facility can handle four clients at a time, and in each cubicle there is a candle to heat the mixture. Staff offer advice about injection techniques and the amount of heroin to inject. Staff are on hand in the rest room outside the injecting room to monitor possible overdosing, and to help clients get in touch with other healthcare and social work agencies and programmes.96 Within the first few weeks of opening, 160 persons had registered as clients of the facility, mounting to 300 by August 31, 2005, at which point capacity problems made it impossible to accept more. Opening hours extend from 9:30 a.m. to 3:30 p.m. every day of the week. The service became an instant hit with drug users, and soon proved too small in relation to the demand. 95 96 Alkotips are sterile swabs impregnated with isopropyl alcohol. They are used to disinfect the skin prior to injection to reduce the risk of cross-infection. The heating utensil is used to heat and dissolve a mixture of heroin and ascorbic acid in water, forming an injectable solution. Known as “smoking heroin” in other countries, the type of heroin preferred by most Norwegians is difficult to dissolve in water; the addition of ascorbic acid speeds up the process. In Hedrich’s (2004) classification, this type of injection room is a “specialised consumption room”, which, unlike the “typical injecting room” and “integrated facilities”, is not sited next door to other services (ibid.). 180 That said, the facility was and remains contested among experts, drug users and the public. It would take all of three and a half years from the passing of the necessary legislation by the Norwegian Storting (national assembly) to the opening of the service. The debate and arguments for and against are explored in detail by Skretting (2001 & 2003). The use and management of the facility must comply with statutory laws and regulations.97 Clients must be at least eighteen, classified as “heavy heroin users”; only heroin may be injected on the premises; and clients are allowed to bring no more than one user dose into the facility. The views of the user community and user organisations were obtained as part of a 2003 government consultation and from interviews with focus groups. I refer frequently to these opinions in the following. A few days into the lifetime of the facility, we conducted focus group interviews of eighteen residents (five females and thirteen males) of Oslo’s low threshold shelters, to ascertain views of active drug users about the injecting facility. The interviews and consultation responses reveal a wide range of opinions: indeed, the consultation responses of ex-users and active users show in particular how differently the two groups view the arrangement. Opinions converge more in the focus group interviews; these focus groups comprised active users only however. Interviews with Oslo injection facility clients in the autumn of 2005 provide further data. In this article the term “user” means “drug user”. Users are divided into active and former or ex-users. This was done to see how far the two groups agreed/disagreed on various subjects. Injecting heroin users comprise the group served by the injection facility. Their views on procedures and practices shed light on the function of the facility. All assistance provided by the state is by definition a public service, and the government is increasingly taking steps to obtain the opinions of affected members of the public to a particular issue. For instance, Oslo’s Alcohol and Drug Addiction Service conducts user surveys of its front line services, where clients are asked to evaluate service delivery. There is growing recognition among professionals and in the public in Norway of the short-sightedness of having drug free rehabilitation as the only goal in rehabilitation efforts, and that more needs to be done in the area of harm reduction. According to harm reduction philosophy, the opinions and perspectives of users are supposed to guide practice (Asmussen & Jöhncke 2004). Harm reduction as a concept nevertheless indicates a general acceptance of the existence of drugs and drug use; of a high rate of physical, mental and 97 See Regulation no 1661 of 17 December 2004 related to the pilot scheme (Forskrift 17.12.2004 nr. 1661: Forskrift om prøveordning med lokaler for injeksjon av narkotika – Sprøyteromsordningen) [Regulation No. 1661 of 17 December 2004 regarding pilot scheme with supervised drug injection facilities]. Hereafter referred to as the Regulations. 181 social problems among users; and of ways of tackling those problems (ibid.). The biggest changes in harm reducing practices in Norway in the past twenty five years are represented by the inauguration of the needle exchange services and, most recently, public injection rooms.98 Harm reduction covers a number of measures, some of which address individual harm, others harm to society (NOU 2003:4). According to the “job description” of the supervised drug injection facility, individual harm reduction is the paramount objective. Why Now? Why supervised injecting rooms should appear on the agenda at the turn of the new millennium is a difficult question to answer. Official drugs policy in Norway has held steadfastly to a vision of a drug-free society. There is no change on that point. The Government is clear in its opposition to liberalisation and decriminalisation of drugs. The Government maintains as its overarching drug policy goal a drugfree society, a goal which forms an integral part of the Government’s wider vision. The ban on the use of drugs for non-medicinal purposes will remain in place. (Regjeringens handlingsplan mot rusmiddelproblemer 2003–2005, 13) Norway has been trying to solve the drug problem since the 1960s through control, prevention and treatment, with little success, leaving responsible authorities increasingly perplexed. What should be done? What can be done? According to Skretting (2005), the high incidence of drug-related mortality, the rapid increase in numbers of injecting users and the generally poor state of health of drug users spurred the authorities to pilot supervised injection facilities. But there was an added political reason: politicians need to show that they can act, and drugs offer a particularly conducive area in that sense (Tham 2001). As drug-related problems multiplied and the predicament of users worsened, pressure mounted on politicians locally and nationally to do something. Switzerland (1986), the Netherlands (1994), Germany (1994), Spain (2000) and Australia (2001) were all running supervised injection facilities. 99 Also Canada broached the issue, opening its first facility in 2003. Responsible politicians spied a rare opportunity to demonstrate vigour and determination, in a more or less desperate attempt to contain the growing problem. Injecting rooms offered a relatively simple measure to organise – and would be relatively affordable too. 98 99 Harm reduction policies go back some way in Norway, with drop-in centres emerging in the 1970s. Originally dubbed “warm rooms” (“varmestuer”), these drop-in centres have since been known as “places to be” (“væresteder”) and latterly low-threshold cafés (“lavteskel caféer”). Practice apart, harm reduction as a concept in Norwegian rehabilitation work only emerged in the 1980s. Terminology varies from country to country. Some prefer ”user room”, others ”consumption room”; Norway chose “injecting room” (“sprøyterom”). 182 Much the same reasons induced other countries to set up injecting rooms (Hedrich 2004). What do Injecting Rooms Aim to Achieve? The official aims of injecting rooms are set out in the Regulations.100 Prevention of harm to health is the general objective; under this come four others: ■ help consolidate the dignity of heavy drug users ■ facilitate contact between drug users and the health and social authorities, and offer counselling ■ help prevent infection and the spread of disease ■ reduce overdoses (OD) and overdose mortality rates In our interviews with active drug users we asked them what they thought of these goals. None of our interviewees were critical per se, though some questioned the fourth aim, to cut overdosing and OD mortality rates. Given the small number of clients handled on a daily basis by the service, interviewees believed the impact on OD mortality rates would be limited at best. “Any effect would be like a drop in the ocean,” said one, to which another added, “and with us as the drops.” Comparing Norway’s objectives with those of other countries, we note for instance the more general phrasing of Germany’s goals. The two top objectives of the German scheme are 1. improvement of health for drug users living in the open or visible drug scene; 2. Reduction of the public nuisance caused by open dealing and drug use. (Zurhold et al. 2003) The Norwegian objectives are largely comparable with those of other countries, though with one major exception (Hedrich 2004; Gjesdal 2004). Norway has never seen reduction of public nuisance as the business of injecting rooms. We return to this aspect of the Norwegian approach below, in the section on sanitation. Do Injecting Rooms Bolster the Dignity of Clients? The Views of the User Organisations As mentioned above, two consultations were held on supervised injection facilities. The first took place in 2001 in an effort to elicit views on the 100 See note 3 above. 183 establishment of the service. It was a relatively limited consultation round, and none of the user organisations took part. The second, more wide-ranging consultation, was held in 2004 and concerned the Bill and Regulations. 101 This time, various organisations invited to take part, including in the drug-related field Recovered addicts Interest Organization (Rusmisbrukernes Interesseorganisasjon – RIO) and Tønsberg Users’ Association (BrukerForeningen i Tønsberg – BFiT), both of which submitted responses. I include here for the sake of relevance the submission lodged by the Norwegian Prisoners Association (Straffedes organisasjon i Norge – SON) as prison inmates frequently use drugs as well. BFiT and SON are organisations for active users of legal and illegal substances. RIO is for former users only, and any substance abuse (including alcohol) by members results in sanctions. The organisations are further described and discussed in the article by Willersrud and Olsen in this publication. In RIO’s submission, the organisation made their opposition to injecting rooms abundantly plain. Their objection centred on their interpretation of the term “dignity”, which in their view had little to do with the dignity envisaged with the injecting room scheme (RIO 2004). Dignity became one of the most frequently used arguments for establishing injecting rooms in Norway (Skretting 2001). In RIO’s opinion, injecting rooms are an undignified way of treating people; they imply in effect that users have no value. Injecting room “activists” misuse the word “dignity” in their advocacy of injecting rooms, because the scheme would simply underpin the lack of dignity. The organisation called instead for more detox clinics, stressing that active users have no conception of what is good for them (RIO 2004). RIO’s arguments are familiar enough, having figured in debates on Norway’s policy on drugs for many years. Coming from a different direction, Tønsberg Users’ Association (BFiT) came out in favour of the scheme. “This is something most of our members are looking for, and as a special interest organisation, it is in our opinion a fundamental and necessary initiative, one of a range of excellent low-threshold services” (BFiT 2004). BFiT are strongly opposed to what they term “self-appointed experts” defining what dignity is and what it is not, without ever having used a syringe, adding that “dignity as far as the user is concerned means being heard and having their needs taken seriously”. Given some background knowledge of the two interest organisations and their differences make it relatively easy to decipher the addresse of BFiT’s criticism, not least because their submission refers to an incident in which Oslo city council were reported to the police. According to the allegations, the council were aiding and abetting in the commission of a criminal offence by running the injecting room (Aftenposten 10 December, 2002). The charge was brought by the Alcohol and Drugs Forum 101 Consultation submission. 184 (Alkohol og narkotikaforum), a body set up by RIO and several other abstinence oriented organisations.102 SON are also in favour of the scheme. One finds in their submission also reference to the divisions separating the various special interest organisations, not least which of them knows best (SON 2004). SON support user organisations that conform with the Danish Drug Users’ Union (Brugerforeningen i København – BiK), keen advocates of injecting rooms in Denmark (Asmussen 2005). In my reading of SON’s submission, one senses an unwillingness on their part to go along with user associations like RIO, despite calls in the submission for better cooperation. The debate involving the various organisations is detailed by Willersrud and Olsen elsewhere in this publication. Admission Criteria As the bill was being drafted,103 it was made clear that admission would have to be regulated in some manner. Once registered as clients, however, users would be free to avail themselves of the facility as far as capacity allowed. A need was expressed to keep admission criteria to a minimum to preserve the low-threshold character of the service (Ot. prp. nr. 8 2004–2005). The admission criteria set out in the Regulations are as follows: 1) clients must be at least eighteen years old; 2) clients must be heavy heroin addicts; 3) clients may only bring one user dose of heroin into the injecting room, all other substances and amounts are banned outright; 4) and clients must be registered.104 Two further criteria were included in the draft law, but were thrown out by parliament.105 One of them required users to be involved in substitution treatment (LAR rehabilitation). The Standing Committee on Justice stated the following, however, 102 103 104 105 In addition to RIO they are: Aksjonen mot narkomani, Forbundet mot rusgift (FMR), Street Aid, Maritastiftelsen, Evangeliesenteret, Det Hvite Bånd, Storbyteamet, Juvente, Ungdom mot narkotika, IOGT Oslo and Akershus and Telebamsen. It is common legal practice in Norway to refer to opinions, submissions, intentions etc. made in connection with the preparation of legislation in Norway to interpret legislation. There is no exact equivalent in English for the Norwegian term “forarbeider”, but preparatory works, travaux préparatoires and legislative history are used. Forskrift om prøveordning med lokaler for injeksjon av narkotika (Sprøyteromsordningen). Forskrift 17.12.2004 nr. 1661 [Regulation No. 1661 of 17 December 2004 regarding pilot scheme with supervised drug injection facilities]. Odelstingsproposisjon nr. 56 (2003–2004) [Ot. prp nr. 56 (2003–2004), Ministry of Justice]. 185 It is the opinion of the majority that it is not the responsibility of injecting room staff to ascertain whether clients are undergoing substitution treatment (LAR), and the majority therefore sees fit to recommend the removal of this particular criterion. (Ot. prp. nr. 56 2003–2004) The criterion was therefore not adopted by parliament. The same considerations were brought to bear on the proposed criterion which would ban users from helping each other inject. Exactly how the criteria work in practice is discussed below in the section on consultation submissions from the user organisations and interviews with active users. What do Users Feel About the Criteria? Only a minority of our focus group participants said they would use the injecting room insofar as they had a place to live, and needed above all peace, quiet and security when they injected. A survey done in Sydney, Australia, of injecting drug users found similar reasons for preferring to inject at home rather than in the city’s injecting room (Wright & Tompkins 2004). Several focus group respondents said they would have no compunction about using the injecting room if they had nowhere to live. Some of the respondents with a place to live felt the medical advice provided by the injecting room staff sounded useful, partly because they injected in the groin, where the risk of bleeding is high. In an autumn 2005 survey of users of the Oslo injecting room, we asked about living conditions: 16 per cent had no permanent abode; 42 per cent owned their abode; 25 per cent were quartered in centres, apartment buildings or shelters; and 13 per cent lived with their parents. One of the most frequently cited reasons given by people with somewhere to live for using the injecting room is the safety aspect: the number indicating this reason was as high as 78 per cent (SIRUS, unpublished data). Talking to users of the injecting room in less formal settings, we discovered that some of them with a place to live use the injecting room out of consideration for others in their household, parents and/or partner for instance. While BFiT make no mention of the criteria in their submission, SON offer several observations. In general they are opposed to constraints because clients will be in a vulnerable position anyway and need whatever help the service can offer. RIO do not review the criteria per se, but they are not keen on admission criteria because in practice it is impossible to make sensible comparisons of injecting drug users. As the battle lines between the various user organisations on the injecting room issue are relatively robust, we felt it would be interesting to explore the views of the users themselves. Do they side with RIO or with BFiT, or with neither? 186 Indeed, to what extent do these organisations reflect the concerns and interests of the user population? During the focus group interviews and before handing out the admission criteria, we asked our respondents if they were aware of them. Although the interviews took place in the immediate aftermath of facility opening and none of the respondents had used it yet, at least one in every focus group was aware of the issues involved. Registration To become a registered user of the injecting room, applicants undergo a relatively strenuous assessment. Those who qualify receive a registration number they need to declare every time they use the facility. Users also need to complete a short form about substances and amounts taken in the past twenty-four hours. The information obtained about clients will be used later to evaluate the scheme. As it is defined in Norway as a health service, the staff are required by law to keep records. Users in each of the focus group interviews were quick to raise the subject of “control” before we got to mention it. Several were particularly dismayed about the detailed information required for registration purposes. One respondent put it like this: I know I’m paranoid … that’s why I get stressed out when they say you have to register and get a number. But … how in hell can we be sure who gets to see all this [information] or gets access to it, whatever you people tell us? One of the issues facing the pilot scheme came up in a discussion about registration procedures. While it is important to define the facility as a health service, with qualified staff on hand to provide care and information, the facility is not a health service in the generally accepted sense of the word. The Health Service Personnel Act needed to be amended before health workers could work at the facility. The conflict between having to keep records and running a lowthreshold service was partly mitigated by exempting facility staff from elements of the registration duty. At the same time, some level of registration is necessary to identify those who meet the criteria and obtain evaluation data. At Least Eighteen Years Old Clients must have passed their eighteenth birthday – the age of majority in Norway – to register. As the draft bill states, one of the main objectives of the pilot scheme is to prevent people turning to drugs. It is assumed here that not many under-eighteens sort under the category “heavy drug user”, and that those who do should be dealt with by the health service through other means than the 187 injecting room (Ot. prp. nr. 56 2003–2004). Not all of our interviewees agreed with the Ministry’s arguments on this point, however. I think the injecting room should be an intervention by which intravenous use by youngsters under eighteen is recorded, because there’s a lot of injecting users under eighteen. It’s important to explore the habits of this group, because it’s easier to get them to change. So just cutting the under-eighteens as an age-group out altogether is, in my opinion, plain stupid. The person who said this believes there are more injecting drug users under the age of eighteen than the government, and it is vital precisely for that reason to encourage them to use the injecting room. Most agree with the government’s policy of letting other parts of the health service scoop up these youngsters, but are not convinced that it actually happens. The speaker quoted below disagrees with putting age limits on welfare, and feels it’s up to the police to prevent drug use among the under-eighteens. Either you have to build police numbers to stop these kids getting hold of drugs, or open the welfare and health services up for them. That’s what I think. It’s obvious really. There is then a certain amount of dissatisfaction among the user groups we interviewed to setting the age limit at eighteen. The Norwegian age limit is identical to that of other jurisdictions, in Europe and further afield (Hedrich 2004). One User Dose of Heroin The point of banning substances from the injecting room apart from the single heroin dose users are allowed to bring is to prevent buying and selling on the premises. It was also a roundabout way of allowing heroin to be used in a restricted area of the health service without opening the sluices on heroin use and possession in general. An amendment was necessary to decriminalise possession of the single heroin dose intended for injection on the premises. This means that while all drug use remains illegal in Norway, a person can not be prosecuted for possession and use of a single user dose within the confines of the injecting room. If the amount of heroin had not been limited to one user dose, it would have created anarchy for the police. How could they be expected to enforce the ban on possession, use and sale of drugs if possession of unlimited quantities inside the facility was simultaneously exempt from prosecution? In practice it would have meant the decriminalisation of heroin, something Norwegian politicians are firmly against. Another problem associated with the decriminalising of the single user dose is the failure of the provisions to define what a single dose means in practice, 188 leaving it up to the police to decide whether a given amount represents an offence, who to charge and who to let go. Limiting the amount to a single dose is impractical however you look at it, according to SON, because it varies from person to person, and it is cheaper to buy several days’ worth of the drug at the same time. This variation in what a user dose is in practice was touched on in a conversation between two of our respondents: A: A single dose, that’s a packet or a gram or half a gram, or what is it? B: How do they know if you’ve brought one or ten [doses] with you? A: A dose, that’s…. B: It depends. Respondents also wondered how the injecting room staff were supposed to tell how much a client brought into the facility. This was a question the drafters of the law pondered as well. Although on occasion staff might find it difficult to determine the substance or the quantity, it should be possible to do so in most cases. How they were expected to do this, however, was not specified (Ot. prp. nr. 56 2003–2004). And while user doses may vary, a limit has to be drawn somewhere, as several of the consulted bodies pointed out, including the National Police Directorate. Several interviewees said much the same. A: It can be anything from a quarter [0.25 grams] to a half gram. B: That’s right, from a zero-point-one [0.1 grams] to a quarter, half a gram or a gram. A: There aren’t that many who use a whole gram for one dose. B: No, true. A: But half a gram, that’s common enough. B: Half a gram is normal, but not a whole gram. In light of the signal effect, RIO criticised this haziness about what a dose added up to in practice. They opposed exempting doses used in the injecting room from prosecution. It is hardly surprising to see opponents of injecting rooms criticising this aspect of the scheme, because it is virtually impossible to enforce the regulations to the letter. It would be out of the question to instruct health personnel and social workers to search people’s pockets and bags for drugs over the quota. That is a job for the police, and only the police are authorised to do it. Injectable Heroin Only It was the overdose risk that lay behind the ban on other substances; the risk increases when heroin is mixed with other drugs. The authorities also wanted to convey a message. “Allowing the consumption of other drugs in the injecting room could be interpreted as tacit support for the practice.” Heroin is injected more frequently than other drugs, the authorities added. The habit of combining drugs goes against the grain of the project, and indeed operative 189 recommendations (Ot. prp. nr. 56 2003–2004). A large number of the consulted bodies and organisations were averse to a ban on all other substances in the injecting room, but the scheme’s basic premise effectively ruled out any such leniency. If the point were only to secure the dignity of the drug users, one could perhaps have considered allowing drugs other than heroin. But the pilot scheme is there to serve other purposes, such as reducing overdose rates and harm caused by the injection process. (Ibid., 4) Heroin is the main substance used in supervised injection facilities in other jurisdictions, though cocaine is also permitted (Hedrich 2004). While cocaine is not widely used in Norway, it is increasingly common to inject Rohypnol together with heroin. SON advocate relaxing the rules to allow drugs other than heroin to be injected in the injecting room. Many are dependent on other substances and tend to inject them together with heroin. It was this aspect of the regulations the respondents were most aware of prior to the interviews. They wanted freedom to mix heroin and Rohypnol; without it, many said they would never use the injecting room, because they depend on both drugs. Heroin on its own doesn’t give them the right “fix”. Others, however, were not convinced of the magnitude of the problem. That stuff about only heroin having to be injected in the room, it’s OK it’s in the law as long as nobody checks what you put on your spoon and heat up, so there’s a tiny loophole to add other stuff as well. And that’s fine. Staff would hardly be scrutinizing what people put into their heating utensils and syringes, this informant believed. But in practice, staff are often aware of attempts to mix substances, especially if Rohypnol is involved. The drug’s strong colour makes it relatively easy to spot. The next time a person suspected of mixing drugs turns up at the injecting room, s/he is told where they stand and given a warning. Nevertheless, a significant proportion probably do get away with mixing drugs, something our interviewees expected would happen. … you could have a screen. You’d be on your own, and could make your compound without nurse seeing what you’re doing. And I’m pretty sure that’s what’s going to happen down there, I think. As the quotes show, having a chance to inject a mixture of drugs is clearly important to many users, and a ban in itself is insufficient to turn them into users of heroin only. Heavy Drug Users To gain entry, a person needs to be categorised as a “heavy drug user”. The clause was included to prevent “people using the injecting room to try heroin for 190 the first time in a supervised setting”. Not defining what “heavy drug user” meant was a deliberate omission; politicians wanted to leave it to the discretion of the injecting room staff (Ot. prp. nr. 8 2004–2005, 14). Injecting rooms in other jurisdictions apply more or less the same criterion (Hedrich 2004). But what is a “heavy drug user”? Some would say anybody who uses heroin; others anybody who injects. One of our interviewees offered this definition: Heavy drug user, someone who’s hooked on heroin whether it’s been for six months or ten years. Doesn’t matter. Others envisaged more strenuous criteria, and offered reflections to that effect. And what do you think they look like then? Totally washed out or something? A discussion between two users illustrates the disinclination to categorise oneself as a “heavy drug user”; they believe outward appearance determines how others are likely to categorise them. A: It depends on how you feel as well. Ergo, I’m… B: Ergo you’re stigmatised again. OK, so I’m a really heavy user myself [ironically]. A: The day you visit the injecting room, dress as shabbily as possible. B : I only hope to God I don’t look like a heavy drug user. I expect we all try not to look like one. As the discussion shows, restricting admission to “heavy” drug users appears to be working exactly as envisaged by the authorities. It is assumed by the drafters of the bill that the term “heavy drug user” would in itself serve to limit potential clients. Some of the members of the Standing Committee on Justice wanted to go further than the majority and let clients rather than staff decide whether they fitted the term. “The door to the injecting room should be open to those who define themselves as heavy drug users, a designation hard enough to apply to oneself” (Ot. prp. nr. 8 2004–2005, 13). As the user quoted below makes clear, some are completely averse to the label. Indeed, going along with the definition would be humiliating. You feel like you have to bow down, you know … filthy clothes and … just dirty all over sort of. Put your shoes on your hands instead. Crawl through the doorway. In assessing a potential client’s admissibility, the drafters of the act wanted staff to take account of his/her self-definition. But as the above quotes show, our respondents do not feel run down enough to fit the description. (This despite living at one of Oslo’s low-threshold shelters, normally a place one would expect to find the city’s heaviest drug users.) There is an echo here of the introduction of methadone treatment in Norway in 1994. The intention of the methadone pilot scheme, according to Frantzsen (2001), was to help the fifty eldest and most 191 derelict drug users. Frantzsen described how several addicts began compiling files to describe how wretched they were. It spurred the adolescent psychiatry section at Ullevål Hospital to wonder whether the project had not made applicants more wretched. At the same time, the selection criteria adopted by the methadone project were so strict, even the most run down found it difficult to pass muster. For instance, they needed to be “drug free” in the week before starting their course of methadone treatment. But at the same time, their ability to function had to be very low indeed; otherwise they wouldn’t be “wretched” enough. In Frantzsen’s considered opinion therefore, the project criteria effectively kept the people for whom the project was designed from participating in it (Frantzsen 2001). We see something similar with the injecting room project. By requiring clients to be heavy drug users, politicians and authorities are clearly indicating a desire to reach the most down and out and debilitated users. But at the same time, this is where dependence on a mixture of drugs is the most prevalent. In other words, the most needy users are unable to satisfy the admission criteria. Injecting room clients need to be “down and out – but only to a degree”. Our respondents felt the registration criteria raised several problems. Did they fit the bill, or were they too functional perhaps? A likely consequence of this could be that the people in the target group simply refrain from registering because in their own judgement tells them their habit isn’t “heavy” enough. Nevertheless, the present criterion is wider than the methadone project’s. And in practice, it is extremely difficult for staff to send people away on grounds of not being “heavy” drug users if clients themselves claim to fit the label. Control Versus Necessity The users we interviewed experienced registration criteria as a form of control. Their critical submissions contrast strongly nonetheless with the popularity of the service. Could it be that the criteria prompt a range of opinions among clients or could there be other explanations for the discrepancy? An exchange between two of our respondents suggests people feel it is better to pay the price of submitting to control than having to inject in filthy doorways, with security guards and police ready to pounce on every corner. A: If I hadn’t lived here now, I’d have to say I’d have used it [the injecting room] myself. If the alternative was a filthy multi-storey car park or something. Not to mention security guards waiting to throw themselves at you. B: It’s the way things are today, we have to find somewhere to do it. It’s a pain, but manageable. B: True, but when I’m sitting in an injecting room, even with all those controls and stuff, at least I know there’ll be peace and quiet, nobody ready to jump on me. 192 Their fear of what they term “control” has to do with the city’s approach to control. Following a period of relative lenient policing of possession and use, a stricter line came into force again from mid-2004. Before then, injecting drug users tended to congregate in the square in front of Oslo’s main station, the drug trading centre since the end of the 1990s. With the introduction of low tolerance policing, however, this author has only seen a single instance during the monthly surveys of the drug scene in Oslo centre of an injection administered on the street. The higher stop and search frequency is the likeliest explanation. Users we interviewed were not at all sure how the police would react to the injecting room and its clients, as the quote below illustrates. Theoretically speaking, the police can park themselves outside [the injecting room], and then just pounce on people in order. When people come and go, I’m pretty certain they’re going to keep the place under surveillance and make notes. That’s my personal opinion. Because you might be bringing … I was going to say five grams and a hundred Rohypnol with you, you know. It’s one reason at least I’m staying clear of that injecting room. The quote reveals no confidence in the ability of the police to handle the injecting room issue with tact. But the control implicit in the registration criteria is not the only thing feared by the users. They are also afraid of being stopped and searched on their way to and from the facility. The opinions of the interviewees contrasted with the popularity of the injecting room suggest that people are not willing to let concerns about the registration criteria and control stop them from using the service. Issues Connected With Establishing the Injecting Room The intensity and range of the debate accompanying the opening of the injecting room give some indication of the problems involved when services of this nature are given the go ahead and run by the state. Drugs are illegal in Norway, and will remain illegal; however, some of the country’s drug users have permission to inject heroin under the supervision and guidance of state-employed health workers. How is this possible? Clearly, setting up and operating the injecting room bring a number of difficult issues to the fore. What is the Position of the Police in Relation to the Injecting Room Scheme? When the guidelines were made known, criticism was not long in coming. Impunity for possession of heroin in the injecting room posed a serious challenge, said the police. How were they supposed to enforce this regulation? 193 While possession of a user dose of heroin is an offence outside the injecting room, it would be disloyal of the police to position themselves outside such places with the intention of stopping and searching persons on their way in. On the other hand, “being on one’s way to the injecting room” cannot be taken as a reason to sidestep the law. (Director of Public Prosecutions, 22 December 2004) This formulation is not very clear on how police officers are supposed to act on the ground. Indeed, as the Director of Public Prosecutions himself admits, it is impossible to apply hard and fast rules wherever local councils decide to open an injecting room; local police chiefs, he adds, must instruct the police in their own district (ibid.). In the event, however, the problem never materialised. During the first months of operation, the police left clients alone. This in turn raised another issue. Is it fair to let registered clients of the injecting room walk around in possession of a user dose with impunity, while other drug users remain liable to prosecution for doing the same thing? Sanitation? To sanitise something means to spruce it up by removing unwanted elements. Oslo city council’s waste management division collects rubbish, for instance, and makes the city tidier, neater. In the same way, sanitation as a metaphor106 has been used of policies intended to remove undesired elements from the public eye. It used to be a widely accepted strategy in Norway, as the (now historical) Vagrancy Act testifies.107 Under the Act, public drunkenness could result in a fine or incarceration with hard labour. When the Act was amended in 1970, public drunkenness ceased to be an offence and hard labour a way of dealing with homeless alcoholics was abandoned. It was widely hoped that the injecting room would be used by the drug scene in the Skippergate area,108 not only for the good of the drug users themselves, but for local businesses and the public. While Norwegian politicians shy away from saying so outright, it is obvious that injecting rooms improve public order by reducing injecting in public places. In other jurisdictions, cleaning up the streets has been one of the main aims (see e.g. Hedrich 2004; Reinås & Cron 1998). And it is true that the injecting room remove the act of injecting from the public gaze. We do not know where injecting room clients would have injected in the 106 107 108 The Norwegian term used here is renovasjon. It has the dual meaning of renovation in the usual sense (renovation of buildings, art works etc.) and waste management / waste disposal etc. Lov av 31. mai 1900 om Løsgjængeri, Betleri og Drukkenskab (Act of May 31, 1900, relating to vagrancy, begging and drunkenness). After the square beside the main station was cleared, the drug scene shifted to Skippergata, a few hundred metres further south. 194 absence of the injection facility, but many would doubtless continue to do so in public. In an autumn 2005 survey of injecting room clients, 69 per cent said their last injection would have taken place outdoors somewhere if the injecting room didn’t exist (SIRUS, unpublished data). Several members of our target group broached the subject independently. Some felt treated like dirt by the authorities, and that waste management was what drugs policy was all about in reality. I feel really strongly … that the authorities are trying to hide us away as far as possible…. But they need to realize once and for all, they’ll never get rid of us. Drugs will always be there. We’re always going to be part of the street scene. They can’t get rid of us. However hard they try. When the Vagrancy Act was repealed in 1970, the motion’s spokesperson asked his parliamentary colleagues where it was written that derelicts were a sanitation problem, adding that As long as our society creates vagrants, we must accept the fact head on. It is better to have a true picture of the city than a clean picture. (Mathiesen 1975) Although it is more than thirty years since this was said, it has lost none of its significance. One important difference between the 1970s and now is that back then, people dared call vagrants a sanitation problem openly. Norwegian politicians today take great pains to hide how far policy making relies on this type of thinking. Government anti-drug action plans usually include phrases to the effect that how a city looks should never serve as a measure’s only justification.109 The leader of the Conservative Party (Høyre) stated in 1973, as reported by one of Norway’s major papers, “if we want to ensure progress, we move quickly to eliminate what we might term spanners in the works” (ibid.). In 2005, the police officers’ association suggested that sanitation had been a major factor in the 2004 efforts to relocate the drug scene in the city centre. “This is outrageous!” the leader of the Department of Welfare and Social Affairs in Oslo’s Conservative City Council rejoined, “improving the look of the city has never been a motive, we have only ever had the drug users at heart” (Aftenposten, 3 March, 2005). On the other hand, several drug users interviewed by us agree about the need to take account of the feelings of the public about the drug scene. One interviewee put it like this: It [the injecting room] is a brilliant way of shielding [injections] a bit … I’m thinking about tourism and the public, you know. Even though I do it myself, it’s horrible to watch. Avoid sitting in doorways and mainlining. I’ve done that too, but I don’t think I would today. So I hope that’s a thing of the past now we’ve got an injecting room. I really do. 109 Two instances of which are Regjeringens handlingsplan mot rusmiddelproblemer 2003–2005 [Government action plan on problems related to drug use 2003–2005] and Tiltaksplan for alternativer til rusmiljøene i Oslo sentrum [Alternatives to the Drug Scene in the Centre of Oslo – A Plan of Action 2003–2005]. 195 Skretting (2003) observes concerning the steps taken in 2003–2005 to disband the city centre drug scene 110 that an obvious aim was not only to secure better health and social services for drug users, but also to clean up the streets. She is confident the same can be said of the decision to set up the injecting room. Unconditional Help or Encouraging a Harmful Habit? One could see the injecting room as encouraging people to inject drugs. Users could interpret it along the lines of “we’ve given you lot up, just feel free to carry on injecting harmful substances”. We know that injecting does more physical damage than taking drugs by other routes, like smoking for instance. We also know that injecting is the preferred technique in Norway; only a minority smoke heroin or use other techniques. Is it then justifiable to make it easier for people to perform as hazardous a technique as injecting potentially lethal substances in reality is? Coming from this angle, ideas about securing dignity and respect don’t have much chance, if by dignity we mean that drug users are people with a potential to grow and develop in many ways were it not for their drug habit. Others would say that dignity is being accepted as one is, non-judgementally. That it is chiefly through encounters of this nature, for instance between users of the injecting room and staff, that the seed to an enhanced sense of self and improvement of the individual’s life situation is shown. Perhaps the authorities should have set up a smoking room instead, or at least one in addition to the injecting room, with a view to motivating injectors to smoke heroin, and improve people’s chances in that way? How much the authorities could and should do to facilitate harmful habits among the citizenry is anyway a question requiring constant reappraisal in connection with the design of what we term “harm-reducing measures”. Can we envisage a situation where it was clear that “things had gone too far”? Has establishing the injecting room where staff are not allowed to inject the drug shifted the goalposts? Staff are employed to supervise and guide clients, not to inject the substance into his/her body. At a general level, it is harder to say where the line should be drawn. Should we allow injecting rooms and not allow prescriptions for illegal drugs? Should we allow the prescription of substances in organised drug programmes, such as the heroin prescription project in the Netherlands, or even go as far as letting high street chemists dispense substances free of charge? One would be justified in thinking that the discussion of where to draw the line will become increasingly urgent in the years ahead. 110 The steps commented by Skretting are set out in Tiltaksplan for alternativer til rusmiljøene i Oslo sentrum 2003–2005 [Alternatives to the Drug Scene in the Centre of Oslo – A Plan of Action 2003–2005]. 196 Double Message One pertinent question raised in the discussion on injecting rooms concerned the initiative’s legitimacy in light of Norway’s wider intentions to achieve a “drug free society”. It is not easy to deal with this type of duality, as several interviewees pointed out. It’s illegal to use heroin in the city, so why are we allowed to shoot heroin there? Not unexpectedly, the proposal to organise an injecting room sparked a fierce debate which not unexpectedly turned into a debate about the basic design of Norway’s drugs policy. Papendorf (2004) explains why the discussion focused so quickly on the premises of drugs policy in Norway. The corollary of advocating for injecting rooms is to admit that the vision of a drugs free society was misconceived. The struggle for the injecting room which dominated the public discourse during the summer of 2003, has in this sense a highly important symbolic value. If the struggle is lost, advocates of the drug free society will have lost the battle. (Papendorf 2004, 42) That the injecting room was established could be taken as indicating that powerful special interests of politicians and the public per se also regard harm reduction as an important drugs policy premise. The debate surrounding the injecting room made clear the strength of the views lined up on either side, and the establishment of the injecting room is proof that we in Norway are trying to give something to both sides at the same time. We want a drug-free society and we want harm-reducing measures for those in need of them. Many believe this to be a difficult, if not impossible, combination. The admission criteria adopted by parliament were doubtless necessary given Norway’s general position on drugs, and micro-management was probably necessary to make the proposal politically acceptable. Commenting on the government’s drafting of the bill, the head of the national Data Inspectorate said, “One hears the term grudging used of the consultation paper compiled by the Government, something I find easy to understand insofar as its authors do not appear to believe it is a good idea” (www.nrk.no 2005). Oslo city council go so far as to say in their response to the consultation paper that the pilot scheme is hardly practicable at all, given the many compromises required of the various vested interests (Oslo Kommune 2004). This recalls the climate surrounding other controversial harm-reduction projects, such as the German heroin project for instance. Papendorf (2004) describes how that programme’s stringent admission criteria turned it virtually into a “high-threshold project”. Heroin may only be administered intravenously – a requirement of the Norwegian injecting room also. But if we ask how these relatively inflexible rules came to be adopted, Papendorf says as follows: we are shown in the direction of the political concessions required to get the proposal through. At the end of the day, it is about achieving a political 197 compromise without which the project would never have left the starting blocks. (Papendorf 2004, 54) Frantzsen was led to the same conclusion in her study of the methadone project. It was the result of wheeling and dealing, something else entirely than a welljudged and well-considered project, she says (Frantzsen 2001). Conclusion One of the key issues with the establishment of the injecting room concerns the likely benefits of the service to society. Will it help cut overdose rates? Will it ease contact between the health and social welfare authorities and the drug users? Are individual clients likely to feel more valued? Will it result in less physical harm among the target group? It is too early to assess achievements and consequences. There may be unanticipated consequences, beneficial and/or harmful. The authorities and most active drug users share a generally optimistic view of the service’s ability to work as intended. A large majority of the active drug users we interviewed were clearly in favour of the injecting room because it would make life less complicated in the longer term, as envisaged by the authorities. Among former drug users, the injecting room meets with less unmitigated enthusiasm; in their opinion, its objectives will probably not be achieved to the extent anticipated. The organisations of active users are actually more likely to reflect the views of the target group in the injecting room debate. Several issues about the injecting room informed the public debate. One of them focused on the registration procedures and criteria required to ensure optimal operations. A certain amount of control of clients and the way in which the facility is used is necessary to ensure safety and allow for evaluations later. But at the same time, it is supposed to be a low-threshold service. As a further issue, the injecting room may strike some as rather incompatible with Norway’s averred drugs policy, jeopardising the coherence of the government’s message. How is it possible for a country which holds to a vision of a drugs-free society to open an injecting room? It may be possible to uphold the vision while acknowledging the conditions under which drug users live, and attempt to do something for them. But in extension, one could question the point of maintaining the vision at all. The third issue revolves around what I called above the sanitation aspect. How far is the injecting room an expression of a desire to clear undesirables off the streets? Norwegian politicians are unwilling to admit its relevance to prevent public nuisance and other measures directed at the drug scene. There is no doubt that the public are disturbed by the sight of people injecting drugs, and that consideration of the public good informs policy making. One can only hope this 198 discussion will proceed in a climate of openness where all voices are given a hearing. The question forming the fourth issue is whether using the injecting room is dangerous in itself. Injecting potentially lethal substances is hazardous not only because of the risk of overdosing but because it harms the body. Can the authorities morally justify to make it easier for people to pursue harmful activities of this nature? And if there is a limit to society’s toleration of harmreducing interventions, where does the cut-off point go? The final issue at the present stage is to do with the position of the police on the injecting room pilot scheme and impunity for possession of a single user dose when intended for injection on the premises. Is it fair to let clients of the injecting room carry a user dose with impunity on the street, while others with similar amounts risk prosecution? Isn’t there supposed to be equality before the law? In the heated debate leading up to the opening of the centre, “injecting room” increasingly sounded like a magical incantation, as if saying the magic words would make all problems besetting official drugs policy go away. It is not a magic spell, of course, and there are clear limits to what an injecting room can do, either for individuals or the community as a whole. An injecting room does not affect the marginalisation of drug users. The life of the clients will remain more or less unchanged whether some of the injections are performed under professional guidance and in hygienic surroundings. Personnel have an opportunity to engage with the clients, referring them to other health and social welfare agencies and programmes, liaising between various parts of the “system” better placed and equipped to help the individuals in question. However, the admission criteria may in fact be excluding some members of the target group. The criteria probably dissuade many from giving the service a try, believing they have little hope of passing the admission test anyway. The injecting room’s impact on public order will be limited. Insofar as public order or sanitation is one of the premises of the injecting room, as long as it remains a noncompulsory service, its “sanitation” impact can only be limited. Whether drug users avail themselves of the service or not is up to them, and there is no evidence the city centre drug scene is declining in the wake of the service’s establishment. There will always be a large number of injecting drug users who, for various reasons, are not interested in becoming clients of an injecting room. As the service is organised today, not only is the number of registered clients limited, opening hours are restricted as well. Many are disqualified because they are under age, use the “wrong” type of drug, or were simply too late to register. When the final batch of thirty clients was registered, applicants were asked if they lived in Oslo and whether they intended to use the centre on a regular basis. 199 Again, one wonders whether it is fair to proceed with a service which only benefits a small minority of drug users. Who needs the injecting room most of all, and are they the ones registered as clients of the service? This is an urgent question because we are dealing here with an intervention which, at the end of the day, is intended to save lives. It is a difficult question to answer, and was only cursorily addressed before the injecting room opened. Translation: Chris Saunders References Aftenposten 3.3.2005: Elendig oppfølging av plataaksjonen [Hopeless management of Central Station Action Plan]. Aftenposten 10.12.2002: Anmelder Oslo for sprøyterom [Brings charges against Oslo City on injecting room count]. Asmussen, Vibeke (2005): Fra fixerum til sundhedsrum – den danske situation og debat [From injectng room to health room – The Danish situation and debate]. Nordisk alkohol& narkotikatidskrift, 22 (1): 66–70. Asmussen, Vibeke & Jöhncke, Steffen (2004): Indledning: Perspektiver på brugere [Introduction: Perspectives on users]. In: Brugerperspektiver. Fra stofmisbrug til socialpolitik? [User perspectives – From drug misuse to social policy?]. Århus: Aarhus Universitetsforlag, pp. 9–38 BFiT (2004): Høringssuttalelse om sprøyterom [Consultation response on injection rooms]. Director of Public Prosecutions (Riksadvokaten) 22.12.04: Sprøyterom [Injection rooms]. Forskrift om prøveordning med lokaler for injeksjon av narkotika (Sprøyteromsordningen). Forskrift 17.12.2004 nr. 1661. [Regulation no 1661 of 17 December 2004 Regarding pilot scheme with supervised drug injection facilities]. Frantzsen, Evy (2001): Metadonmakt. 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User Participation in Danish Methadone Maintenance Treatment Vibeke Asmussen Introduction User participation, in the context of social work, is a concept that holds a multiplicity of meanings. In general, it is understood as providing users of social services with greater control and influence over their own lives. User participation can be analysed as an ideology and/or as specific techniques used in social work (Asmussen 2003; Asmussen & Jöhncke 2004; Bjerge 2005; Schwartz 2001). The present article focuses on how techniques of user participation are applied in the practice of social work. It sets out to discuss two ways of giving users influence over their own lives: 1) through the implementation of legally prescribed techniques to encourage user participation in social services, and 2) through specific performances of the relationship between user and social worker. The article is based on experiences of user participation at four Danish methadone maintenance clinics. User participation in social services became statutory in Denmark in 1998. The new Act on Social Service prescribed two kinds of techniques for user participation: user councils (a user participating forum) and social activity plans (a user participating tool for organising and coordinating treatment). Since these methods are statutory, I understand them as formal techniques of user participation. However, the experience from the four clinics was that both of these techniques were difficult to implement. Despite these difficulties both staff members and users themselves felt that there was a high degree of user participation at the clinics. This feeling, I will argue, was embedded in specific performances of the relationship between social workers and users. The concept of “user” implies in itself a rethinking of the relationship between user and social worker. Adams (1996), for example, describes how a “user” is understood as a resourceful person, an expert in his or her own life, who actively participates in changing his or her situation, in opposition to the “client”, who has connotations of a weak, dependent and powerless person who passively receives social services. The social worker provides solutions to the “client’s” specific needs. The “user” and the social worker, on the other hand, engage in a partnership and the social worker help to facilitate changes in the user’s life. The 202 empowerment perspective places the “user” and his or her own perception of the problems in the centre and so returns to him or her the power to change the situation. In this way empowerment is fundamentally about democratising the relationship between the user and the social worker or institution and giving the user greater influence over his or her own life. At the four methadone clinics, the relationship between user and social worker was based upon a sense of trust instead of control, it was more pragmatic, and made use of support contact person schemes (støttekontakt-person ordning)111 in order to help drug users with the problems and life circumstances that they had defined themselves. I describe these specific performances of the relationship between user and social worker as informal techniques of user participation. Formal techniques of user participation focus more on different ways of organising social work, whereas informal techniques focus more on how the relationship between user and social worker is performed. The two techniques should not be seen as mutually exclusive, but rather as interdependent. In the following I describe and discuss two important issues related to user participation: First, why is it so difficult to implement formal techniques of user participation in methadone treatment; and second, how do the above-mentioned informal techniques actually empower users in their own treatment? The adoption of an empirical approach to user participation and to experiences of both formal and informal techniques of user empowerment has two main aims: 1) to draw attention to some of the practical dilemmas involved in formal and legally prescribed techniques of user participation and 2) to show how other techniques can give the user possibly even greater influence over their own treatment than legally prescribed techniques. The article is based on a three-year qualitative study of the four methadone clinics. The descriptions and analyses are based on 42 qualitative interviews with counsellors and 37 qualitative interviews with users. In addition, participant observations were conducted at all four clinics. One of the key aspects of the study was to examine the interplay between the different actors involved. Here I focus exclusively on the interaction between counsellors and users in regard to user participation. The Four Methadone Clinics In 1999 the Danish parliament decided to set up a pilot on methadone treatment with extended psychosocial support. This pilot was intended as an alternative to a heroin trial. Instead of changing the substitution drug used – from methadone 111 In some respects the support contact person scheme can be compared to case management or a trajectory manager. The Danish version of this initiative is described below. 203 to heroin – the aim was to find out whether extended psychosocial support could improve the effect of treatment with methadone. Four new methadone clinics were set up for a term from 2002 to 2004/2005 using various types of extended psychosocial support (Asmussen & Kolind 2005). The four clinics all focused on user participation as a way of motivating users to get involved in their own treatment and thus of achieving better results from extended psychosocial treatment. The four clinics were located in Korsør (A), Silkeborg (B), Århus (C) and Copenhagen (D) (see Table 1). Three of the four clinics (A, B, C) enrolled the most seriously affected drug users and, like heroin trials elsewhere in Europe, focused on offering beneficial treatment to drug users described as “treatment resistant”. Among the specific criteria set for these users, they were to be aged over 30, have more than ten years' history of heroin abuse, and have tried various forms of treatment. They were all users who were known to the treatment system, but they had either failed to adhere to treatment programmes aimed at reducing the physical damage resulting from active abuse, or they had not benefited from the treatment they had received. In contrast, the fourth clinic (D) did not enrol a defined target group. Here the users were selected randomly from standard treatment programmes in Copenhagen and the user group was much more diverse (Asmussen et al. 2003). The discussion below demonstrates the relevance of this difference between the users enrolled with regard to user participation. Extended psychosocial support in the four projects has relied on a very low counsellor/user ratio (see Table 1). Table 1. User/counsellor ratio in the four methadone projects. Project A B C D Counsellors 4 2 6 8 Users 28 11 30 60 Ratio 1:7 1:6 1:5 1:8 At all four clinics, extended psychosocial support consisted effectively of an intensification of methods and initiatives already used in methadone treatment, such as counselling, therapeutic interviews, and the provision of training and employment opportunities. At the same time, new methods and initiatives were introduced, such as drop-in centres. Counsellors also provided users with help as part of the support contact person scheme, assisting them when they needed to visit the doctor, dentist or welfare office. Other elements included social activity plans, user councils, and various kinds of activities (e.g. sports, handicraft or picnics). Counselling was offered whenever needed by the client, or at least every other week. In standard treatment it is not unusual that counselling is provided only once every three months (Pedersen & Asmussen 2002). New initiatives, for their part, are either non-existent or very rare in standard 204 treatment (ibid.). Initiatives such as user councils, social activity plans, and the support contact person scheme are therefore all new forms of psychosocial support in methadone treatment in Denmark (Asmussen & Kolind 2005). Legal Aspects of User Participation: User Councils and Social Activity Plans User participation became statutory in Danish social services with the introduction of the Act on Social Service in 1998 (Asmussen 2003). The Act prescribes various techniques of user participation techniques. The technique used for involving users at an organisational level is that of user councils, at an individual level that technique is social activity plans. Below I outline what these two types of participation imply.112 User Councils: Organisational Participation A user council is a democratic forum where users and staff and/or management within a treatment institution can work together to discuss and make decisions on various factors concerning treatment. A user council can be set up in different ways. Users can be elected or selected to sit alongside staff representatives and managers. User councils can also be open to all users who wish to participate along with staff members or managers.113 In the brochure User participation for vulnerable groups, Thomsen (2000) identifies the following areas in which user councils can be involved: a) the formulation and approval of a philosophy for the treatment institution, b) specifying targets, methods and subsidiary goals for the initiative, c) physical layout, d) house rules, e) opportunities to give opinions on recruitment and dismissal of staff members, f) the creation of concrete services or treatment offers, and g) being informed about and allowed to express opinions about all 112 113 A third type of user participation prescribed in the Act on Social Service could be called participation at a political level. This means that users have a visible voice in political fora and in public debate more generally. Political participation requires the involvement of user organisations where they have the opportunity to contribute to the relevant political debates. The guidelines for this political involvement are laid down in §114 and §115 of the Act on Social Service, where the municipalities or counties are called upon to set up advisory cooperative bodies to which voluntary organisations can be invited to discuss the organisation of an initiative. In this publication Jørgen Anker discusses this aspect in his article about the Danish Drug Users Union (DDUU). The Act on Social Service does not explicitly specify user councils as the forum that social services must establish to allow user participation. It does, however, prescribe that the municipality shall establish councils for users and relatives in connection with nursing homes, and this comes immediately after §112 which states that municipalities and counties have a duty to ensure that users can exert an influence on social services. 205 issues of significance to the user group (Thomsen 2000, 38). The reason I have chosen to mention this brochure is that it is aimed at vulnerable groups and it was produced as a type of guidance or inspiration for the user participation prescribed by the Act on Social Service. The possibilities that according to Thomsen are open to user groups, as we will see later, are far removed from the functions allocated to user councils at the four clinics. Social Activity Plans: Individual Participation The Act on Social Service requires that social activity plans are drawn up jointly by the municipality’s social security office and methadone treatment centre in close consultation with the user. The plans must be based on the user’s own terms.114 The Act further states that the social activity plan must be produced in writing and specify the ultimate goal for the user. It must detail the initiative that is necessary in order to achieve this goal, how long it is expected to take, and include other circumstances such as accommodation, employment, personal help, treatment or necessary aids. In other words, the social activity plan sets out what is expected to happen to the user in the planning period. It is aimed at changing or improving the user’s situation. Social activity plans should be revised after a certain period, for example six months. This should include an assessment of what has been achieved during this period and a listing of the priorities for the following six months.115 Formal Techniques of User Participation in Practice: Opportunities and Limitations The following proceeds to describe how user councils functioned at the four clinics, the difficulties they encountered, and suggests reasons as to why it is so difficult to implement user participation in the form of user councils in methadone treatment. This is followed by a corresponding discussion for social activity plans. 114 115 Social activity plans are described in §111 of the Act on Social Service. It should be stressed that methadone treatment can also involve plans other than §111 social activity plans, such as treatment plans. The discussion here is confined to legally prescribed social activity plans. Mahs (2002) emphasises that it is unclear who is ultimately responsible for the implementation of social activity plans and how often they should be followed up. In this respect there is room for interpretation. However, social activity plans have been devised as a tool for coordinating the initiative between various systems and in such a way that the individual user or citizen can be involved in the process. Social activity plans hence also have an important coordinating function, which I shall not deal with here. On this topic, see Asmussen & Kolind (2005, 58–75). 206 User Councils The preferred form of user council at all four clinics are meetings that are open to all users, with the participation of one or more staff representatives. The following case illustrates what was put forward for debate as well as the general procedure at such a meeting. The user meeting is held just before noon. Lunch is served today so many of the users are present. There is some confusion among staff members before the meeting gets under way, and a counsellor goes round to check among the users whether they are coming. Several users say they do not want to attend. One of them, however, is very interested; he says he goes to every user meeting because it gives him a chance to exert influence. The meeting begins, and the counsellor asks whether they should start by drawing up a weekly plan. There are four users at the meeting with the counsellor. One of them complains about the poor attendance: “it’s just not good enough that 20 people are sitting in the café and cannot be bothered to come.” Another user suggests that those who do not join in should not be allowed to have a meal. The counsellor ignores this, and asks again whether they should draw up a weekly plan. He explains that the centre will be closed on Friday because of the public holiday, and that they will therefore serve the traditional warm wheat rolls on Thursday. He also explains that on Thursday the centre will be open until 14:00 instead of 12:00, because on Wednesday it is closing early at 10:00. No explanation is given to the users about these changes in opening hours. A user enters the room and sits down to join the meeting. The counsellor continues, saying that because of the changes to opening hours, Wednesday’s and Thursday’s activities will have to swap places so that the meal and swimming will be on Thursday. Two users interrupt and say they do not want to go swimming on the Thursday, because their girlfriends are coming on Wednesday. They would rather cancel than reschedule. The counsellor accepts this. He suggests that they have a day out on the Thursday and make a visit to the Scandinavian Animal Park, for example. One of the users asks about departure and return times. There is some discussion as to how long the drive takes. Then the counsellor says: “So, we all agree then, do we? Scandinavian Animal Park on Thursday.” Nobody really answers. The counsellor carries on: “I suggest we all go on an outing together in the summer, like last year. Maybe it could be a canoe trip?” One user complains and says he does not want to go, because he is sure he will only end up falling in the water. Another user says he would like to go. He grew up with canoes. They fail to agree on whether or not they should go on a summer outing. Instead, the counsellor makes a couple of announcements before asking: “Is there anything else we should talk about?” The users say no, but two of them start complaining again about the absence of the other users. The user who was last to enter agrees, even though he has taken no active part in the discussion. The counsellor does not join in, but as the discussion winds down, he says: “The meeting is closed.” The user meeting lasted approximately 15 minutes. Only four out of a total of 30 users at the clinic took part in this meeting. It was run by a counsellor and focused on forthcoming activities. The meeting lasted no more than 15 minutes. This is by no means an untypical example, but in general attendance at user meetings was very low at all four clinics. The agendas covered nothing beyond what is described in the case above: users were informed about changes to the weekly schedule, activities and trips were organised, the menu for 207 the next communal meal was planned, or rules of behaviour for users at the clinic were debated. The experiences from user meetings at the clinics are indeed far removed from Thomsen’s (2000) proposal mentioned above. The meetings gave users only very limited influence over treatment practices at the clinics. Nonetheless all four clinics tried throughout the pilot to make the user councils work, with arguments like: “Personally, I think it makes sense to give the signal that users have a responsibility to bear. The fact that I haven’t seen a user council work in practice is another matter” (counsellor). The counsellors were also aware that the nature of user participation at methadone clinics may differ from the “textbook” formal techniques of user participation: We – how can I put it? – middle-class people have a notion of what user participation should be. We want influence, and we have to accept responsibility and so on. But for our users, exercising influence might consist in something as simple as the choice of one type of coffee over another. And perhaps they don’t have the personal resources to manage any more influence than that. Another counsellor said: I bet you a million that if you explained to users what user participation means, and if you asked them whether they were participating in their own treatment, they would say yes. I know that from our contacts. We talk about everything. We talk about my girlfriend or his girlfriend being an idiot, that my children are ill, or whatever else you can talk about. We also talk about life as a drug user, and what will happen when they get old. So I think they feel they are participating. The fact they are not participating according to the book is quite another matter. It is clear from these excerpts that the counsellors do not expect user meetings to be about much more than what kind of coffee is available at the clinic. However it also emerges clearly that user participation is something that grows up out of the contact between user and counsellor. More on this later. The users themselves were generally satisfied with the influence they wielded through user meetings. When asked about how the user meetings work, one user said: U: If somebody thinks that something is not right, we agree on a date and a time and we have a meeting. People can then put forward their views and opinions and we go on to sort these things out. I: What kind of thing might that be? U: It could be anything from the coffee being too strong to the coffee being too weak. I think it’s really just a matter of making us feel noticed. But the counsellors are prepared to listen if we have a view on anything. I: Have you used this opportunity? 208 U: No, I haven’t, because in fact I haven’t been dissatisfied with anything – quite the opposite. I: So the user council is mainly for situations where someone is dissatisfied with something? U: Yeps, that’s about it. I: Do you feel you have enough influence? U: Yes. More than enough, I think. It’s bloody great in that regard, I have to say. This user is satisfied with the amount of influence he has, but it is also clear that user participation in the form of the user council is not important to him. But why do both users and staff members have such low ambitions with respect to user meetings? From the users’ point of view, this has to do with their life situation and the mutual relationships within the user group. The life situation of drug users is obviously deeply complex, but one recurring characteristic is the constant vacillation between stable and unstable periods. The unstable periods are characterised, among other things, by increased supplementary use. The increased focus on drugs makes it hard to look at anything beyond the here and now. This aspect of the users’ life situation inflict upon the user council. In this kind of life situation, it is difficult to meet regularly, to keep to agreed times, to agree to carry out tasks and so on. This is the point made by one of the counsellors quoted above when she says that users do not necessarily have the personal resources to manage influence. Many drug users also lack the experience of attending meetings run by a chair, which have a set order of speaking, minutes etc. The method of exerting influence espoused by user councils requires experience and skills that most drug users – and particularly the most seriously affected drug users – do not have and cannot fathom. One counsellor said: “Take a completely ordinary matter, such as writing minutes. Many users are not very good at writing and therefore it’s always a struggle just to have the minutes taken.” Another, albeit less conspicuous aspect which complicates decision-making at user councils is the web of internal relationships within the group. Grytnes (2004) has described how many users at drop-in centres are reluctant to make decisions on behalf of other users (such as on house rules), especially if this has consequences for other users. They are worried that their commitment to the centre can affect their relationships with co-users outside the centre. This aspect was also highlighted by individual users in our interviews, although only occasionally. However, the difficulties of getting user councils to function “according to the book” also relate to the clinic as an institution and to its frameworks for creating user participation. Just as in many other institutions, the clinics were constrained by organisational and financial considerations. The staff were already there and 209 employed when the users arrived. The budget was set and fixed. The opening hours were as long as staffing levels permitted. The premises were already in use when the users were enrolled, and laid out so that they were suitable for the treatment concept implicit in the project. The five weekdays were all scheduled with various types of initiatives and activities, etc. The frameworks within which the clinics had to run and in which the users were to be involved were thus already established. The amount of influence that the users could exert was therefore strictly limited. The difficulties of implementing user participation, in the form of user councils, at an organisational level thus have to do with the user group and its characteristics, and on the other hand with the fact that the institutional frameworks for involving users were already largely established. The latter applies not only to methadone treatment, but social services in general (see also Jöhncke 1999–2000). Social Activity Plans A social activity plan typically includes a description of the user’s current situation, background, everyday life and personal resources. In addition, it sets out the goals for treatment and specifies who is responsible for the achievement of these goals. A social activity plan is drawn up in cooperation with the user and is signed by the municipality, the treatment provider and the user. 116 A social activity plan might look like this117: 116 117 Only two (A and D) of the four clinics worked systematically with social activity plans and the experiences reported here are from these clinics. For reasons of anonymity I have invented a fictitious social activity plan. 210 Table 2. Example of a social activity plan: Background information: User’s current situation: (housing, children, health, financial situation, cohabitation, etc.) User’s background: (upbringing, education, work experience, abuse, treatment, criminality) User’s everyday life: (interests, networks, daily life) User’s own resources: Name of the user, counsellor, social worker, and doctor. User’s wishes and goals: Lise wants a new place to live. A two-room apartment with a shower and toilet. She wants dentures, to have her eyesight checked and perhaps new glasses, and elasticated stockings to help the circulation in her legs. Expectations for cooperation: (user, municipality, project A) Responsibility for the treatment initiative: Lise expects that she can achieve her wishes and goals through her own efforts. Project A and the municipality expect that their cooperation with Lise will be successful, as the counsellor is in daily contact with Lise. Lise lives in poor conditions: a privately rented apartment with a toilet in the basement and a shower in the yard. Because of lack of maintenance and the poor conditions, Lise’s heating and water bills are very high. Lise has no children and is single. She receives a pension. Lise has six teeth left. She has problems with her eyesight. And she has circulation problems in her legs as a result of her injecting. Lise has been receiving outpatient methadone treatment since 2000. She is prescribed 130 ml methadone preparation. She has a daily supplementary use of hash and amphetamines. Lise has been in residential treatment on one occasion. She has been prosecuted for possession of amphetamine, but otherwise she has not been in prison for the last two years. Lise’s main interest is painting. She is in contact with her mother, sister and brother-inlaw. She attends the project daily and takes advantage of what it has to offer. Her social circle consists mainly of drug users. Lise is creative and good at painting. She is normally good-humoured and contributes to a positive atmosphere. Lise is good at keeping appointments and in general has a realistic and rational attitude to life. She can often see for herself when she is partly responsible for things going wrong in her life. Lise also has a survival ability and a pride which benefits her in the milieu of which she is part. Project A will work closely with Lise to find her a new place to live. Project A will make an appointment for her to see a dentist and an optician. Project A will obtain an application form so that Lise can apply for elasticated stockings. A social activity plan is always based on an assessment of the user. The goals set for enrolment in a methadone treatment programme or other social service institution are determined on the basis of each user’s current situation and personal resources. The social activity plan can be seen as a contract between the user, the municipality and the treatment provider regarding what form the initiative is to take for the individual user. In short, the social activity plan is a tool for the provision of “individual” and “differentiated" treatment. However, the actual compilation of social activity plans at the clinics has proved rather difficult. At one clinic there were difficulties with the following up of the 211 social activity plan, contradicting the idea that these plans should be a guarantee of progress in treatment and user involvement in the process. At the clinic that had a more differentiated user group, it proved difficult to draw up social activity plans for users in the most difficult circumstances. But what did the users think of the social activity plans? The excerpt below is from an interview with a user who managed the type of user participation for which the work with social activity plans was intended. His expressed goal was to be drug-free, and his social activity plan was primarily geared to this aim. When asked about the drawing up of his social activity plan, he said: U: I think it’s great, because you have to think about what you really want from your life once you start with a social activity plan. You don’t go round thinking about that every day if you are a drug user. It’s more about living from one day to the next, staying healthy and getting drugs. I: Does it matter that you are personally involved in deciding on the content of a social activity plan? U: Yes. Yes. Of course. Otherwise it’s the counsellor that should be in the social activity plan! However, the user quoted here was one of only a small minority. By far the most users were not sure whether they had a social activity plan in the first place, could not remember what was in it, or regarded the social activity plan as useless or irrelevant. As an example of the latter, one user said: I don’t like that word: social activity plan. It’s about setting a goal before a date and then you have to reach that goal. I find it hard to focus if I have something hanging over my head: for example if I have said to my contact person that in one month’s time I will have cut down on the methadone. What if I don’t make it? Overall then, users are not very keen on the idea of social activity plans and do not see them as a significant part of their treatment. There are several explanations for why social activity plans are hard to implement and why users do not consider them particularly important to their treatment. These explanations can be found both in the user group and in the frameworks in which treatment takes place. If social activity plans are seen as a technique for involving users, then, just as in the case of user councils, they collide with users’ life situation, since their lives are much more focused on the here and now than on the future. The forward-looking, written and systematic approach to reflection involved in this kind of treatment is in stark contrast to the life situation of many users. Theirs is a life of navigating through chaos, focusing on immediate problems, and relying on verbal experience and exchange (Table 3). 212 Table 3. Social activity plans versus drug users’ life situation. • • • • The world of social activity plans Structured Forward-looking Written Systematic reflection • • • The life situation of drug users Navigating through chaos Acute problems Verbal communication Not only the user group, but also the framework of the clinics conflicted with the requirements of social activity plans. One clinic devoted much time and energy to creating networks of cooperation with the municipality during the pilot period; the other clinic already had formally established channels of cooperation. Nonetheless it was still hard to implement social activity plans as a way of involving users. A final explanation for the difficulties of implementing social activity plans is that counsellors working in substance abuse treatment consider written documentation – such as social activity plans – peripheral to the overall psychosocial initiative. An example is provided by the following quotation: Not everything that counts can be measured, and not everything that can be measured counts. As far as I am aware there have been no studies to see whether documentation is worthwhile in the first place. It is a matter of belief. I’m not saying that there shouldn’t be any documentation, just that sometimes it’s done for its own sake, just like making a budget. It doesn’t give you any more money, but you know where it’s all going. The important thing about the documentation phase is the reflection that it enforces. But this could be done just as easily with counselling. I think it is the space for conversation that actually creates development. It is not necessarily when I am sitting here at the computer and having to write something. It’s just like when you send a postcard from Mallorca: having a nice time, the food is cheap, the sun is shining – I have documented it that I have been to Mallorca. That is pretty much the purpose of a postcard. It doesn’t give rise to very much reflection. And it does not necessarily say very much, at least for others who have to read it, about the content of the project. This counsellor has difficulty seeing the purpose of written procedures or the written agreements implicit in social activity plans. He sees documentation as a reduction and something that only superficially describes the user’s situation. He also takes the view that counselling is a better way of listening to the user, i.e. using verbal communication, as discussed above. The difficulties of implementing social activity plans can thus be rooted in the characteristics of the user group and in the frameworks within which the projects are run, including the negative attitude of some counsellors to written documentation.118 118 Other experiences of social activity plans (for example in the field of psychiatry) indicate that effective social activity plans integrated into treatment require a targeted, 213 User or Drug User? The concept of the resourceful user who is an expert in his or her own life and who is an active participant in changing his or her situation, which underpins the empowerment approach and the idea of user participation, is in stark contrast to the picture of drug users enrolled at the four clinics. Against this background the difficulties of implementing user participation in the form of user meetings and social activity plans are hardly surprising. The simplicity with which user participation can be discussed and described in the form of user councils and social activity plans is counteracted by the difficulties of carrying out these techniques of user participation in practice. For this reason the projects also focused on other areas in an attempt to give users greater influence over their own treatment. Informal Techniques of User Participation Three aspects of treatment were particularly important in giving both users and counsellors a sense that the users exercised real influence over their own treatment. The first was establishing a relationship of trust instead of control between users and counsellors. The second was the adoption of a pragmatic attitude towards users at the clinics. The third was the use of the support contact person scheme. Trust Versus Control Working with relationships is fundamental in social work. As discussed above, empowerment theories offer new perspectives on the relationship between user and counsellor. Analyses of client creation also open up a critical view on this relationship (e.g. Järvinen & Mik-Meyer 2003). In its analyses of the relationship between counsellor and client/user, the literature on methadone treatment focuses on the culture of treatment. Even though this culture is not the most widely described aspect of methadone treatment, there are studies that in various ways highlight the creation of different relationships between counsellor and user in different treatment cultures (e.g. Bourgois 2000; Lilly et al. 2000; Rosenbaum 1985). In a classic article from 1985, Marsha Rosenbaum identifies three different treatment models: the medical, reformist and libertarian model. In simple terms, these models create users as ill patients, individuals with behavioural problems or as conscious effort on the part of the the organisation, including training and an upgrading of staff qualifications (Olesen 2002). 214 consumers, respectively. The different treatment models thus ascribe different roles to the user. In other words, the various treatment models have different interpretations of the relationship between counsellor and user, as the counsellor necessarily has to act differently depending on whether they are faced with an ill patient, a person with behavioural problems or a consumer. One of Rosenbaum’s points is that the way in which control of the users is maintained depends on which of the treatment models is used at a given methadone clinic. And control is a recurrent theme in methadone treatment. Rosenbaum’s article inspires a closer look at how the relationship between counsellor and user is established in practice. At all four clinics trust is perceived as absolutely basic to conducting any treatment at all. Counsellors from all four clinics said in unison that they spent a lot of time in the first 12 to 18 months creating a sense of trust among users. Trust is in fact a totally decisive parameter in the relationship with another person. That is ordinary human nature. It plays a significant role in establishing contact, but then becomes implicit. It is something we now have in regard to users, so we now need to move on with something else. German sociologist Niklas Luhmann (1999) has argued that demonstrating trust towards others is a fundamental part of the human condition. Trust is essential for us to be able to act in the world, because we are always positioned in relation to others, whose actions will affect us regardless of whether or not we want them to. Trusting others is thus a way of dealing with the uncertainty of the future, i.e. dealing with the fact that the actions of others have significance for our selves. One of Luhmann’s points is that trusting another person is based on experience, that the relationships we have with others are actually what they seem to be. It could be said that trust is a generalised experience, and that this experience can be extended to other similar cases to the extent that it is confirmed, i.e. that the same experience is constructed. It is therefore reasonable to ask what trust really means, and what it consists of. At the clinics it is about how people deal with supplementary use and what expectations are placed on users, as the following two quotations illustrate: We have openness about everything, whether methadone or supplementary use, and we give the user time. Therefore trust has been created. I think this is very different to the experience I have had otherwise. It makes it somewhat easier further down the road to help them with what it is really all about. It is better than that they guard their speech for what they might otherwise reveal People have always been confrontational towards drug users. You mustn’t bash them on the head if they don’t keep agreements. They cannot do that. They lose their families, for example, because they are on heroin. They think about drugs all the time. And they have already been bashed on the head so many times because of their failures and because they don’t keep agreements. So you have to think differently. If this doesn’t work, what do we have to do differently? 215 The point made by the counsellors in these quotations is that trust is created, among other things, by being open to the user’s world and the associated use of drugs, by taking time and being patient, by being available, and by not imposing sanctions on the user. Openness is practised in the projects by providing the opportunity to talk about supplementary use without any reaction in terms of treatment. This is accepted as part of the users’ world, like their housing situation, finances and family relations, which can be dealt with in their treatment. The use of illegal substances by users receiving methadone treatment has traditionally resulted in sanctions, such as reduced doses or even progressive cessation of treatment. Accepting supplementary use during the course of methadone treatment is a strategy for creating trust between user and counsellor. This is important since previous research has shown that substance abuse treatment is often characterised by a high level of mistrust, with limited room for empathy, and that treatment is often impersonal and involves a strong element of control (Høgsbro et al. 2003; Jöhncke 1997; Hunt & Rosenbaum 1998). It is perhaps hardly surprising then that the users describe the attitude of trust and commitment shown by the counsellors towards them as extremely important: They can bloody well see when something’s wrong. But it’s just great. They worry about us. And that’s a pretty rare feeling. We’re just junkies, after all – the scum of the earth. My contact person came out to see me at hospital. He coddled me, and he was just so great. It was the first time in my life someone has brought me flowers to hospital. For me it’s the small things that mean a lot. When I was in hospital for 26 days, my girlfriend never once brought me flowers. She just came and asked whether I could stow away some of the medicine I was getting. That’s what addicts are like! I could easily have done the same myself. When I dried out, I suddenly realised how the counsellor was really interested in helping me – helping little me! As a drug addict I have never seen such a huge effort to help a single person. In these quotations, the users describe how they felt about being treated with respect, noticing that their contact persons cared about them, that someone was interested in them. They underline how valuable it is that the counsellors take them seriously, understand their situation and listen to their problems openly, and do not, as one user expressed it, “wag their fingers at us”. This applies above all to being able to talk openly about supplementary use and any problems with controlling that use. Many users have previous experiences of being sanctioned if they talked about supplementary use (or if it was discovered), and so they had previously tried to hide or deny such abuse. It can thus be said that the strategy of the counsellors in being open about supplementary use and not imposing sanctions for it is an effective way both of bringing the users into treatment and also giving them influence over their treatment. 216 Being Pragmatic The second area emphasised by the four clinics in giving users influence over their treatment is being “pragmatic”. As far as the counsellors are concerned, this, in general, means creating “resource-oriented” and “individual” treatment. But how is this done in practice? When asked what is involved in daily treatment, one counsellor said: “That’s completely unpredictable.” This counsellor does not work with a planned schedule, but instead starts out from the issues raised by the users here and now. It could be said that the pragmatic approach is to take the user’s life situation seriously and to start from there. Another aspect of being pragmatic is to consider the work process within the personnel group, so it benefits the user, as the next two quotations show: We are not particularly strict and categorical. We don’t insist that you absolutely have to be referred to your own contact person. If it’s easier for a client of mine to talk to one of my colleagues, that’s fine. With one of my clients there were repeated misunderstandings, or at least that’s what he felt. We misunderstood each other. He didn’t feel that we were reaching each other, and fundamentally he was right. He came up with a very objective presentation of what he wasn’t satisfied with, and what he thought was not going particularly well. He felt that my colleague had a much better understanding of what he came up with. But in the counsellor group we initially had a bit of the attitude that “you can’t tell us down here what to do, we decide that ourselves”. And so he was once again very objective and put forward some arguments as to why he didn’t feel very good about being with me. And so he went over to my colleague. Being pragmatic in the relationship between user and counsellor can thus also influence how work within the project is allocated. Being pragmatic is also apparent in how the counsellors approach a user’s wishes, that is, in actually taking the users’ wishes seriously. I have a user who does a lot of heroin and I talk to him about how we could help to reduce that. “You don’t need to help me with that. It’s just as it should be”. Their agenda is not that they want to be treated. They never said that. They have said that they want a better and a more orderly life and would like to be in control of various things. That’s where I start from. Another counsellor is pragmatic about the user’s alcohol abuse, since this has resulted in him becoming estranged from his own children and in such serious ill health that he is actually at risk of dying: This user asked me quite straight out whether it would be healthier for him to start taking heroin again instead of alcohol. I said yes, if you have no other choice, I think you should go back to heroin. Because it’s really terrible for him, he is destroying his liver and damaging his brain. 217 In these two quotations, the counsellors take the questions asked by users very seriously. In the first quotation, from the user’s point of view, the problem is not the heroin use, and it is not with that he is asking for help. The counsellor therefore lets it be. In the second quotation, the counsellor acknowledges that the user does not have the choice of quitting his abuse. The choice is to find the type of abuse that has the least damaging health effects. The pragmatic element in the relationship between the user and the counsellor thus consists of constantly taking the user’s world into consideration and adjusting the treatment accordingly. Support Contact Person Scheme The idea behind the support contact person scheme is to actively deal with the “chaos” and “acute problems” experienced by drug users. The support contact person scheme is a technique applied by the counsellors to help users in their contacts with the authorities (doctors, hospitals, the municipality, the judicial system, etc.) and to help them gain control of their own life (finances, accommodation, contact with family members, etc.). In this way the counsellor is active in helping the user with various aspects of his or her life. Following users around the various social systems in order to help and support them is not common practice in Danish methadone treatment. The motive behind this technique is to make a “real” difference in the users’ everyday life, to help them with things that for various reasons are difficult for the users themselves to implement. It is well documented that drug users often have difficulties and conflicts with municipal case officers and indeed with doctors, dentists and hospitals, and that these conflicts can be hard to resolve (e.g. Bømler 1996). Conflicts arise because case officers tend to see drug users as threatening and as falling outside the norm. Drug users, however, feel that they are not listened to or taken seriously. The counsellors point to the importance of accompanying a user on a visit to a municipal case officer to avoid these unnecessary conflicts: We have a huge advantage, we meet people every day. When a user has threatened to kill their case officer, I can intervene. I have learned that for such a psychologically weak group as users are, it is necessary that there is someone there who can act as a buffer. Users themselves also feel that the presence of a contact person helps to alleviate conflicts. When asked what it was like to have his counsellor with him at a meeting at the municipality, one user said: It works very well. I don’t think I would have ever got there without him. He got me to pull myself together. I had been up to talk to the municipal case officer once, and that turned into a row. It has ended in a row many times on the phone, so I needed him with me. If I go on my own, they don’t really listen. My contact person can remember what I have on my mind. I can’t. I have unbelievable problems with my memory when I am sitting there under stress. 218 The user describes how he found it difficult to go to the meeting on his own and that encounters with the public system are considerably less conflict-ridden and more constructive when the counsellor is present. This is both because the counsellor can help the user to remember the agenda, and also because the user feels he is treated better by the authorities when he is accompanied by the counsellor. One of the motives for the support contact person scheme is thus the frequently poor situation of users, their chaotic lives and their occasional lack of communication skills. Another is that the public systems and their procedures are often highly bureaucratic and impenetrable, not just for users, but also for counsellors, as the next case shows: A user was motivated to undergo detoxification. The counsellor contacted Hospital A, but was told that the medical ward was overloaded. At Hospital B, he was referred back to Hospital A. The counsellor explained that Hospital A was overloaded. The nurse at Hospital B said she would look into the matter and call back. When she did, she said that she had talked to Hospital A, and been told that if the counsellor asked the doctor at the treatment centre to ring Hospital A, they would admit the user for detoxification. That was done, and the counsellor and the user had to report to the emergency ward. Here they waited about an hour for a doctor. Several times during this period, the user wanted to leave, because he felt he was not being treated properly. The counsellor persuaded him to stay. When they finally met the doctor, the user was heavily intoxicated. The doctor would not admit him, though, before he had visible withdrawal symptoms. The contact person and the user left the hospital, both disappointed that the user had not been admitted for detoxification (case edited from Videreførelse af Substitutionsprojektets elementer 2004). The contact person’s role often puts him between a rock and a hard place. He has to represent the user towards the system and deal with the user’s problems and frustrations with that system. At the same time, he also has to deal with the frustration that representatives of the system have with the particular user or with drug users in general. As one counsellor put it: Sometimes it’s easier to deal with the user than with the system. I sometimes feel like banging my fist on the table or shouting over the phone when dealing with the system. But of course this will not help the user. I have to get things to work. But it is difficult sometimes. It takes a lot of energy, for example, to meet case officers and lawyers who are angry with a user. Another area addressed through the support contact person scheme is “clearing up the chaos”, in other words helping with practical everyday matters. This can be in the form of help with moving, paying bills, money matters, shopping, washing clothes, etc. This initiative consists of many small actions that in themselves may seem minor, but in the user’s world they all add up to a very significant total. One user said: U: I am more in control of myself and I am more in control of my apartment. I have become good at keeping it clean and tidy. 219 I: When you say that you also have more control of yourself, what are you thinking of? U: Being clean and putting on clean clothes. Before, I just came down to get methadone. It was just a matter of getting in, getting your dose and then out again. If you don’t have to spend time with people, you can be a bit more of a pig and don’t shower that often. But here, where we all spend every day together, it’s a bit different. You start to think about what you look like. I also mean dealing with the electricity, TV and phone bills and those kinds of things. The counsellors helped me with all that. And they have helped me get out of a huge debt to the state and a huge debt to a private firm. The support contact person has helped this user gain greater control over his life. As described above, project staff have 1) helped users deal with what they consider acute problems; 2) made sure that users are treated fairly and properly in other public systems; and 3) ensured that the communication between the user and the public systems is constructive. The clinics have given users greater influence over their own treatment by taking them seriously and by working on the basis of the wishes and goals that the users themselves feel are most important. In that sense the support contact person scheme can be seen as a technique of user participation. Concluding Remarks In Denmark it is statutory for users of various forms of social services to be involved in their own care and treatment, for example via user councils and social activity plans. However the experiences of user participation at the four clinics show that these techniques for involving users are not particularly effective. The reasons for this lie in the users’ life situations and in the frameworks within which the institutions work with user participation. Most users at the four clinics were not forward-looking, organised, or oriented towards written procedures, as required by social activity plans. They were not used to the culture of meetings, nor did they consider it important to have or to participate in a body such as a user council. In contrast, they were involved in their own treatment through other, more informal techniques of user participation characterised by a relationship of trust between user and staff. These informal techniques took departure from the users’ life circumstances: they accepted supplementary use, based the treatment on the users’ own wishes and needs, and through the support contact person scheme helped users with their everday life and their contacts with public systems. User perceptions of participating in their own treatment at these four clinics were based upon the approach adopted by the clinic to treatment, rather than on the legally prescribed techniques for user participation. 220 It is, of course, relevant to ask whether it is worth spending time and energy in setting up user councils and drawing up social activity plans in methadone treatment. Several reasons suggest that it is. First and foremost, user councils are prescribed by law and are a form of local democracy that should be supported and developed. Besides being a technique of user participation, social activity plans also have a very important coordinating function. However it is important to emphasise that according to the experiences gained from the four clinics here, the formal techniques are not sufficient to give drug users influence over their own treatment. Drug users’ life circumstances differ in important respects from the motivation behind user councils and social activity plans. If the users in methadone treatment are to gain real influence over their own treatment, then their life circumstances have to be taken seriously as the point of departure in treatment. Therefore informal techniques of user participation based on the relationship between user and counsellor must be given greater prominence in methadone treatment than is currently the case. References Adams, Robert (1996): Social Work and Empowerment. London: Macmillan. Asmussen, Vibeke (2003): User participation: possibilities and limitations in Danish social services directed towards drug users. 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Luhmann, Niklas (1999): Tillid – en mekanisme til reduktion af social kompleksitet [Trust – a mechanism to the reduction of social complexity]. Copenhagen: Hans Reitzels Forlag. Mahs, Bertil (Ed.) (2002): Jeg har planer, eller har jeg? – Sociale handleplaner og praksis. [I have plans or have I? – Social activity plans in practice]. Copenhagen: FOKUS. Olesen, Kenwyn (2002): Handleplaner i socialpsykiatri [Social activity plans in psychiatric treatment]. In: Mahs, Bertil (Ed.): Jeg har planer, eller har jeg? – Sociale handleplaner og praksis [I have plans or have I? – Social activity plans in practice]. Copenhagen: FOKUS. 2nd. Edition, pp. 25–33. Pedersen, Mads Uffe & Asmussen, Vibeke (2002): Metadon-projektet. Design og metode [The methadone project. Design and methods]. Aarhus Universitet: Center for rusmiddelforskning. Rosenbaum, Marsha (1985): A matter of style: variations among methadone clinics in the control of clients. Contemporary Drug Problems, Fall, pp. 375–399. Schwartz, Ida (Ed.) (2001): Livsværdier og ny faglighed [Values and new professionalism]. Brøndby: Semi-Forlaget. 222 Thomsen, Ole (2000): Brugerindflydelse for udsatte grupper [User participation for vulnerable groups]. Copenhagen: Formidlingscentret Storkøbenhavn for the Ministry of Social Affairs. Videreførelse af Substitutionsprojektets elementer (2004). Århus: Århus Kommune. 223 Authors & Editors Jørgen Anker Department of Society and Globalisation Building 25.3, Roskilde University P.O. Box 260 DK-4000 Roskilde, Denmark E-mail: janker@ruc.dk Vibeke Asmussen Centre for Alcohol and Drug Research University of Aarhus Nobelparken, bygn. 1453, Jens Chr. Skous Vej 3 DK-8000 Aarhus C, Denmark E-mail: va@crf.au.dk Astrid Brandsberg Willersrud City of Oslo, Alcohol and Drug Addiction Service MAR Oslo / Villa Mar øst Kjølberggata 9 NO-0654 Oslo, Norway E-mail: astrid.willersrud@rme.oslo.kommune.no Björn Johnson Swedish National Institute for Working Life SE-205 06 Malmö, Sweden E-mail: bjorn.johnson@niwl.se Petra Kouvonen Nordic Council for Alcohol and Drug Research (NAD) Annankatu 29 A 23, FI-00100 Helsinki, Finland E-mail: kouvonen@nad.fi Leili Laanemets Malmö University School of Health and Society SE-205 06 Malmö, Sweden E-mail: Leili.Laanemets@hs.mah.se Hilgunn Olsen Norwegian Institute for Alcohol and Drug Research (SIRUS) P.O. Box 565 Sentrum NO-0105 Oslo, Norway E-mail: ho@sirus.no 224 Jessica Palm Centre for Social Research on Alcohol and Drugs (SoRAD) Stockholm University, Sveaplan SE-106 91 Stockholm, Sweden E-mail: Jessica.Palm@sorad.su.se Tuukka Tammi Finnish Foundation for Alcohol Studies P.O. Box 220 FI-00531 Helsinki, Finland E-mail: tuukka.tammi@helsinki.fi Dolf Tops School of Social Work Lunds University P.O. Box 23 SE-221 00 Lund, Sweden E-mail: dolf.tops@soch.lu.se 225 226