LISA WALLANDER
Research
report
JAN BLOMQVIST
Who “needs”
compulsory care?
ABSTRACT
L. Wallander & J. Blomqvist: Who
“needs” compulsory care? A factorial
survey of Swedish social workers’
assessments of clients in relation to the
Care of Abusers (Special Provisions) Act
A factorial survey of Swedish social workers’
assessments of clients in relation to the Care
of Abusers (Special Provisions) Act
BACK GROU ND
Due to its wide scope and the way
in which it is applied, the Swedish
compulsory care legislation for problem
substance users is rather unique, both
from an international and a Nordic
A
lthough several countries around the
perspective. Accordingly, from the time
world have laws that allow problem sub-
of its introduction about twenty-five
stance users to be coerced into care, the widely
years ago, the current legislation has
formulated inclusion criteria and the applica-
repeatedly been criticised on ethical and
tion process associated with the Swedish com-
scientific grounds.
pulsory care legislation make it rather unique,
MET HOD S
both from an international and a Nordic per-
This study employs the factorial survey
spective (Lehto 1994; Tännsjö 1999). Within
approach to disentangle predictors
the Swedish substance misuse treatment sys-
relating to assessments of eligibility
tem, with its high per-capita expenditure, and
for compulsory care among a sample
where the primary responsibility rests with
of 205 social workers from 36 social
the municipal social services (Klingemann &
services units. The data, which comprise
Takala & Hunt 1992), compulsory care1 has
social workers’ ideal assessments
played an essential, although not a dominant,
of randomly constructed hypothetical
role throughout the 20th century. At the be-
clients, have been analysed using
ginning of the century, from the time of the
multilevel logistic regression.
introduction of the Alcoholics Act in 1913/16,
RESU LT S
compulsory care was employed on a relatively
The results show that overall, the social
small scale. Its use was expanded over the fol-
workers’ assessments of client eligibility
lowing decades, however, to reach a peak in
for compulsory care correspond well
the 1960s, after which it has declined, at least
with the legislation. However, the results
when viewed from a long-term perspective (cf.
also reveal that several factors not
Blomqvist 1998). On the 1st November 2003,
specified in the legislation have an effect
there were 222 individuals placed in care in
on these assessments. These include
This project has been funded by The National Board of Institutional Care (Project number 2.200/0019.3). We would
like to thank Dr. David Shannon for suggesting improvements to our English.
NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT
elements from the popular discourse
on drugs in Sweden, the social
workers’ ideological convictions and
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Who “needs” compulsory care?
the organisational structure
accordance with the compulsory care legislation. This figure
of, and experiences of
can be compared with that of the numbers of clients in vol-
handling compulsory
untary inpatient and outpatient substance misuse treatment,
care applications at, the
which at the time were 960 and 8,211 respectively (National
respondents’ workplaces.
Board of Health and Welfare (NBHW) 2004, 80–85).
KEYWORDS
The main objectives of the current compulsory care legisla-
Substance misuse,
tion, which was introduced in 1982 (1981/82:91)2 as a com-
compulsory care,
plement to the Social Services Act (1980:620), are to prevent
assessments, Sweden,
problem substance users from acting self-destructively and
factorial survey approach,
to protect people close to these individuals from potential
multilevel analysis
harm. From the time of its introduction in 1982, the Care of
Abusers (Special Provisions) Act (LVM), according to which
a problem substance user can currently be forced into care
for a period of up to six months, has been strongly criticised
on both ethical and scientific grounds. One critical argument
is that there is no ethical basis for incarcerating mentally
healthy, non-criminal adults who are not in any acute danger (Samrådsgruppen 1987). Another critical factor is that to
date, no scientific support has been produced for the contention that long-term compulsory care produces positive effects
that might balance possible violations of the legal rights of
the individual (see Ekendahl 2001 for a research review). In
addition, it has been suggested that compulsory care is more
an expression of a political or an ideological position than of
anything else. Bergmark and Oscarsson (1990, 64) maintain
that compulsory care may be regarded as a manifestation of a
“rehabilitative and equitable project” in which the use of social control as a societal response to substance misuse problems is disguised as treatment and rehabilitation.
During the first half of the 1990s, there was a substantial
decrease in the number of applications for compulsory care
orders submitted to the County Administrative Courts, where
the final determination is made as to who is eligible for compulsory care (Government Official Reports (SOU) 2004).3
This decrease, which became more pronounced at about the
same time as the local social services boards took over the
responsibility for applying for compulsory care orders, has
been noted with interest by the National Board of Institutional Care (NBIC), the government agency responsible for
the management of institutions providing compulsory care.
Drawing on reports of an increasing per-capita consumption
of alcohol (e.g. Leifman & Gustafsson 2003) and an increas-
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ing recreational and problem use of nar-
enough to exclude subjective judgements,
cotics (e.g. Lander & Olsson & Rönneling
thereby guaranteeing the legal rights of the
& Skrinjar 2002), the NBIC has argued
individual.
that the local social services have failed in
Against this backdrop, and as part of a
their obligation to apply for compulsory
larger project exploring referral processes
care orders for problem substance users,
within the substance misuse treatment
and have thereby endangered the lives and
system in Sweden, we conducted an em-
general welfare of these individuals (Kor-
pirical study to examine social workers’
pi 2001). Moreover, it has repeatedly been
assessments of client eligibility for com-
suggested that the decline in applications
pulsory care. Our research questions were
for compulsory care orders witnessed dur-
as follows: What is the relative importance
ing the last decade is a direct consequence
of each compulsory care criterion – as
of the increasingly poor financial situation
specified in the legislation – for the social
being experienced by local authorities,
workers’ judgements of client eligibility for
since compulsory care provision is much
compulsory care? Do client characteristics
more expensive than voluntary care, and
other than those specified in the criteria
thus the social services try to avoid it at all
influence social workers’ judgements? Are
costs (e.g. NBHW 1996).4 Others have in-
social workers’ personal experiences and
stead claimed that the downward trend in
convictions to some extent reflected in
the use of compulsory care is not problem-
their judgements? Do contextual condi-
atic in itself, but rather reflects the fact that
tions, such as the financial situation, for
the social services have noted the failure
example, and practice at a given work-
of long-term compulsory care to produce a
place, have a bearing on the judgements?
positive effect on clients and have adjusted to this reality (Bergmark 2004).
Studies conducted to date into the question of “who receives compulsory care”
In the wake of these developments, some
have either taken the form of general de-
researchers have criticised social workers,
scriptions of compulsory care clients (e.g.
who are the principal investigators of a
NBIC 2005), or of case studies in which
client’s potential eligibility for compul-
researchers have explored a selected
sory measures, for not following the alleg-
number of records for clients adjudged
edly unambiguous legal criteria indicating
either to be eligible or ineligible for com-
when compulsory care is required (Ström-
pulsory care (for a review of case studies,
berg 1999). Other researchers have claimed
see SOU 2004, 249–278). Neither of these
that the criteria in themselves are vague,
two forms of inquiry is appropriate for the
allowing numerous and divergent inter-
examination of our research questions.
pretations (Gustafsson 2001; Blomqvist &
Thus, although descriptions of clients
Wallander 2004). Gustafsson (2001) points
may reveal, and allow for the systematic
out that criteria of this kind are inevitably
comparison of typical characteristics of
difficult to formulate, since they must be
the compulsory care clientele, they cannot
general enough to incorporate all the situ-
tell us why these clients were judged to be
ations the legislation is intended to cov-
eligible in the first place. Case studies, on
er, whilst at the same time being specific
the other hand, may provide an indication
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as to how individual social workers assess
client characteristic on the social workers’
individual clients, but they cannot serve
assessments.
as a basis for systematic comparisons of
Our selection of dimensions was partly
social workers’ compulsory care judge-
governed by the need to include indicators
ments. In order to investigate the research
of the legal criteria for compulsory care in
questions outlined above, and to allow for
the vignettes. However, in order to choose
the conduct of systematic comparisons
relevant levels for these dimensions and
of the judgements under study, we have
to identify additional dimensions of in-
introduced a research tool that is new to
terest, we conducted a preliminary study
this particular field of inquiry. This has
designed to take the form of a “reversed”
involved the use of the factorial survey ap-
vignette study. Thus 39 social workers
proach (Rossi & Andersen 1982), employ-
were asked to describe what type of client
ing standardised hypothetical clients who
they would normally consider eligible for
have been designed to represent a broad
compulsory care. The preliminary study
spectrum of problem substance users. In
results proved useful, not only for select-
addition, since factorial survey data are
ing dimensions and levels for the vignette,
automatically hierarchically structured,
but also for conceptualising these in a
we analysed the data using multilevel lo-
language familiar to social workers. Sub-
gistic regression, employing the HLM soft-
sequently, we constructed the vignettes in
ware (Raudenbush & Bryk & Fai Cheong &
a specially designed computer program5,
Congdon 2000).
after which we pilot-tested these on a sample of eighteen social workers. During the
Method
construction process, we worked in close
▀ The factorial survey approach
collaboration with a group of experienced
In factorial surveys, the respondents’
social workers whose comments gave us
judgements are measured in terms of their
valuable insights into the workings of the
responses to descriptions of people or so-
social work decision-making processes.
cial situations, most commonly referred to
as vignettes. Vignettes are experimentally
▀ Dependent variable
constructed by randomly selecting a value,
Our response variable consisted of a meas-
or level, in the form of a textual fragment,
ure of the social workers’ assessments of
from a set of variables, which are also re-
the vignette clients’ eligibility (“need”) for
ferred to as dimensions, and by combining
compulsory care. The measure was binary:
these values into unique scenarios (Rossi
respondents were required to judge each
& Andersen 1982). By systematically vary-
client either as eligible or not eligible for
ing the dimensions that are thought to be
compulsory care.6 Given that the factorial
of importance in the specific judgement-
survey approach by definition generates
making process under study, multicolline-
situations that are hypothetical in charac-
arity is eliminated. Thus in our study, the
ter, it is not possible on the basis of the
use of randomly constructed hypothetical
social workers’ responses to our vignettes
client descriptions has made it possible
to make direct inferences about the judge-
to estimate the separate influence of each
ments they would make in real-world
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situations. With this in mind, the study
and where the need for care cannot be met
chose the social workers’ ideal judge-
in accordance with the Social Services Act
ments of client eligibility for compulsory
(2001:453), or by some other means. The
care as the object of research, rather than
latter condition denotes that compulsory
their “real” judgements. By contrast with
care is an alternative only when there are
a real-world situation, in which social
reasons to believe that problem substance
workers might explicitly take account of a
users do not have the motivation or a rea-
number of contextual factors when mak-
sonable capacity to complete treatment
ing judgements on compulsory care, we
voluntarily (NBHW 1997). In the vignette,
asked our respondents to exclude all such
three dimensions were employed to repre-
considerations from their responses to the
sent the general criterion: the “substance
vignettes. Instead, one of the objectives of
misuse pattern” dimension (levels: regu-
this study was to investigate whether the
lar, frequent, accelerating) corresponded
social workers’ ideal judgements were in
to the severity of the clients’ substance
themselves structured by respondent or
misuse problems. The dimensions meas-
contextual variables.
uring the clients’ “consent to treatment”
(levels: strong, medium, weak) and their
▀ Independent variables
▀ Client variables – vignette dimensions and
levels
Each of our hypothetical clients was com-
past treatment history, in terms of “failed
prised of eleven characteristics selected
ment on a voluntary basis. The special cri-
from dimensions each of which had two
teria state that someone is in need of care
or three levels (see Appendix A, Table A1).
if he, as a result of [substance] misuse: se-
Where the dimensions had three levels,
riously endangers his physical or mental
these were ordered on the basis of their per-
health, is at obvious risk of ruining his life,
ceived severity. Since our aim was to study
or if there are grounds to fear that he will
the social workers’ assessments in relation
injure himself or people close to him. Four
to the compulsory care legislation, most
dimensions were included in the vignette
of the dimensions chosen were linked to
to represent these special criteria: a “phys-
the criteria outlined in the Care of Abusers
ical health” dimension, a “mental health”
(Special Provisions) Act (1988:870) 4 §.
dimension, a “social situation” dimension
These criteria are formulated as one gener-
and a “violent behaviour” dimension. All
al criterion, which must always be present
four dimensions were divided into levels
when compulsory care is considered, and
indicating no problems, some problems or
three special criteria, of which at least one
acute problems respectively.
must also be present.
treatments” (levels: none, one, several)
together represented the clients’ relative
willingness and capacity to complete treat-
The compulsory care Act does not in it-
According to the general criterion, a
self differentiate between alcohol and var-
compulsory care order should be issued
ious forms of narcotics or solvents in the
for anyone who, as a result of an ongoing
sense that users of particular substances
misuse of alcohol, narcotics or solvents, is
are to be regarded as being more “in need”
in need of care to overcome this misuse,
of coercive interventions than others.7
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Nonetheless, in Sweden the “governing
general, but to a risk for self-inflicted harm
images” (cf. Room 1978) as well as the offi-
or harm done to persons close to the client
cial policies relating to alcohol and narcot-
(NBHW 1997).
ics are very different. As has been summa-
Below is an example of a vignette com-
rised by Hübner (2001, 5), narcotic drugs
posed from randomly selected dimension
are perceived as “dependency-generating,
levels.
dangerous and (…) [people believe they]
The client is a 25-year-old man who
should be forbidden,” whereas attitudes
misuses heroin on a more-or-less daily
towards alcohol include both positive
basis. He does not consider himself to
and negative elements. In addition, a pilot
be in need of any type of intervention
study of lay and professional discourses in
from the social services and he has fai-
the area of dependence has revealed dif-
led to complete treatment on several
ferences in the estimated dangerousness of
occasions during the past year. He has
various narcotic drugs, with heroin being
an unstable social situation and lives
regarded as the most addictive (Anders-
alone, without children. He has no in-
son & Florell & Samuelsson 2004). As a
clination towards violence. He seems
result of these factors, and because the cli-
to be in poor physical health but has
ent’s “primary drug” was also frequently
no known mental health problems.
mentioned in our preliminary study, we
regarded the inclusion in the vignette of
▀ Respondent variables
a dimension measuring the primary sub-
It has often been claimed (e.g. Lindström
stance (levels: alcohol, amphetamine, her-
1992) that substance misuse treatment in
oin) as crucial.8 For exploratory purposes,
Sweden (and elsewhere) has relied more
a dimension measuring the clients’ “sex”
on ideological conviction than on scien-
(levels: male, female) was also included in
tific evidence. As was indicated in the
the vignettes.
introduction to the current article, this
In principle, the dimensions included
claim may be particularly relevant with
in the instrument may influence respond-
regard to the imposition of compulsory
ents’ judgements not only directly, but
care (Bergmark & Oscarsson 1990). In an
also by interacting with other variables. In
attempt to assess the impact on the re-
the present context, for example, we might
spondents’ judgements of their attitudes
expect to find an interaction between the
towards narcotics and alcohol problems,
social dimension and “age” (levels: young,
we constructed a sixteen-item scale, based
middle aged, old), since young people
on the distinction of four basic approaches
were the ones considered when the social
to helping and coping outlined by Brick-
criterion was included in the 1989 revi-
man et al. (1982). These authors proceed
sion of the Act (SOU 1987). In addition, it
from the notion that the attribution of per-
might be relevant to test for potential inter-
sonal responsibility involves two basic
actions between the violence criterion and
issues: the issue of blame (or responsibil-
“family status” (levels: no family, family),
ity for causing a problem), and the issue
since the former was not intended to apply
of control (or responsibility for solving a
to a disposition for violent behaviour in
problem). By combining these factors they
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arrive at a model with four approaches (see
work degree. Our “work experience” vari-
Blomqvist 1998 for further discussion).
able measured the number of years spent
The traditional “badness – illness” dichot-
working with problem substance users.
omy distinguishes between the “moral ap-
In addition, we might expect the social
proach”, holding people responsible for
workers’ roles and responsibilities at work
both creating and solving their problems,
to be reflected in their judgements. Thus,
and the “medical approach”, which claims
while it is the regular social workers that
that people’s problems are caused by fac-
presumably have the most face-to-face
tors outside their own control and that
contact with clients, it is the unit managers
their solution requires expert intervention.
who are responsible for making decisions
In addition, Brickman et al. (1982) deline-
as to where to allocate scarce resources
ate an “enlightenment approach”, blaming
and which client groups to prioritise. Our
people for their own weaknesses but main-
“work position” variable measured wheth-
taining that they are unable to overcome
er the respondent was a unit manager or a
these without submitting to a higher “mor-
“regular” social worker.
al authority”. They also outline a “compensatory approach”, which involves lib-
▀ Contextual variables
erating people from guilt associated with
As was mentioned above, it has repeat-
their shortcomings, but regarding them as
edly been suggested that the decline in the
being in principle capable of solving their
number of applications for compulsory
own problems, whilst nonetheless being
care orders witnessed over the last decade
entitled to a certain amount of assistance
may be a direct consequence of financial
in order to deal with the predicaments that
cut-backs in the social services sector. For
fate (nature or an unjust society) has im-
this reason we included a “unit finances
posed on them. By combining the respond-
criterion” in the analyses, operationalised
ents’ answers to a number of scale items
as each social services unit’s average ex-
for alcohol and narcotics respectively, we
penditure in units of 1 000 SEK (approx.
formed five groups representing the ap-
110 Euro) per client during the year 20029.
proaches outlined above and an addition-
It is important to note that this variable
al group, characterised by a non-coherent
was not included to directly test the claims
ideological position (see Appendix B for a
described above, but rather to examine to
description).
what extent financial considerations have
Another aspect that any study of pro-
become part and parcel of social workers’
fessional decision-making in social work
judgements of client needs, as has been
needs to consider, is that of the social
suggested by Bergmark (1994).
and
Local traditions or routines in this area
skills. These professional prerequisites
may constitute another contextual vari-
are presumably acquired both during uni-
able with potential relevance for social
versity training and in daily practice (see
workers’ compulsory care judgements.
Munro 1998 for a discussion). Our “edu-
In an attempt to measure this, we con-
cation” variable measured whether or not
structed a “compulsory care experience”
the respondent had a university social
variable, defined as the average number of
workers’
professional
knowledge
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applications submitted to the county court
(including 26 unit managers), accounting
per unit and year during the period 1997
for approximately 75 percent of the entire
to 2001.
target group, and 86 percent of all eligible
In a similar vein, individual social workers’ judgements might also be affected by
social workers at the 36 units that took part
in the study.11
their overall workload and the severity of
During a three-hour visit to each of 3512
problems experienced by the average client
units, all social workers present at work
at the local unit. Based on the assumption
that day assessed the eligibility for com-
that these factors will in turn to some extent
pulsory care of fifteen randomly construct-
reflect the overall “problem prevalence” in
ed hypothetical clients, and answered
a given local area, we constructed an index
questions about their own background, at-
that combined register data on alcohol-re-
titudes and working conditions. Those ab-
lated mortality during the period 1995–1999
sent from work on the day were provided
with local estimates of the number of heavy
with an opportunity to complete the ques-
drug users drawn from the national MAX-
tionnaire on another occasion and mail it
project (Lander et al. 2002).
to us. In total, 3,003 (98 %) of the distrib-
Finally, since Swedish local authorities
uted vignettes were assessed. To collect
enjoy a large degree of autonomy, the or-
data on the organisational context of the
ganisational structure of local social serv-
respondents, we distributed a separate
ices units may vary. One important distinc-
postal survey to be completed by the 36
tion is that between “specialised” units,
unit managers (all 36 surveys were com-
which focus solely on problem substance
pleted). Remaining contextual data were
users, and “integrated units”, which also
collected from official registers and public
receive other adult clients. To investigate
statistics.13
whether the degree of specialisation influenced the social workers’ judgements, we
▀ The multilevel logistic regression model
included a “unit structure” variable meas-
Because each of our respondents assessed
uring whether or not a unit’s clientele was
multiple vignettes, our factorial survey
comprised exclusively of problem sub-
data have a hierarchical structure by de-
stance users.
sign. Further, this hierarchical structure is
enhanced by the fact that the respondents
▀ Respondents
are clustered, or nested, within workplaces
The target group for the study included
or contexts. To take account of these struc-
all social workers from local social serv-
tures, and to further advance the data ex-
ices units in the county of Stockholm who
ploration, the data analyses were conduct-
assess and work with problem substance
ed using the multilevel logistic regression
users. In addition we wanted to include
model (for a discussion of the multilevel
the unit managers that supervise these
modelling of factorial survey data, see Hox
assessments. Out of the 50 managers ap-
& Kreft & Hermkens 1990).14 This model
proached, 36 (72 %) agreed to the partici-
presupposes a hierarchical data set, with
pation of their employees.10 The final sam-
a single binary dependent variable meas-
ple comprised 205 frontline social workers
ured at the lowest level, and with the op-
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portunity to define explanatory variables
care, see Appendix A, Table A1; for a des-
at all levels of the model. We used a three-
cription of the respondent and contextual
level design, with explanatory variables
variables, see Appendix C, Table C1). Be-
specified as vignette variables (level one),
cause the vignettes were randomly compo-
respondent variables (level two) and con-
sed, the vignette variables, by design, are
textual variables (level three).
unrelated to either respondent or contex-
Multilevel regression models are typi-
tual variables. Therefore, when additional
cally divided into two parts: the fixed part,
explanatory variables were included in
consisting of calculations of regression co-
the model, the strength of the effects of
efficients (odds ratios), their standard er-
the vignette dimensions on the outcome
rors and probability values, and the ran-
remained virtually unchanged. Taking ad-
dom part, comprising the decomposition
vantage of this, we have chosen to vary the
of the unexplained variance into variance
means by which we present the results for
components for each level.15 This study
the vignette variables (see Table 1).17
employed a random-intercepts model in
In Model 1, dummy variables are em-
which only the intercepts were allowed
ployed for each of the dimension levels
to vary across the Level-2 and Level-3
with the first level of each variable serv-
units.16 When the model follows a binomi-
ing as the reference category. In Model 2,
al distribution, as in our case, the lowest
the reference category was switched to the
level variance is fully determined when
middle level, so as to enable comparisons
the mean is known, as a result of which
between all dimension levels included in
there is no Level-1 variance component to
the analysis. The use of dummy variables
display (Hox 1995). The Level-2 variance
in these two regression models makes it
component measures the unexplained be-
possible to compare the dimension levels’
tween-respondent variance and the Level-
effects on compulsory care judgements
3 variance component measures the unex-
relative to one another, but the models do
plained between-context variance. If the
not reveal the relative magnitude of the
size and significance of these components
importance of each vignette dimension.
decrease with the inclusion of respondent
To allow for this, we employed a proce-
or contextual variables, we may conclude
dure known as “coding proportional to
that the variables added (if significant)
effect” (Rossi & Andersen 1982) to trans-
account for some of the previously unex-
form each set of dummy variables into an
plained variance.
interval-level variable.18 The results produced when these quantitative variables
Results
were included in a multilevel regression
▀ Main effects
We employed a three-stage-procedure, suc-
model are displayed in Model 3, where the
cessively adding vignette, respondent and
the relative influence of each variable on
contextual variables to the multilevel lo-
the social workers’ judgements.
standardised (beta) coefficients indicate
gistic regression models (for a description
An examination of the odds ratios (OR)
of the percentage of vignette dimension
and significance levels for the vignette
levels assessed as eligible for compulsory
variables presented in Model 1 and Model
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Table 1. Multilevel logistic regression of vignette, respondent and contextual variables on
compulsory care judgements
Model 1
OR
SE
Model 2
OR
SE
0.37***
0.14
1.42***
0.10
0.35***
0.15
2.99***
0.11
0.76**
0.10
2.64***
0.14
0.62***
0.09
2.05***
0.12
0.65***
0.11
2.04***
0.13
0.61***
0.11
0.99
0.14
0.70**
0.13
1.08
0.12
0.83
0.11
1.96***
0.11
Model 3
Beta
SE
0.57***
0.05
0.88***
0.07
0.55***
0.06
0.50***
0.04
0.48***
0.05
0.25***
0.04
0.20***
0.05
0.38***
0.05
0.07
0.04
0.15***
0.04
0.06
0.05
Fixed part
Vignette variables
Misuse pattern
Regular
Frequent
Accelerating
Consent to treatment
Strong
Medium
Weak
Failed treatments
None
One
Several
Physical health
No problems
Some problems
Acute problems
Mental health
No problems
Some problems
Acute problems
Social situation
Stable
Unstable
Acute
Violent behaviour
None
Earlier signs
Recent signs
Primary drug
Alcohol
Amphetamine
Heroin
2.59***
3.64***
2.71***
7.86***
1.32**
3.34***
1.58***
3.21***
1.50***
3.01***
1.64***
1.62***
1.42**
1.52***
1.18
2.26***
0.14
0.13
0.16
0.17
0.10
0.14
0.08
0.11
0.10
0.13
0.10
0.10
0.13
0.11
0.11
0.12
Sex
Male
Female
1.13
0.08
1.13
0.08
1.32***
0.08
0.93
0.10
Age
Young
Middle aged
Old
Family status
No family
Family
72
0.76***
0.70***
1.12
0.08
0.10
0.09
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Table 1. continues
Model 1
OR
SE
Model 2
OR
SE
1.78**
1.18
2.13**
1.58**
Model 3
OR
SE
0.19
0.22
0.29
0.16
1.87***
1.23
2.18**
1.61**
0.19
0.23
0.29
0.16
6.70***
1.04
0.84
0.77
0.53
0.17
0.28
0.17
6.47***
1.02
0.81
0.78
0.53
0.16
0.30
0.18
1.02
1.01
0.20
0.01
0.98
1.01
0.22
0.01
0.73
0.20
0.76
0.20
1.00
1.07**
0.00
0.02
0.66*
0.31**
0.19
0.34
Fixed Part
Respondent variables
Approach to alcohol
Compensatory
Moral
Medical
Enlightenment
Non-coherent
Approach to narcotics
Compensatory
Moral
Medical
Enlightenment
Non-coherent
Education
No social work degree
Social work degree
Work experience
Work position
Regular social worker
Manager
Contextual variables
Unit finances criterion
Compulsory care experience
Unit structure
Non-specialised unit
Specialised unit
Intercept
0.01***
Random part
Variance components
Level 2
Level 3
0.33
0.30**
0.94***
0.31***
0.35
0.76***
0.26***
0.76***
0.15**
N for Level 1 = 2988, N for Level 2 = 200, N for Level 3 = 36
* p < .05; ** p < .01; *** p < .001
2 reveals that there are significant group
often judged to be eligible for compulsory
differences for almost all of the dimen-
care. However, Models 1 and 2 also reveal
sions included in the models. In addi-
that two dimensions not related to the
tion, the directions of these differences, as
compulsory care criteria had a significant
indicated by the sizes of the odds ratios,
impact on social workers’ judgements. Ap-
reveal that in most cases the respondents
parently, young people were more likely
agreed with the predetermined ordering
to be adjudged eligible for compulsory
of the dimension levels. Thus, not very
care than were middle aged or old people.
surprisingly, the least motivated clients,
Furthermore, by comparison with alcohol
with the most acute problems according to
and amphetamines, heroin emerged as the
most of the legal criteria, were those most
drug with by far the greatest predictive
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73
Who “needs” compulsory care?
value in relation to judgements of eligibil-
omitted due to its being highly correlated
ity for compulsory care.
with the compulsory care experience vari-
Finally, Model 3 reveals the clients’
able (r = .59). As is indicated by the model,
willingness to consent to treatment to be
this latter variable had a significant effect
the strongest predictor of compulsory care
on the respondents’ judgements. Thus,
judgements, followed by the clients’ sub-
the greater the units’ overall experience
stance misuse pattern and treatment his-
of handling compulsory care applications,
tory, the other two dimensions relating to
the stronger the social workers’ overall in-
the general criterion in the compulsory
clination to advocate compulsory care.20
care Act. Among the special criteria di-
In addition, respondents working at units
mensions, the clients’ physical and mental
specialising in problem substance users
health scored equally highly. Interestingly,
were significantly less inclined to judge in
the model also indicates that the clients’
favour of compulsory care than were those
primary drug was a much better predic-
who worked at non-specialised units.
tor of respondents’ judgements than was
A comparison of the variance compo-
either their social situation or manifesta-
nents for the three models shows that the
tions of violent behaviour.
incorporation of the respondent variables
Turning to the respondent variables,
reduced the Level-2 variance component
Model 2 shows that the social workers’
from 0.94 to 0.76, and that despite this re-
ideological convictions, i.e. their preferred
duction the variance component retained
approach to alcohol and narcotics prob-
its statistical significance. This means that
lems, were significantly related to their
social workers’ ideological convictions
compulsory care judgements. More specif-
explain some, but far from all of the be-
ically, respondents with a compensatory
tween-respondent variance. The inclusion
approach towards alcohol problems were
of contextual variables in the model re-
significantly less inclined to advocate com-
duced the Level-3 variance component to
pulsory care than were respondents who
almost half its size, from 0.26 to 0.15, and
endorsed a moral, an enlightenment or a
in addition also reduced its p-value. This
“non-coherent” approach. As regards the
indicates that the compulsory care experi-
approach to narcotics problems, respond-
ence and degree of specialisation of the so-
ents with a moral approach were signifi-
cial services units explain a considerable
cantly more inclined to judge in favour of
amount of the between-context variance.
compulsory care than were those with a
compensatory approach.19 An important
▀ Interaction effects
caveat in this context, however, relates to
As was noted above, there may be important
the fact that very few respondents (n = 6)
interactions between the explanatory vari-
actually endorsed the moral approach.
ables. Since an explorative search for such
Turning to the contextual variables pre-
interaction terms might open the door to an
sented in Model 3, it may be noted that the
endless “hall of mirrors” (Cronbach 1975,
model includes only three of the four po-
119), we have chosen to present only those
tential contextual predictors. The reason is
that can be related to the intentions outlined
that the problem prevalence variable was
in the compulsory care legislation. The in-
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teractions between vignette dimensions are
1a
Odds ratios:
Compulsory care
35
no failed treatment
one failed treatment
several failed treatments
presented in the form of graphs of odds ratios (with controls for the other explanatory
variables). Figure 1 presents three clustered
bar graphs of interaction terms.
30
Figure 1a shows that consenting to re-
25
ceive assistance did not necessarily pre-
20
clude being judged as eligible for compul-
15
sory care. Thus, having failed several treat-
10
ments during the past year substantially
5
increased the probability of being judged
0
strong
medium
Consent
weak
to be “in need” of coercion, even among
clients consenting fully to enter voluntary
treatment. Figure 1b shows that the impact
1b
Odds ratios:
Compulsory care
3
stable social situation
unstable social situation
acute social situation
of the social criterion was modified by the
clients’ age. Thus, being in an acute social
situation resulted in a larger increase in
the probability of being considered eligible for compulsory care among young cli-
2
ents, than among their middle-aged or older counterparts. Finally, and contrary to
what might be expected, Figure 1c reveals
1
that clients’ family status did not significantly modify the respondents’ estimation
0
old
young
middle aged
Age
of the violence criterion.
Discussion
1c
Odds ratios:
Compulsory care
3
no signs of violent behaviour
earlier signs of violent behaviour
recent signs of violent behaviour
Applying multilevel logistic regression to
factorial survey data collected from a sample of 205 frontline social workers from
36 social services units, this study has ex-
2.5
plored the contributory effects of vignette,
2
respondent and contextual variables on
1.5
the social workers’ assessments of clients’
1
eligibility for compulsory care. Our find-
0.5
ings show that overall, the social workers’
0
judgements of the vignette dimensions reno family
Family status
family
Figure 1. Interactions between vignette
dimensions
lating to the compulsory care criteria correspond well with the relevant legislation.
The clients adjudged to be most eligible for
compulsory care are those with an accelerating substance misuse, who either do
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75
Who “needs” compulsory care?
not want to undergo voluntary treatment,
also worth pointing out that clients’ fam-
or who are judged to be incapable of doing
ily status does not modify the social work-
so. In addition, these clients suffer from
ers’ estimations of the clients’ inclination
acute physical and mental health prob-
to violence. One plausible interpretation
lems, share an unstable social situation
of this result is that social workers’ con-
and have shown signs of violent behav-
cerns about potentially dangerous clients
iour. This close correspondence between
are not limited to, or primarily focused
our results and the contents of the legisla-
on, the safety of family members, but also
tion is neither surprising nor remarkable.
include the notion that violent behaviour
However, our findings include several as-
can affect other people, including the cli-
pects that cannot be directly inferred from
ents themselves.
the compulsory care legislation.
Secondly, it is worth highlighting the fact
Firstly, it is noteworthy that the re-
that client characteristics other than those
spondents regard the special criteria re-
specified in the compulsory care legisla-
lating to (physical and mental) health
tion are also important in relation to the
as more important than those relating to
judgements made by social workers. Both
violence and the client’s social situation.
age and the primary drug are important
Our findings, which imply that the health
predictors in this context, with younger
status of the client is an essential aspect of
clients and heroin users being singled out
compulsory care decision-making, are in
as those most eligible for compulsory care.
line with recent developments in the use
The findings relating to the primary drug
of compulsory care. Over the past decade,
dimension are to some extent in line with
the number of problem substance users
the variations that exist in the “governing
who have been coerced into care with im-
images” of alcohol and various types of
mediate effect (in accordance with LVM,
narcotic substances. They are also in line
13 §) – e.g. those whose health has been
with results reported in Ekendahl’s (2004)
assessed to be so poor that they cannot
interview study, confirming as they do the
await a regular investigation and due legal
finding that social workers see problem
process – has not decreased to the same
heroin users as the most important target
extent as the number of regular applica-
group for compulsory care in Sweden.
tions for compulsory care orders (SOU
Thirdly, it is worth noting that the ideo-
2004). One interpretation of this develop-
logical convictions of respondents also
ment, and one which is also in line with
have a bearing on their compulsory care
the findings of previous research in this
judgements. Thus, those who share a com-
area, is that on the whole social workers
pensatory approach towards alcohol prob-
do not believe in the long-term rehabilita-
lems are less inclined to advocate compul-
tive qualities of compulsory care, but that
sory care than are respondents who en-
they do believe that short-term coercion is
dorse any of the other approaches besides
sometimes an indispensable tool in their
the medical view. Logically, this finding
work with problem substance users (Gerd-
is a result of the fact that people who en-
ner 1998; Palm & Stenius 2002; Ekendahl
dorse the compensatory approach believe
2004). As regards the special criteria, it is
that subjects are capable of solving their
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own problems (albeit with the help from
that social workers are indeed socialised
society to which they are entitled), and
at their workplaces into different ways of
that compulsory care will by definition
viewing clients’ needs.
run counter to the subject’s preferences.
This study is subject to a number of lim-
Fourthly, respondents’ judgements were
itations. For one thing, the participating
also affected by contextual variables. Thus
units are not necessarily representative of
respondents at social services units with
the Swedish social services sector at large.
more experience in handling applications
On the other hand, it is worth noting that
for compulsory care orders were more
the county of Stockholm accounts for a
inclined to judge the fictitious clients as
large part of the substance misuse treat-
eligible for compulsory care. This find-
ment provided in Sweden, and that our
ing might reflect some form of “routinised
sample includes approximately 75 percent
practice” whereby social workers con-
of all frontline social workers involved in
tinue making the type of judgements they
the assessment of problem substance users
are used to making. In addition, the re-
in this county. A second limitation of this
spondents working at specialised units are
study relates to the fact that it is the coun-
less prone to advocate compulsory care
ty administrative courts rather than the so-
than are those working at non-specialised
cial workers that make the final decision
units. How this might be explained is not
as to who is eligible for compulsory care.
self-evident: what it does suggest, how-
However, given that most of the compul-
ever, is that different ways of organising
sory care applications made to the courts
social work with problem substance users
are granted (in 2003, 94 % were granted)
seem to give rise to different “judgement
(NBHW 2004, 67), it could be argued that
cultures”. It is also worth mentioning that
the initial, and perhaps most important,
the financial situation of the social serv-
part of the process of selecting clients for
ices units is not significantly related to the
compulsory care takes place within the lo-
personal judgements of the social work-
cal social services units. At the local level,
ers. This finding indicates that financial
and on the basis of investigations written
considerations, measured as the mean ex-
and presented by social workers, local
penditure per client, have not permeated
political boards decide whether or not an
social workers’ professional judgements
application should be sent to the court.
relating to compulsory care. Finally, even
Accordingly, social workers undoubtedly
after the modelling of respondent and con-
constitute a central actor in the process of
textual variables, unexplained Level-2 and
implementing the compulsory care legis-
Level-3 variance remains. On the basis of
lation.
the analyses conducted in this study, we
Thirdly, it must be noted that the focus
cannot ascertain whether the unexplained
of this study has been directed at social
Level-2 variance is systematic, due to re-
workers’ ideal judgements of compulsory
spondent predictors which were not in-
care eligibility, and that behavioural inten-
cluded in the models, or random. The
tions are not necessarily synonymous with
remaining unexplained Level-3 variance
actual behaviour. In addition, while the
provides additional support for the view
results from this study add to our under-
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Who “needs” compulsory care?
standing of the structure of social workers’
tion of the factorial survey and multilevel
judgements of client eligibility for com-
analysis could be used for investigating
pulsory care, we have arrived at them us-
predictors of any decision or “critical”
ing a method that does not fully capture
choice in the process of referring clients
the complexity of real-world situations.
to different care or treatment options (see
Notwithstanding these limitations, the
also Degenholtz & Kane & Kane & Finch
study’s findings may be regarded as having
1999; Wallander & Blomqvist 2004; Wal-
a number of potentially important impli-
lander & Blomqvist 2005). In addition, be-
cations for the fields of both practice and
cause the factorial survey provides a pow-
policy. First of all, we have shown that
erful, and easily administered, instrument
several factors not specified in the legisla-
for making systematic comparisons – and
tion, such as the respondents’ ideological
because multilevel analysis can handle hi-
convictions as well as the organisational
erarchical data – this combined approach
structure and prevailing traditions at local
easily lends itself to comparative studies.
workplaces, have an effect on the social
Within this field, future research could ad-
workers’ ideal judgements of client eligi-
vance the understanding of professional
bility for compulsory care. To the extent
judgements relating to compulsory care
that these results can be translated into
through comparing all the key decision-
real-world judgements, this means that
makers working with the implementa-
whether or not a problem substance user
tion of the legislation. Moreover, bearing
is admitted to compulsory care will in part
in mind that the compulsory care laws in
depend on his or her place of residence,
the Nordic countries differ, with Sweden
and on which social worker he or she is
being positioned at the upper extreme of
assigned. Were this to be the case, it would
the “scale of paternalism” (Lehto 1994, 17)
clearly be at odds with the requirement for
and Denmark at the opposite extreme, the
equality under the law at the individual
conduct of a cross-national comparative
level in the processing of potential com-
study of professional judgements concern-
pulsory care clients.
ing the question of “who ‘needs’ compul-
On the methodological level, the study
has shown that the exploration of profes-
sory care” would prove an interesting, and
challenging, task.
sional judgements and assessments may
benefit substantially from the use of the
factorial survey approach in combination
with multilevel modelling. In fact, the
experimental power of the factorial survey approach, and the fact that it renders
possible the simultaneous disentangling
of the effects of a fairly large number of
client characteristics, make it one of the
more sophisticated methods available for
Lisa Wallander, Doctoral student
Department of Sociology
Stockholm University
SE-106 91 Stockholm
E-mail: [email protected]
Jan Blomqvist, Associate Professor
Research & Development Unit
City of Stockholm
SE-106 64 Stockholm
E-mail: [email protected]
this type of research. Clearly, the combina-
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NOTES
1. Using the term compulsory “care” instead
of “treatment” hasn’t been undertaken
lightly. There are three more or less explicit
compulsory care goals, namely (1) to stop a
destructive process, (2) to motivate the client to undergo voluntary treatment and, (3)
to support the client in the process of overcoming his or her misuse (National Board
of Health and Welfare (NBHW) 1997). As
of today, the use of recognised motivational and treatment techniques within
compulsory care is neither established nor
compulsory (Billinger 2000). Therefore, we
have chosen to use the term “care”.
2. Revised in 1989, 1988:870.
3. The clients are entitled to be present
in court and to receive legal assistance
(LVM §§ 39, 42).
4. The local authorities pay 68 percent of
the total costs of compulsory care. The
remainder is provided for by government
subsidies (NBIC 2004, 10).
5. A computer program, in which dimension
levels in the form of textual fragments were
substituted for randomly selected category
values, was constructed specifically for
this project. For further details about the
software, contact the first author.
6. Exact question wording: “For each of the
15 fictive clients presented in the following, we ask you to state whether or not you
judge him or her to be in need of compulsory care. Here, we ask you to ignore the
formal referral process at work and state
only what you yourself believe to be reasonable.”
7. However, the instructions for applying the
law state that all intravenous use of narcotics is to be regarded as ongoing substance
misuse (NBHW 1997).
8. The compulsory care legislation also covers
solvent abuse. Due to the small number
of clients that predominantly use solvents
– during the year 2003, for example, not
one of a total of 587 compulsory care applications referred to a person who primarily
used solvents (NBHW 2004, 67) – we chose
not to incorporate this particular type of
substance in the current design.
9. Since our measure of each unit’s average
expenditure in units of 1,000 SEK per client during the year 2002 is based on figures
collected from each of the social services
units independently of the others, the
figures may not be entirely comparable.
10.The sample included seventeen of eighteen
autonomous local districts in the City of
Stockholm and nineteen units from the
remaining 25 municipalities in the county
of Stockholm.
11.Among those who did not agree to participate, the most commonly stated reason was
“work overload”.
12.Due to lack of time, the social workers at
one unit employed postal questionnaires.
13.Public statistics regarding the number of
applications for compulsory care submitted to the county court were collected
from the Stockholm Office of Research and
Statistics (USK) and from Statistics Sweden
(SCB). Data on alcohol-related mortality
were collected from USK and from The
National Board of Health and Welfare. Local estimates of the number of heavy drug
users were drawn from the national MAXproject’s database (Lander et al. 2002).
14.Disregarding these nested structures in the
analyses is likely to produce miscalculations of point estimates and to downwardly
bias standard errors for the respondent
and the contextual variables as a result of
residual dependency (Bryk & Raudenbush
2001).
15.The calculations for the fixed part of the
model are interpreted in the same way as
in ordinary single-level logistic regression
models.
16.The fully random regression model also
allows for the estimation of the variability
in the regression coefficients across the
Level-2 and Level-3 units.
17.Due to missing values, the analyses were
conducted on the basis of 2,988 vignettes
(> 99% of the vignette sample), 200 social
workers (98% of the social worker sample)
and 36 units (100% of the unit sample).
18.Coding proportional to effect requires the
recoding of each dummy variable to the
size of its unstandardised regression coef-
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ficient, with deleted categories recoded
to some constant value (0 in our case). In
so doing, and in including the quantitative variables in a regression model, the
new unstandardised coefficients become
uninterpretable. However, the standardised (beta) coefficients indicate the relative
influence of each variable on the social
workers’ judgements.
19.When the moral approach was used as
reference category, respondents in this
group proved to be more inclined to judge
in favour of compulsory care than were all
the other respondents.
20.Because of the high correlation between
compulsory care experience and problem
prevalence, the former variable could be
regarded as also capturing the prevalence
of substance misuse problems in the area.
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Appendix A
Table A1. Description of vignette dimensions, wordings, level descriptions, vignette
composition (vig) and percentage of vignette dimension levels in vignettes judged as eligible
for compulsory care (cc)
Dimensions and wordings
Level description
% vig
(N=3075)
% cc
(N=3003)
Misuse pattern
a) A couple of times a week
b) More-or-less daily
c) Daily and accelerating
Regular
Frequent
Accelerating
31%
35%
34%
22%
38%
42%
Strong
Medium
32%
35%
18%
31%
Weak
33%
54%
34%
32%
26%
30%
34%
47%
No problems
Some problems
Acute problems
50%
25%
26%
27%
35%
48%
Mental health1
a) No known mental health problems
b) Seems to be mentally unstable
c) Recently hospitalised following a suicide attempt
No problems
Some problems
Acute problems
49%
26%
25%
28%
35%
46%
Social situation1
a) Stable social situation
b) Unstable social situatioAn
c) Is on the road to social marginalisation
Stable
Unstable
Acute
49%
25%
25%
30%
39%
37%
Violent behaviour1
a) No inclination towards violence
b) Earlier violent acts under influence of drugs
c) Recent violent acts under influence of drugs
None
Earlier signs
Recent signs
50%
25%
25%
31%
37%
39%
Primary drug
a) Misuses alcohol
b) Misuses amphetamine
c) Misuses heroin
Alcohol
Amphetamine
Heroin
33%
32%
34%
27%
31%
44%
Sex
a) Man
b) Woman
Male
Female
50%
50%
33%
35%
Age
a) A 25-year-old
b) A 39-year-old
c) A 56-year-old
Young
Middle aged
Old
35%
33%
32%
37%
34%
31%
Family status
a) Lives alone, without children
b) Lives with partner and children
No family
Family
50%
50%
34%
35%
Consent to treatment
a) Wants help
b) Recognises that he/she has misused the drug
to a high extent lately
c) Does not consider himself/herself to be in need of
any type of intervention from the social services
Failed treatments
a) No treatment during the last year
None
b) Failed to complete treatment on one occasion during One
the past year
c) Failed to complete treatment on several occasions
Several
during the past year
Physical health1
a) No known physical health problems
b) Seems to be in poor physical health
c) Recently treated for medical injuries caused
by the drug misuse
1
As can be seen, the levels for this special indicator dimension are not equally represented in the vignettes. On the basis of the
results from the pilot study, where “too many” hypothetical clients were judged as eligible for compulsory care, we decided to
double the chance for the first level, i.e. the “no problem” level, to occur in the vignettes. By manipulating the vignette construction procedure in this way, we wanted to reduce, and in fact succeeded in reducing the proportion of case vignettes judged as
eligible for compulsory care (34 % of the case vignettes were judged as eligible for compulsory care).
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Appendix B
T
he five basic approaches to helping and coping were constructed by combining four
scale items (two for both alcohol and narcotics respectively), which measured the
respondents’ attitudes with regard to substance users’ personal responsibility for causing
and solving a substance misuse problem. Here we present “standardised” versions of the
scale items, which were originally worded slightly differently for alcohol and narcotics
respectively.
(a) Nobody becomes a problem substance user of his/her own free will.
(b) In the right circumstances, it is possible to overcome substance misuse without treatment.
The respondents who moderately or strongly disagreed with item (a) and strongly
agreed with item (b) were categorised as having a moral approach to helping and coping.
The respondents who moderately or strongly agreed with item (a) and moderately or
strongly disagreed with item (b) were categorised as having a medical approach. The
respondents who moderately or strongly disagreed with both items (a) and (b) were
categorised as having an enlightenment approach. The respondents who moderately or
strongly agreed with item (a) and strongly agreed with item (b) were categorised as having a compensatory approach. Respondents with other response patterns were assigned
to a “non-coherent” category.
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Appendix C
Table C1. Descriptive statistics: Respondent and contextual variables
Mean1
Min
Approach to alcohol
Compensatory
Moral
Medical
Enlightenment
Non-coherent
.31
.17
.12
.05
.34
0
0
0
0
0
1
1
1
1
1
201
201
201
201
201
Approach to narcotics
Compensatory
Moral
Medical
Enlightenment
Non-coherent
.22
.03
.33
.05
.36
0
0
0
0
0
1
1
1
1
1
201
201
201
201
201
Respondent variables
Max
N2
St.D.
Respondent variables
Education (SW degree = 1)
Work experience
Work position (Manager = 1)
.83
0
1
11.04
0
40
.13
0
1
202
8.39
202
202
Contextual variables
Unit finances criterion
Compulsory care experience
Problem prevalence
Unit structure (1 = Specialised unit)
108.64
18.69
359.26
74.48
3.51
.40
15.40
2.93
36
36
88.69
13.00
190.00
46.73
36
.42
.00
1.00
36
1
The mean value of a dummy variable reports the proportion of cases in the category coded 1
2
Due to missing values for all respondent variables, the number of social workers units included is less than 205
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