Beyond treatment? : widening the approach to alcohol problems and solutions

Abstract: The dissertation includes four different studies which, from different points of departure, aim to illuminate problems and prospects of social work with alcohol problems in contemporary Sweden.Paper 1 analyses the historical succession of predominant public images of, and societal responses to, alcohol problems in Sweden during the past century. The analysis distinguishes between a moral, an enlightenment, a medical and a compensatory approach to these problems. The main development in society's handling of alcohol problems is described to have been a gradual shift from the moral to the medical approach, despite the fact that the compensatory approach is in many respects the one most akin to the general social policy ideal of Sweden. The paper concludes by discussing the future prospects of community-based approaches to alcohol problems, relying on the assumptions of the latter approach.Paper 2 scrutinises, based on reanalyses of a variety of empirical sources, developments within residential care for substance misusers in Sweden during the past three decades. The results of these analyses belie several popular notions about the role of institutions in social work with alcohol problems. Thus they show, in contrast to claims in some public reports, that the annual number of alcohol misusers cared for decreased during most of the 1980s, already before the major decrease in the beginning of the 1990s. Further, they show that residential care has - despite a growing "treatment rhetoric" over the years - been primarily utilised for a rather small group of long-term misusers with severe social problems, and with a pattern of repeated - and often prematurely interrupted - admissions and readmissions over a long succession of years.Paper 3 reviews and discusses the significance of research on "spontaneous recovery" from substance misuse and treatment outcome research. The paper outlines and develops further the notion that there may be "common elements" or mechanisms in all successful change processes, whether these include professional interventions or not. Formal treatment is further discussed in terms of temporary interventions in the client's life course, which may, if successful, facilitate and accelerate "naturally" occurring rehabilitation processes. The paper concludes by proposing a closer integration of research on "spontaneous recovery" and treatment outcome research, as a way of learning more about the potential interplay between life events, formal interventions and change of lifestyle.Paper 4 is an account of an attempt to put the ideas of Paper 3 into practice, by comparing subjects who recovered from severe alcohol problems without formal assistance, with subjects who were assisted in doing so. Comparisons were made with regard to drinking patterns and occurrences of significant life events during a period of time, encapsulating four years before and two years after the resolution, and with regard to subjects' attributions as to what initiated and maintained recovery. As regards drinking patterns and event occurrences, comparisons were further made with assisted and unassisted subjects with current alcohol problems. The results indicate that initial attempts to solve the drinking problem and initial help-seeking, as well as long-term maintenance of the resolution, are influenced by environmental factors, operating outside the context of formal treatment. Unassisted remitters showed greater social stability before the resolution than assisted remitters, more often stated positive incentives for trying to change their lifestyle, and more often tapered their drinking gradually. The results underline the need to consider and try to harness contextual factors when planning individually directed and preventive measures.In an introductory chapter, the four papers are linked together by an examination of prevailing theoretical models of alcohol problems, and the outlining of an overarching perspective that accounts for habitual ex-cessive drinking as a "central activity" in the drinker's way of life. Finally, some joint implications of the four papers, with regard to social work with alcohol problems, and with regard to future research, are discussed.