4. 3 Treatment of alcoholics

A historical description of assistance to alcohol abusers in both
societies is of importance for several reasons. First, it shows in which
the way assistance to alcoholics was structured in relation to its
contextual conditions. Secondly, when drug use among youth became a
social problem in the late sixties, the existing agencies specialised in
assistance to and treatment of alcohol abusers were initially set to take
care of this new category of clients/patients.


Sweden

At the end of the nineteenth century, alcohol treatment was an option
for the privileged. Poor alcoholics were admitted to institutions such as
mental hospitals, prisons, etc. (Blomqvist 1998: 2). However, at the turn
of the century, this changed, due to the influence of temperance
movements and to liberals and socialists advocating a more active role
for the state in solving social problems. Motions to the Riksdag
demanded compulsory care of excessive drinkers in special asylums. In
1908, the question was assigned to the Poor Relief Committee (Ibid. 5).
The committee regarded excessive drinkers as an unnecessary burden to
society. They constituted a unique category that demanded new
measures and practices (Sutton 1998: 53). On the recommendation of
the Committee, the Act on Care of Alcoholics was enacted in 1913 and
came into force with the opening of the first public asylum forcompulsory care of alcoholics in 1916. The criteria for compulsory care
were persons who, due to excessive drinking, constituted a danger to
the safety of others or to their own lives, failed to provide for their
families, or were a burden to the relief system (Ibid. 9). Gradually the
criteria were widened to include repeated drinking offences, being a
burden on the poor relief system, leading a disruptive life and refusing
to support oneself by honest means (Ibid. 9).
Public asylums (with compulsory care) were operated by the state,
county councils, and municipalities but also by NGOs, acknowledged
by and under the supervision of the central state (Stenius 1999: 58).
Asylums not acknowledged to provide compulsory care were not
subsidised by the state. The provision of care was shared between the
central state, local government, the church and religious/temperance
movements, at least until the end the end of World War II.
In the post-war period (1945­1965) professionalisation, rationality
and planning in the care of alcoholics became more important
organising principles than the mobilisation of voluntary forces.
Consequently, the share of county councils and municipalities in
intramural care increased substantially (Ibid. 82). At the end of the
1960s, there were 5 state asylums (500 beds), 22 acknowledged
institutions (1500 beds) and 23 private institutions (800 beds) for
alcoholics (Socialstyrelsen 1970).
This means that the Swedish state had chosen to stimulate the
extension of intramural treatment of alcoholics, but what about
ambulatory care? Another proposal from the Temperance Committee
was to establish municipal temperance boards. The boards comprised
laymen, who were appointed by the municipal council. They would
supervise the sale of alcohol, the general state of temperance in the
community and take care of alcohol problems at the individual level.
Properly educated and personally suitable employees were to strengthen
the drunkard's motives for becoming sober and providing him with
sound alternatives to excessive drinking (Blomqvist 1998: 6). Until
1931, the tasks of the boards were giving advice and assistance and if
necessary applying for compulsory admission to the county board.20
From 1931, supervision and meting out warnings were also added to the
competence of the boards. Providing information to the System
Company about customers that applied for a ration book and approving
driving licences became part of their duties too.
In 1955, when the ration book system was abolished, the boards were
assigned a more active role in ambulatory care and prevention to
intercept the expected increase of alcohol consumption. The NGOs and
other volunteers were needed in the execution of the new tasks of the
temperance councils, for example as supervisors of clients (Stenius
1999: 79).
After the Second World War, another actor appeared on the
assistance arena, the medical profession, in particular psychiatry.
Previously, physicians had been involved in temperance councils (often
as chairman) but were primarily charged with recommending
appropriate care, not treating the alcoholic patient (Sutton 1998: 77).
The introduction of psychotherapy and a pharmaceutical, disulfiram,
better known as Antabus, entailed a shift from care to cure. Another
reason for this shift of focus was the breakthrough of the discourse of
alcohol as a disease. The concept of alcoholism as a mental disorder
was accepted and officially recognised in the Act on Intramural
Psychiatric Care (LSPV) from 1966 (Socialstyrelsen 1970: 34). After
the enactment of the law the number of alcohol patients within
intramural psychiatric care increased sharply and psychiatry would
achieve a large share in the intramural treatment of alcoholics.21
Ambulatory care of alcoholics was also built up in outpatient clinics
and advice bureaux. At the end of the 1960s, the number of alcohol
outpatient clinics was estimated at 130 and a number of advice bureaux
(Socialstyrelsen 1970).
The development as outlined above shows some salient features of
the Swedish system of assistance to alcoholics. First, the central state
took active part in intramural compulsory treatment. Voluntary
intramural treatment has been dominated by NGOs and their services
were to a large degree utilised by municipal temperance councils
(Lundström and Wijkström 1997). Municipal temperance councils and
outpatient clinics at psychiatric hospitals operated ambulatory care.
NGOs were largely involved with informal, non-bureaucratic and non-
professional activities and operated in certain niches of the social
services. 22
Secondly, as pointed out by several Swedish scholars, the emphasis
on inpatient treatment of alcohol and drug abusers constitutes a peculiar
feature of the Swedish system (Bergmark and Oscarsson 1994;
Blomqvist 1998; Stenius 1999).


The Netherlands

At the end of the nineteenth century, the liberal temperance movement
established the first asylum for alcoholics. Some years later a Protestant
asylum opened, followed by a Catholic one. They encountered several
problems. First, they did not receive any state subsidy and consequently
it was mostly well-off alcoholics who could afford treatment.
Furthermore, the share of cured drunkards (in terms of lasting sobriety)
was only 30% over the first ten years. The most serious shortcoming of
asylums was the inadequate reintegration of the patient when returning
home (van der Stel 1993: 193).
As in Sweden, temperance movements and the parliament discussed
compulsory care of alcoholics in special asylums. A bill from a state
committee on compulsory care in 1907 was rejected by the government,
which did not like becoming actively involved in the care of alcoholics
(Ibid. 261).
Instead, the liberal temperance movement started a consultation
bureau for alcoholics (CB) in Amsterdam in 1909, inspired by positive
experiences with consultation bureaux for tuberculosis in the
Netherlands and ambulatory care in some German cities. 23 The aim of
the bureau was to get alcoholics on their feet again in their own
environment, amidst everyday life situations.
Soon after the establishment of the Amsterdam bureau, other cities
followed suit. From the start, it was set up as a professional agency
where a social worker and a psychiatrist worked together. The medical
touch was important for both therapeutic and pragmatic reasons. The
medical examination that every patient had to undergo made it easier to
make him aware of the detrimental effects of alcohol. The already
popular opinion of alcoholism as a disease could be strengthened and
the resistance of the alcoholic to assistance could be broken (Ibid. 210).
The results of the examination were systematically collected to learn
more about the disease. The pragmatic reason was that the bureau was
allowed to take residence in the central building of the Local Public
Health Authority.
The bureau was set up as a foundation, free from pillars and
temperance movements. The objective to make the bureau a general
facility together with the ambition to professionalism may explain why
the CBs largely escaped pillarisation. The only division was between a
north (neutral) and south (Catholic) section (Ibid. 243). Soon CBs had
been established throughout the country but they operated in different
ways adjusted to local needs and opportunities such as access to
professional manpower. The financial difficulties that the CBs
encountered were partly relieved in 1915, when the possibility of
imposing a conditional conviction combined with instructions, for
example, on temperance was enacted. The state contracted probation to
private organisations and this enabled the CBs to partly finance their
activities. In Amsterdam, the bureau also co-operated with the local
poor relief boards and distributed social benefits to alcoholics.
After World War II, a development of further professionalisation of
social work started with the introduction of the method of social
casework from the US (Ibid. 294). The core principle of social
casework is that knowledge of human relations and the skill in using
these relations are essential to mobilise individual capacities and social
resources (Waaldijk 1999). The method was influenced by
psychoanalysis but also by sociology, which studied the interaction
between the individual and his environment. Social casework would be
implemented by most social work agencies in the Netherlands,
irrespective of their background, neutral, confessional, private, or
public.
Secondly, the introduction of social psychiatry in the Netherlands in
1932 by the psychiatrist Querido. The core principle for social
psychiatry was that psychiatric symptoms occurred in the interaction
with the social environment and the individual living conditions of the
patient. Admission to intramural care should be avoided because it
seldom led to the intended effect and was expensive. This line of
thinking meant that social factors had to be included in the therapy from
the beginning and would strongly influence ambulatory psychiatric
treatment in the Netherlands (van der Stel 1999).
Another important development was the acceptance of the disease
model introduced by the American scholar Jellinek. While the
perception of alcohol abuse as a disease was not a novelty, Jellinek was
the first to give it a theoretical foundation. Crucial for further
developments was the acknowledgement of alcohol as a disease by the
Health Insurance Act at the end of the 1950s and the granting of
financial compensation for admissions to hospitals and sanatoria (if
staffed by physicians and nurses) for alcohol-related problems (van der
Stel 1995: 317).
Developments within the Dutch social security system, with a
stronger role for the central state, led to the initiative of the CBs in
Amsterdam and Rotterdam to establish a national association, the
Federation of Agencies for Care of Alcoholics (FZA), in 1953. Almost
all the CBs and three sanatoria joined the FZA.24 One of the aims was
to build a platform that could negotiate with departments on subsidy
matters.
While the majority of the CBs were still sceptical about the benefits
of the sanatoria, the need to observe and treat some patients over a
longer period eventually entailed the establishment of a clinic in
Amsterdam in 1960. The bureau in Rotterdam followed suit in 1961. In
middle of the 1970s there were four CBs with clinical facilities, the two
surviving sanatoria turned into clinics and a new one had been
established in the south. Furthermore, there were two clinics in
psychiatric hospitals. 25


20 County boards are central state administrative bodies that supervise the
implementation of state regulations on the local level.
21 The number of dismissals of alcohol-related patients would reach its peak in 1979
with 42.4% all of dismissals (N= 113.991) (CAN 1988: table B.9.1.)
22 Another area where non-profits organisations have traditionally been engaged is
assistance to the homeless (Ibid. 80).
23 The consultation bureaux had different names until the 1960s when they became
Consultation Bureau for Alcohol and Drugs (CAD). I will use the term consultation
bureau (CB) in this part.
24 The Catholic CB did not join the FZA until 1968.
25 In 1955 the first psychiatric clinic for addicts opened but such clinics would
remain few in number.

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