I was awarded my PhD qualification in 2002 on a dissertation about substance users’ views on lifestyle change and compulsory treatment. Since then my research has drawn on mainly qualitative approaches to study policy and practice in the field of alcohol and other drug use. It has covered a wide range of topics related to social work, such as motivation, mandatory treatment programs, aftercare interventions, opioid substitution treatment, risk perceptions, service provision and user perspectives.
A selection from Stockholm University publication database
Cannabis i Sverige - en komplex substans, en enkelspårig drogpolitik?
2020. Mats Ekendahl, Josefin Månsson, Patrik Karlsson. Socionomens forskningssupplement (47), 16-25Article
I Sverige är cannabis, särskilt ungdomars bruk av substansen, kontroversiella ämnen som uppmärksammas såväl i media och politik som bland myndigheter och allmänhet. I denna artikel presenterar vi ett forskningsprojekt som belyser det svenska cannabisbruket, med fokus på vilka som gör det, deras åsikter och motiv, samt hur det kan gå till när de möter preventionsinsatser. Våra resultat pekar mot att cannabisbruk kan ha många olika betydelser och funktioner i människors liv, samt att den svenska förbudspolitiken sätter ramarna för hur användare förstår sina handlingar och hur de bemöts av omgivningen. Yttre inflytande från en drogliberal omvärld har dock inneburit att det knappast längre går att identifiera en allenarådande ”berättelse” om vad cannabis är, vilka effekter substansen har och vad som kännetecknar användarna. Vårt projekt understryker vikten av en mer nyanserad politik och praktik i förhållande till cannabisbruk i Sverige.
2021. Mats Ekendahl, Patrik Karlsson. Contemporary Drug Problems 48 (2), 99-113Article
This study analyzes how staff in Swedish alcohol and other drug (AoD) treatment interpellate service users as people who can benefit from relapse prevention. Relapse prevention is a widely used intervention. Research is scarce, however, on how relapse prevention is practiced locally and how treatment staff perceive the relationship between AoD use as a problem and relapse prevention as a solution. Drawing on Actor-Network Theory and critical studies of AoD issues within this tradition, we elucidate how staff through specific interpellative logics enact service users, their individual characteristics, and living conditions. The data derive from interviews with 18 professionals working with assessment, counseling, case-management, therapy, and healthcare at AoD treatment agencies in the Stockholm region. The results show that the participants drew on four interpellative logics, and thereby enacted service users as four different object types. Region and network logics pinpointed that individuals have stable observable characteristics that determine their problems and eligibility for treatment (e.g., living conditions, diagnoses). Fluid and fire logics emphasized that their characteristics also vary depending on context and can be present and absent at the same time (e.g., harms, agency). This flexible interpellation of service users echoes the tendency among treatment staff to embrace sometimes irreconcilable understandings of AoD problems and to enact multiple realities of addiction. This suits a professional field where many factors are thought to cause and help resolve problems, but where the treatment supply is often limited to specific interventions. We conclude that it is easier to create a reasonable match between the service delivered and the potential service user if the characteristics of the latter are considered diverse and flickering. This exemplifies Carol Bacchi’s tenet that problem representations are adjusted to fit the solution at hand.
Atmospheres of craving: a relational understanding of the desire to use drugs
2022. Josefin Månsson (et al.). DrugsArticle
Craving is commonly described as an ‘intense desire’ to use drugs. Due to its relevance for addiction theories and treatment, much effort has been put into understanding how and when craving occurs. An undisputed definition of craving is however still lacking. The aim of this article is to explore how craving is experienced and resisted after cessation of substance use.
This article analyses interviews with former addiction treatment clients. By analyzing the described event of craving, the study shows the complexities in such narratives.
We found that the interaction between temporal, relational and material forces move people toward or away from craving. Craving thus seemed to be both relational and located in-between forces.
We conclude that craving appeared in the studied narratives to emanate from different atmospheres, with a concurrent focus on settings rather than on substances. A relational understanding of craving can add to the typical, but limited, account of craving as an individual issue. It also avoids stigmatizing ideas that people who do not resist cravings simply fail to say no. We end by asking if craving is a relevant concept within the addiction field at all.
Self‐interpellation in narratives about craving: Multiple and unitary selves
2022. Mats Ekendahl (et al.). Sociology of Health and Illness 44 (9), 1391-1407Article
The concept of addiction seeks to explain why people actcontrary to their own best interest. At the centre stageof addiction discourse is craving, conceptualised as astrong urge to use substances. This article analyses howtalk therapies such as relapse prevention and self-helpgroups shape identity constructions and understandingsof craving among clients. Drawing upon interviewswith individuals who have engaged in talk therapies inSweden, we analyse how craving is made up through‘self-interpellation’, that is, personal narratives aboutpast, present or future thoughts, feelings and actions.The main ‘self-interpellation’ included multiple selves,where craving was elided by the true self and only feltby the inauthentic self. Less dominant were narrativeswhich drew on a unitary self that remained stable overtime and had to fight craving. The notion of multipleselves appeared as a master narrative that the participantswere positioned by in their identity constructions.We conclude that this multiplicity seems ontologicallydemanding for people who try to recover from substanceuse problems. A demystification of craving, in whichneither substance effects nor malfunctioning brains areblamed for seemingly irrational thoughts and actions, may reduce the stigmatisation of those who have developedhabitual substance use.
Fixed and fluid at the same time
2021. Mats Ekendahl, Patrik Karlsson. Critical Public HealthArticle
This article explores how professionals within Swedish addiction treatment (n = 18) describe and make sense of relapse prevention (RP). RP is known as a self-control programme for maintaining behavioural change, helping people deal with high-risk situations. However, since self-control techniques have been incorporated widely in the addiction treatment field, the specificities of RP have become vague. To grasp what RP ‘is’, we draw on John Law’s and Annemarie Mol’s thoughts on how logics enact objects and realities. We thus follow critical scholarship in Science and Technology Studies and view treatment as a local knowledge-making practice that may depart from how it was originally designed. A key question is how RP is potentially transformed and made-to-matter when moved from the controlled settings of theorising and experimental studies to practice. The professionals used a logic of fixity to make RP stable, structured and evidence-based, easily distinguishable from other interventions. They also used a logic of fluidity to explain how and why they tinkered with it and adapted it to the preferences of both staff and attendees. The two logics enacted two different realities of addiction treatment: one in which RP is standardised, temporally demarcated and can solve most addiction problems, and another where interventions must be individualised, continuous and adapted to local settings and needs. It did not appear contradictory to ‘make up’ RP as both fixed and fluid; the two realities exist side by side, but with different material effects.
A matter of craving–An archeology of relapse prevention in Swedish addiction treatment
2022. Mats Ekendahl, Patrik Karlsson. International journal of drug policy 101Article
This article concerns how craving is approached and handled, how it is ‘made up’, in the practice of so-called relapse prevention (RP) for addiction problems. There is a lack of research on what RP in general, and craving in particular, ‘is’ and can become across settings. Drawing upon science and technology studies (STS) and critical addiction research, we analyze how craving is enacted in manuals and training material related to the intervention, and in interviews with professionals in the Swedish treatment system. Adopting an archeological approach, we scrutinize different layers of craving enactments in RP, in search of assumptions that give rise to what John Law refers to as ‘collateral realities’. We identified three collateral realities: 1) ‘The materialization of craving’; 2) ‘The transcendence of the individual’ and 3) ‘The merging of treatment and everyday life’ The data show that the brain, cognition, emotions and behavior are enacted in RP as demarcated targets of intervention that the individual can transcend and control. This approach, in turn, relies on the more foundational tenet that there are no clear-cut boundaries between different identities (I/me/self; body/brain/cognition), between different settings (inside/outside treatment; real/imagined situations) or between different points in time (now/then/before). We discuss the relevance and usefulness of addiction treatment realities where craving is approached as a stable object that can be effectively treated, and where interventions inaugurate neoliberal governance of responsibilized individuals.
Comparisons in the making
Mats Ekendahl, Patrik Karlsson. Drugs: Education, Prevention and PolicyArticle
Research shows that cannabis is understood differently across cannabis cultures. In Sweden, young cannabis users are seen as vulnerable, problem-burdened and increasingly embracing drug-liberal attitudes. Despite low prevalence rates, youth cannabis use is considered a high-profile problem that warrants prohibition. Previous studies show that staff in Swedish addiction treatment legitimize resolute interventions by making up young users as irrational. The treated young people claimed instead that starting to use cannabis and quitting were informed decisions. In this article, we revisit interviews with 18 young clients in Swedish addiction treatment, and examine the data with a focus on comparisons (e.g. A is unlike B). We perceive comparison as a tool in the formation of narrative identity, rather than a logical outcome of accounts. We ask what is compared with what in young people’s accounts of cannabis use, and what these comparisons reveal about their thoughts on well-being, the self and the setting. The interviewees used comparisons that drew on cultural, institutional and organizational narratives when they discussed cannabis. Taken together, their accounts instantiated ideas about powerful drug effects, the primacy of the neoliberal subject and the potential of cannabis addiction. We discuss whether these accounts mirror rather than challenge drug prohibition.
Logics of Legitimation in Swedish Treatment for Youth Cannabis Use: The Problem Representations of Social Workers in a Prohibitionist Policy Context
Mats Ekendahl, Patrik Karlsson, Josefin Månsson.Article
Liberal views on cannabis use are widespread in many Western countries, but prohibitionism remains strong in Sweden. According to Swedish drug policy, comprehensive prevention and treatment interventions are necessary because young people are considered particularly vulnerable to cannabis-related harm. In this article, we examine how staff at Swedish outpatient treatment centers for young substance users (called “MiniMaria”) use different logics when legitimizing their work in youth treatment. We also analyze how this legitimizing process contributes to both justifying solutions and constituting the cannabis “problem” that MiniMaria centers are established to handle. This will shed light on what “drug reality” the staff make up through their articulations. Eighteen interviews with social workers from six MiniMaria centers in the Stockholm region were analyzed. To illustrate how staff made sense of their work, we used the concepts of “problem representation”, “legitimation”, and “logics”. We identified four logics: A scientific and a structural logic linked to knowledge claims, policy goals, and organizational setting, and a professional and a procedural logic linked to work experience, client interaction, and therapeutic methods. Participants used logics to emphasize that the character of the cannabis problem demands wide-ranging interventions and to explain how they made youth cannabis users realize they need treatment. The structural logic of drug prohibitionism was only mentioned as a last resort when other logics were not applicable, for example, when a young person refused to engage in treatment and quit using cannabis. The strategic use of logics provided MiniMaria with a moral legitimacy that represented youth cannabis use as a high-profile problem and young people as in need of protection and control. This legitimizes prevention of youth cannabis use in a national setting where cannabis prevalence and harm remains relatively low.
Exploring the Link between ADHD and Cannabis Use in Swedish Ninth Graders: The Role of Conduct Problems and Sensation-Seeking
2023. Patrik Karlsson, Mats Ekendahl, Jonas Raninen. Substance Use & Misuse, 1-9Article
Background: Attention deficit hyperactivity disorder (ADHD) has in several studies been linked to substance use, including cannabis use. However, crucial gaps remain regarding how to understand this association. Analyzing the association between ADHD and substance use is complicated because of a pronounced overlap between ADHD, conduct problems, and traits such as sensation-seeking. Objectives: Using data from a large and nationally representative study among Swedish adolescents, this study explored the role of conduct problems, but also of sensation-seeking, in accounting for the association between ADHD and cannabis use. Results: There was a notable association between ADHD and cannabis use that was attenuated when conduct problems were controlled for. The association between cannabis use and conduct problems, in turn, was attenuated when sensation-seeking was controlled for. Individuals with both ADHD and conduct problems were more likely to have used cannabis than individuals with ADHD only, but not compared with individuals with conduct problems only. Conclusions: Whereas conduct problems largely explain the link between ADHD and cannabis use, sensation-seeking seems to account for the association between conduct problems and cannabis use.
Has illicit drug use become normalised in groups of Swedish youth? A latent class analysis of school survey data from 2012 to 2015
2019. Patrik Karlsson (et al.). Nordic Studies on Alcohol and Drugs 36 (1), 21-35Article
It is often assumed that illicit drug use has become normalised in the Western world, as evidenced for example by increased prevalence rates and drug-liberal notions in both socially advantaged and disadvantaged youth populations. There is accumulating research on the characteristics of young illicit drug users from high-prevalence countries, but less is known about the users in countries where use is less common. There is reason to assume that drug users in low-prevalence countries may be more disadvantaged than their counterparts in high-prevalence countries, and that the normalisation thesis perhaps does not apply to the former context.
This article aims to explore to what extent such assertions hold true by studying the characteristics of young illicit drug users in Sweden, where prevalence is low and drug policy centres on zero tolerance.
Material and Method:
We draw on a subsample (n = 3374) of lifetime users of illicit drugs from four waves of a nationally representative sample of students in 9th and 11th grade (2012–2015). Latent class analysis (LCA) on ten indicators pertaining to illicit drug use identified four classes which we termed “Marijuana testers”, “Marijuana users”, “Cannabinoid users” and “Polydrug users”.
Indications of social advantage/disadvantage such as peer drug use, early substance-use debut and truancy varied across groups, particularly between “Marijuana testers” (low scores) and “Polydrug users” (high scores).
Our findings corroborate the idea that the majority of those who have used illicit drugs in the Swedish youth population have tried marijuana a few times only. We discuss whether or not the comparably large share of socially advantaged “Marijuana testers” in a comparably small sample of lifetime users can be interpreted as a sort of normalisation in a prohibitionist drug policy context.
Legitimacy through scaremongering
2013. Josefin Månsson, Mats Ekendahl. Addiction Research and Theory 21 (6), 469-478Article
In Sweden, prohibitionist drug policy has contributed to making cannabis an illegal drug, viewed as dangerous, while alcohol is considered a legitimate recreational commodity. But the official Swedish cannabis discourse is now being contested on internet. In virtual environments an often employed way to try to legitimize cannabis use is by comparing it to alcohol. This indicates the importance of analyzing how substances are attributed with meaning in various contexts. This study aims to describe and analyze the discursive role of alcohol in Swedish online discussions of cannabis use and policy. Approximately 700 alcohol-related comments, posted during one year period, were retrieved from the cannabis-section of Swedish Flashback Forum (a website open for public viewing). The sample was analyzed qualitatively with analytical tools such as nodal points, analogies, distinctions and typological examples. Two concepts, danger and discrimination, were identified as nodal points in a cannabis legalization discourse, and provided a backdrop from which comparisons between alcohol and cannabis were made meaningful. We have found that cannabis and alcohol ‘‘changed places’’ in these online discussions. The participants drew on a prohibitionist cannabis discourse but applied its arguments to alcohol; alcohol was thereby given the role of the ‘‘ideal enemy’’ while cannabis was presented as a harmless plant rejected by society on moral rather than scientific grounds. The relevance of acknowledging and reflecting upon the influence that online ‘‘talk’’ has on young people’s attitudes towards drugs is discussed.
2015. Josefin Månsson, Mats Ekendahl. Contemporary Drug Problems 42 (3), 209-225Article
During recent years, political discussions about how to deal with cannabis use have become increasingly centered on harm reduction and liberalization in large parts of the Western world. In Sweden, however, no such re-framing of the issue has occurred. There has been political status quo with emphasis on prohibition and zero tolerance. This study aims to elucidate how the cannabis policy discourse in Sweden is characterized today to legitimize restrictive drug policy and counter global changes. Two symposia dedicated to dissemination of cannabis information in Sweden were analyzed to understand how policy players, service providers, and other professionals invited to speak at these events argue to maintain cannabis use a high-profile societal problem that necessitates prohibition. With the help of Carol Bacchi’s theoretical approach “What’s the Problem Represented to be,” we critically analyzed how cannabis is constructed in the material. This meant focusing on what policy and service provision that is described as meaningful and effective as a way to understand what the problem of cannabis is represented to be. Our analysis showed, among other things, that cannabis-positive attitudes are seen as utterly problematic, that youth users are portrayed as extremely vulnerable, and that current government responses are perceived as righteous and compassionate. It also showed how speakers at symposia construct a morally upright “us” who promote “reliable” scientific evidence about the dangers of cannabis. In this way, the choice between keeping prohibition and trying liberalization stands out as one between letting reliable or unreliable research guide drug policy. We conclude that youth becomes a perfect category to rationalize current problematizations; a vessel that may carry and protect drug prohibition in a globalized world where cannabis is increasingly handled like an ordinary commodity.
Obscuring Gendered Difference
2020. Duane Duncan (et al.). Social PoliticsArticle
Despite public debate about alcohol and public violence among young people in Australia, the issue of masculinities or gender is rarely visible in alcohol policy. Instead, policy recommendations aimed at reducing violence focus on changing the availability and consumption of alcohol. Drawing on concepts from feminist and science and technology studies scholarship, this article analyses how “alcohol-related violence” is constituted as a specific policy object, and how it coheres to obscure men’s contributions to and experiences of violence. Attention to the political effects of these policy practices is necessary for the development of more equitable alcohol policies.
The analytical, the political and the personal: Swedish stakeholder narratives about alcohol policy at football stadiums
2022. Mats Ekendahl, Helen Keane, David Moore. Critical Policy StudiesArticle
For public health interventions to be effective, they need to be supported or at least accepted by those affected, and social policy should therefore be understood as political and strategic. This raises questions about the relationship between the analytical, the political and the personal in policy processes. This article offers an in-depth analysis of such issues, as they were enacted during interviews with Swedish alcohol policy stakeholders. It focuses on the assumptions and a priori 'truths' articulated in interviews about Responsible Beverage Services (RBS) at Swedish football stadiums or 'Football Without Bingeing'. We argue that the participants combined different narrative forms, such as seemingly objective chronological accounts and personal ethical judgments, in talking about the policy initiative. Through such narrative intersections, three key 'truths' were produced that reinforced the link between alcohol and violence, necessitated blanket population-level measures to reduce alcohol use and made gendered behavior an irrelevant policy target.
Gendering practices in quantitative research on alcohol and violence: Comparing research from Australia, Canada and Sweden
2022. David Moore (et al.). International journal of drug policy 103Article
In this article, we analyse the treatment of gender in Canadian and Swedish quantitative research on alcohol and violence and compare it with the treatment of gender in similar Australian research. In previously published work, we argued that Australian research on ‘alcohol-related presentations’ to emergency departments, and on alcohol and violence among young people participating in the night-time economy, tends to overlook the stark gendering of violence in its analyses and policy recommendations. It does this via a series of ‘gendering practices’ (Bacchi, 2017): omitting gender from consideration; overlooking clearly gendered data when making gender-neutral policy recommendations; rendering gender invisible via methodological considerations; displacing men and masculinities via a focus on environmental, geographical and temporal factors; and addressing gender in limited ways. We identify a similar set of gendering practices at work in Canadian and Swedish quantitative research on alcohol and violence, as well as a key difference. This key difference emerges in relation to the practice of addressing gender. Here, we see a bifurcation in the Canadian studies: between one group of articles in which gender is central to the analyses and ensuing policy recommendations, and a second group containing only one example in which gender is partially addressed. We draw attention to the differing realities of gender, alcohol and violence iterated by these contrasting knowledge practices, and offer two possible explanations for this difference. We close by asking how future research analyses and policy recommendations might differ if gender-sensitive quantitative tools were developed, gender considerations were systematically integrated, and gendered effects were taken into account when alcohol policy choices are made.
Noticed and then Forgotten: Gender in Alcohol Policy Stakeholder Responses to Alcohol and Violence
2022. Adrian Farrugia (et al.). Qualitative Health Research 32 (10), 1419-1432Article
In this article, we analyse interview data on how alcohol policy stakeholders in Australia, Canada and Sweden understand the relationship between men, masculinities, alcohol and violence. Using influential feminist scholarship on public policy and liberal political theory to analyse interviews with 42 alcohol policy stakeholders, we argue that while these stakeholders view men’s violence as a key issue for intervention, masculinities are backgrounded in proposed responses and men positioned as unamenable to intervention. Instead, policy stakeholders prioritise generic interventions understood to protect all from the harms of men’s drinking and violence without marking men for special attention. Shared across the data is a prioritisation of interventions that focus on harms recognised as relating to men’s drinking but apply equally to all people and, as such, avoid naming men and masculinities as central to alcohol-related violence. We argue that this process works to background the role of masculinities in violence, leaving men unmarked and many possible targeted responses unthinkable.
The hammer and the nail: The triple lock of methods, realities and institutional contexts in Australian research on nightlife violence
2022. Duane Duncan (et al.). International journal of drug policy 110Article
There is considerable public and policy debate in Australia about measures to reduce violence associated with alcohol and young people in the night-time economy. Though overrepresented in violence, the role of men and masculinities is rarely explicitly addressed in policy responses to such violence, which rest on a narrow range of mainly quantitative research and recommendations favouring blanket alcohol restrictions. Drawing on John Law and colleagues’ account of the ‘double social life of methods’ (2011), we analyse interviews conducted with Australian quantitative researchers about the role of gender in such violence. According to Law et al., methods inhabit and reproduce particular ecologies and reflect the concerns of those who advocate them. From this ‘triple lock’ of methods, realities, and institutional advocacies and contexts emerges particular modes of knowing. Participants described a research ecology in which the authority of quantitative research methods emerged in relation to an imperative to respond in a ‘timely’ and ‘pragmatic’ fashion to public policy debates, and prevailing governmental and policy priorities and public framings of violence. Though participants frequently acknowledged the role of men in violence, these arrangements sustain taken-for-granted assumptions about the properties and effects of alcohol while displacing men and masculinities from policy attention. The political consequences of these arrangements demand the development of innovative policy responses and new modes of knowing that make visible the gendering of violence.
Making gender along the way
2020. Duane Duncan (et al.). Critical Policy StudiesArticle
Analysis of alcohol policy suggests women are marked out for special attention while men and masculinities are often ignored. In this paper, we employ Carol Bacchi’s work on ‘gendering practices’ and John Law’s concept of ‘collateral realities’ to examine how gender is constituted in Australian alcohol policy. For Bacchi, policies actively produce what it is possible for ‘men’ and ‘women’ to become. For Law, realities are constituted through methodological instruments and representational practices. We analyze the making of three collateral realities in Australian alcohol policy: gender as an individual attribute; gender as a synonym for women; and gender as confined to the domestic sphere. These collateral realities contribute to the maintenance of binary notions of gender and reinforce a straightforwardly causal role for alcohol in harms, including violence. Attention to the political effects of these ‘realities’ should be prioritized in the development of more equitable responses to alcohol and harm.
Displacements of gender
2020. David Moore (et al.). Journal of SociologyArticle
‘Alcohol-related violence’, especially among young people participating in the night-time economy(NTE), has been the subject of intense public and policy debate in Australia. Previous sociologicalwork has highlighted the relationship between men, masculinities and violence, but this relationshiphas received little attention in the research that tends to garner policy attention. In this article,we focus on the treatment of gender in Australian quantitative research on alcohol and violencein the NTE. We identify four ‘gendering practices’ through which such research genders alcoholand violence: de-gendering alcohol and violence through obscuring gender differences; displacingmen and masculinities via a focus on environmental, geographical and temporal factors; renderinggender invisible via methodological considerations; and addressing gender in limited ways. We arguethat these research practices and the policy recommendations that flow from them reproducenormative understandings of alcohol effects and lend support to gendered forms of power.
2018. Suzanne Fraser, Mats Ekendahl. Contemporary Drug Problems 45 (2), 87-106Article
The alcohol and other drug field is characterized by great diversity in kinds of treatment and treatmentphilosophies. Even the kinds of problems treatment is expected to address vary significantly, althoughagreement seems to exist that the general purpose is to help people “get better.” This article considersthis diversity, drawing on a qualitative project conducted in three countries: Australia, Canada, andSweden. Inspired by the project’s multisite approach and the questions it raises about comparativeresearch, the article critically engages with the notion of “comparison” to think through what is atstake in making comparisons. Analyzing 80 interviews conducted with policy makers, service provi-ders, and peer advocates, the article maps key ways treatment is conceptualized, identifying in them acentral role for comparison. Participants in all sites invoked the need to consider addiction a multi-faceted problem requiring a mix of responses tailored to individual differences. Related notions of“holism” were also commonly invoked, as was the need to concentrate on overall improvements inwell-being rather than narrow changes in consumption patterns. In conducting this analysis, this articleposes a series of critical questions. What kinds of comparisons about quality of life, the self, and well-being do treatments for addiction put into play? What categories and criteria of comparison arenaturalized in these processes? What kinds of insights might these categories and criteria authorize,and what might they rule out? In short, what does it mean to understand alcohol and other drug useand our responses to it as intimately intertwined with the need to “get better,” and what happenswhen we scrutinize the politics of comparison at work in getting better through addiction treatment?We conclude by arguing for the need to find new, fairer, ways of constituting the problems we pre-sently ascribe to drugs and addiction.
Drugs, Brains and Other Subalterns
2018. Suzanne Fraser, Kylie Valentine, Mats Ekendahl. Body & Society 24 (4), 58-86Article
Over the last few decades feminists, science and technology studies scholars and others have grappled with how to take materiality into account in understanding social practices, subjectivity and events. One key area for these debates has been drug use and addiction. At the same time, neuroscientific accounts of drug use and addiction have also arisen. This development has attracted criticism as simplistically reinstating material determinism. In this article we draw on 80 interviews with health professionals directly involved in drug-related public policy and service provision in three countries to identify the main ways the neuroscience of addiction (and thus the agency of the brain) is understood. We analyse these understandings using contemporary posthumanist theory to develop new options for conceptualizing matter in public responses to addiction. We close by calling for a new approach to addiction and the brain based on a process model of materiality and public debate.
Danish heroin prescription in Swedish print media
2012. Mats Ekendahl. Addiction Research and Theory 20 (5), 423-434Article
Sweden's response to drug problems has long been governed by zero tolerance, as manifested by the motto 'a drug-free society' and the criminalisation of drug use. In this context, the legitimacy of methadone maintenance treatment and other interventions often depicted as harm reduction has been questioned. This highlights that solutions to drug problems are circumscribed by culture-specific ideologies and definitions of reality that are articulated in different discourses. The study aims to elucidate how Denmark's decision in 2008 to launch heroin prescription (a controversial form of maintenance treatment) was addressed in Swedish print media, and identify how key concepts such as 'heroin users' and 'treatment' were attributed with meaning. In order for the analysis to go beyond apparent differences between the discourses of harm reduction and zero tolerance, specific interest was placed in constructions that were shared by protagonists on the issue of heroin prescription. The data encompasses 29 articles (news agency announcements plus daily press) that were analysed with focus on binary oppositions and then coded thematically. Four themes were identified: 'Users as passive victims'; 'Methadone as benchmark'; 'Treatment as necessity' and 'Swedish drug policy as unique'. These themes appear as presuppositions, or silent agreements, that precede different understandings of heroin prescription in Swedish press. It is concluded that the media representations reproduced traditional constructions of heroin users as victims in need of society's help. The relevance of characterising heroin prescription as a 'new way' of handling heroin dependence problems is discussed.
Individual and school-class correlates of youth cannabis use in Sweden
2018. Patrik Karlsson (et al.). Nordic Studies on Alcohol and Drugs 35 (2), 131-146Article
Background and aims: The school-class context is a crucial social environment for young people but substance use researchers have largely overlooked potential influences operating at this level. This study explores associations between school-class and individual-level factors and cannabis use in Swedish youth.
Data and methods: Data comprised four waves (2012–2015) of the Swedish Council for Information on Alcohol and Other Drugs’ (CAN) nationally representative school surveys among individuals in 9th and 11th grade. For the present analyses, we had data on totally 28,729 individuals from 2377 unique school classes. Multilevel logistic regressions predicted lifetime and 10+ times use of cannabis from both individual-level predictors and school-class-level measures derived from the individual-level variables.
Results: There were individual-level associations between most predictor variables and cannabis use. An early debut of tobacco use and binge drinking as well as low cannabis related risk perceptions had strong associations with cannabis use. Conversely, several school-class-level variables had aggregate relationships with cannabis use, most notably the overall level of risk perceptions in the school class. Some of the school-class factors predicted cannabis use over and above the individual-level covariates, suggesting the presence of contextual effects. Surprisingly, while female gender was negatively related with cannabis use at the individual level, a higher proportion of females in the classroom increased the odds for lifetime cannabis use even after controlling for individual and other contextual-level covariates.
Conclusions: Youth cannabis use is related to various factors at both the individual and school-class level in Sweden. Truancy and perceived risk related to cannabis use had contextual associations with cannabis use. The positive contextual association between a higher proportion of females in the classroom and lifetime use should be explored further.
The credibility of risk information about licit substances
2015. Mats Ekendahl, Patrik Karlsson. Nordic Studies on Alcohol and Drugs 32 (4), 395-410Article
AIMS – Providing risk information on licit substances is a central health promotion strategy. Thereis, however, very little knowledge about public attitudes on this information. In this exploratorystudy we analyse the extent to which Swedish adults: 1) trust risk information regarding alcohol,cigarettes and wet snuff (“snus”) provided by public authorities, 2) perceive risk informationregarding alcohol, cigarettes and snus as consistent, and 3) have received an adequate amountof risk information from public authorities regarding these substances. The aim is also toinvestigate if certain characteristics among participants are related to their perceptions of suchrisk information. METHODS – A questionnaire was mailed to a random sample of individuals aged18 to 70 (n=1623, 54% response rate). Descriptive statistics and logistic regression techniqueswere used to process data. RESULTS – Participants trusted risk information concerning cigarettes,snus and alcohol provided by public authorities, and reported that they had received an adequateamount of it. Information about cigarettes was seen as more trustworthy and consistent thaninformation about alcohol and snus. The study suggests that attitudes on risk information aresubstance-specific and associated in complex ways with gender, age, education and experience ofown substance use. CONCLUSION – While only a first attempt to map an under-investigated area,our study highlights complexities in how people perceive risk information about licit substances. Italso indicates that the general population in Sweden receives what is seen as an adequate amountof knowledge from public authorities, and finds it consistent and trustworthy.
Clashing Perspectives: Cannabis Users and Swedish Drug Policy
2021. Josefin Månsson, Mats Ekendahl, Patrik Karlsson. Retreat or Entrenchment? Drug Policies in the Nordic Countries at a Crossroads, 267-290Chapter
Urine testing wasn’t fun. I mean, they are so advanced now, theysee the THC [tetrahydrocannabinol] count go up and down. Notonly if it’s a positive or a negative, but to what extent. It was hard,because I thought that they would only detect if it was a positiveor a negative, and that I could smoke a little while tapering off.But all along it went up and down… They called it a relapse whenI came in for a meeting: ‘You’ve had a relapse!’ Oh my god, such ahassle. I just smoked a joint.
Cannabis use under prohibitionism – the interplay between motives, contexts and subjects
2019. Mats Ekendahl, Josefin Månsson, Patrik Karlsson. DrugsArticle
A key question in drugs research is why people use psychoactive substances. Diverse motives such as boredom, habit, and pain relief have served as explanations, but little is known about how adult cannabis users motivate their use in prohibitionist policy contexts, like Sweden. The aim is to explore what motives a sample of adult Swedish cannabis users refer to when they give meaning to their use. We ask: what aspects of cannabis use (e.g. drug effects, individual characteristics and social contexts) are emphasized in their accounts, and how are such aspects combined to describe motives and justify use? In this study, motives are perceived as culturally situated action, and our analysis is based on online text messages (n = 238) and interviews (n = 12). Participants emphasized either the characteristics of the use situation (motives such as party, relaxation and social function) or of him-/herself as an individual (motives such as mindfulness, identity marker and somatic function). They often mentioned medical and recreational motives in the same account, and carefully presented themselves as rational individuals. The motives reflect that the drugs discourse is increasingly medicalized, that responsibility is highly esteemed in contemporary societies, and that cannabis use is still stigmatized in Sweden.
Risk factors for substance use in Swedish adolescents: A study across substances and time points
2022. Nicklas Dennermalm, Patrik Karlsson, Mats Ekendahl. Nordic Studies on Alcohol and Drugs 39 (5), 535-552Article
Aim: The public health model for prevention of disease and disorder has been influential in informing interventions regarding substance use. While a number of risk factors within this model have been found to predict substance use, few studies have explored the associations across substances, at different time points and in the same individuals. The aim of this study was to test this model across legal and illegal substance use among adolescents, and to identify potential changes in associations over time. Methods: Data from two waves of a nationally representative cohort study among Swedish adolescents were used. Baseline data were collected in 2017 (9th grade) with a follow-up in 2019 (11th grade). Using modified Poisson regression analyses, we explored cross-sectional associations between factors from different domains and prevalence of cigarette use, binge-drinking and illegal drug use at both baseline and follow-up. Results: The results in part supported the public health model. Substance use was predicted by factors within the family, school and the individual/peer domain, but several associations were not statistically significant. The only consistent risk factors across substances and time points were lack of parental monitoring, truancy and minor criminal activities. Conclusion: Despite widely different prevalence rates across substances, some risk factors were consistently associated with adolescent substance use. Nonetheless, the findings challenge the assumption that risk factors are stable over adolescence. They suggest a need for flexible prevention interventions spanning across substances and legal boundaries of substances, but also over domains to reflect the heterogenous needs of adolescents.
Limits of evidence
2009. Mats Ekendahl. Nordic Studies on Alcohol and Drugs 26 (4), 399-414Article
In Sweden, maintenance treatment (MT) with methadone has been a controversial exception to drug-free treatment. However, efficacy, prescription control and the provision of simultaneous psychosocial treatment (PST) have provided MT with political legitimacy. This view, notably stressing that PST is an important complement to medication, was presented in central Swedish policy documents that paved the way for less strict MT regulations in 2005.
Aim: The present study aims to analyse how the various stakeholders involved in this policy process described and evaluated the efficacy and legitimacy of PST within the framework of the MT discussion.
Data & method: The data consists of a document authored by a state agency (a preliminary review of MT research) and various stakeholders' written commentaries on it. Different representations of PST (so-called constructions) were coded thematically and analysed using discourse analytical concepts.
Results: The results show that stakeholders' constructions of PST draw on different discourses related to the governance of Swedish opiate addiction treatment. Four constructions were identified, PST as: "mere complement" (narrow empirical discourse); "underrated intervention" (practitioner discourse); "preferred intervention" (ideological discourse) and "complex intervention" (anti-reductionist discourse).
The study illustrates how the narrow empirical discourse's construction of PST as a mere complement was challenged by the three other discourses, but shows that the former remained the dominant influence on subsequent MT regulations. It also highlights that references to beliefs and alleged facts are intertwined in stakeholders' rhetorical efforts to assign meaning to PST.
This suggests that science and ideology are interrelated in policy discussions on opiate addiction treatment, and that firm conclusions about the value of help interventions rely as much on scientific evidence as on strategic argumentation
Socialtjänst och missbrukarvård
2011. Mats Ekendahl. Nordisk Alkohol- og narkotikatidsskrift (NAT) 28 (4), 297-319Article
Social service and addiction treatment: rehabilitation or harm reduction?
AIM –This paper aims to depict and analyze how professionals in Swedish social services legitimize two ideologically controversial help interventions, methadone maintenance and coercive treatment. Should addiction treatment primarily rehabilitate clients, or should it be a short-term measure for harm reduction? This question has been less and less discussed inSwedenduring the past few years, as it has been accepted that all help should be based on science, not ideology – irrespective of it being aimed at harm reduction or rehabilitation. However, there is a lack of research regarding how crucial players in addiction treatment relate to this development, especially when applied on socially vulnerable clients. MATERIAL & METHOD – The empirical material consists of 33 qualitative interviews with social workers from Stockholm and its surrounding area. The interviews are analyzed through discourse analysis. RESULT – When describing their work, the respondents' discourse assumed and advocated progress in client case management. CONCLUSION – By emphasizing concepts such as lifestyle change, client motivation, psychosocial support and aftercare the social workers could construct the two forms of treatment as less ideologically extreme, but also as undoubtedly aligned with the political goal of rehabilitation.
The user in Swedish abstinence-oriented opioid substitution therapy
2016. Mats Ekendahl, Patrik Karlsson. Evidence in European social drug research and drug policy, 51-67Chapter
The idea of placing the views of service users at the centre of evidence-based practice has been praised in theory but rather neglected in empirical drug treatment research. Knowledge is scarce about how users’ perspectives are handled in policy and practice. In this chapter, we explore how Swedish opioid substitution treatment (OST) was perceived by users themselves and how their views were taken up by the Swedish National Board of Health and Welfare in developing new treatment regulations for OST. We argue that, despite the current valorisation of ‘the user’s voice’ across the health professions, the concept basically has no meaning in Swedish drug policy. The user preferences we identified (such as a desire for less suspicious staff, and acceptance of some drug use on top of their prescription) appeared to be more or less impossible to realise given the core prohibitionist values underpinning Swedish OST policy. While user involvement is commonly described as a keystone in the ‘evidence movement’, our analysis, of a contemporary policymaking process in the field of drug treatment, indicates that it served more as a rhetorical device than as a sine qua non of OST.
The limits of legitimacy
2011. Mats Ekendahl. Addiction Research and Theory 19 (5), 427-437Article
Background: It is widely acknowledged that the social meaning of maintenance treatment (MT) with methadone is context-dependent and that different discourses influence how this approach to opiate addiction problems is practised. In Sweden, MT has long been ideologically controversial, even if the past decade’s emphasis on evidence-based interventions has made it more accepted and prevalent in the treatment system. MT may thus be seen as a discursive field where science and values are intertwined and impact practice jointly, which emphasises the importance of analysing how MT is attributed with meaning. Objectives: The study aims to identify and analyse the discourses that service providers in Swedish opiate addiction treatment refer to in their efforts to legitimise MT. Methods: Twenty-eight interviews focused on MTrelated issues were conducted with Swedish social workers and health care workers. The material was analysed qualitatively according to discourse theory. Findings: Three key features of MT were identified: as therapeutic intervention; as beyond harm reduction and as pragmatic solution. The respondents constructed MT as a necessary medical and psychosocial treatment aimed at rehabilitation and patients’ complete break with drug abuse, which reflects a policy-context where solutions to drug problems are supposed to be resolute, thorough and abstinence-oriented. Conclusions: The service providers handled the controversy between science and values by drawing on a decent-life discourse, where opiate addiction problems are solved with a pragmatic stance towards evidence and where only interventions that make patients’ lives allegedly decent are considered legitimate (excluding, e.g. heroin prescription and liberal methadone distribution).
Drogproblematik på internet
2016. Josefin Månsson, Mats Ekendahl. Socialt arbete och internet, 74-89Chapter
The construction of maintenance treatment legitimacy
2009. Mats Ekendahl. Evidence & Policy 5 (3), 247-265Article
Opiate addict maintenance treatment (MT) has been controversial in Sweden. In 2004, however, a public authority conducted a review of MT research that paved the way for a relatively less restrictive policy. The present study examines how scientific evidence was constructed in the preparation of this policy shift. Written commentaries (by authorities, organisations etc) on a preliminary version of the review were analysed by use of discourse theory. The results suggest that the final review contains elements of three competing discourses and elucidate how a particular MT regime was made to appear objectively as the only viable solution for dealing with opiate addicts.
Alcohol abuse, compulsory treatment and successive aftercare
2009. Mats Ekendahl. International Journal of Social Welfare 18 (3), 260-269Article
In Sweden, the social welfare boards have a statutory duty to provide aftercare for compulsorily treated substance abusers. However, there are no data on how the aftercare is organised and how clients perceive this phase of the compulsory treatment process. The aim of the study is to analyse how a sample of compulsorily treated alcohol abusers (n = 12) characterise the current coercive treatment episode and evaluate previously experienced and forthcoming aftercare interventions. Qualitative interview-data were coded into themes and sub-themes encompassing relevant client perspectives. Results show that the alcohol abusers claimed to want (but be denied) adequate help for their problems, both during primary treatment and after discharge. Their perspectives on coercive care and aftercare interventions appeared related to their views on their own problems and on being incarcerated. For instance, those who recognised their own alcohol problems emphasised the importance of quitting consumption and were dissatisfied with interventions offered during and subsequent to compulsory treatment referrals.
Aftercare and compulsory substance abuse treatment:
2007. Mats Ekendahl. Contemporary Drug Problems: An Interdisciplinary Quarterly 34, 137-161Article
2014. Mats Ekendahl. Sociology Study 4 (8), 714-727Article
Heroin is considered potent and addictive and users are often stigmatised as the other. On the internet, however, hegemonicideas about drugs can be resisted. This study elucidates how efforts to normalise and demonise heroin meet at a Swedish online message board (Flashback Forum). The study aims at analysing how heroin use is given meaning by discussants in athread called “I will start with heroin”. The data were perceived and structured as a collaborative, overarching narrative about when, why, and for whom heroin use can make sense. Discussants used stories about pleasure‐seekers, miserable junkies, and self‐medicating addicts to depict the activity as unproblematic and rational, problematic and irrational, or as problematic and rational. No stories about heroin use departed from the plot‐lines of pleasure maximisation and pain minimisation. Results elucidate a discursive battle in which: (1) heroin use as minimisation of pain “wins” over heroin use as maximisation of pleasure; and (2) there is a general agreement that heroin use cannot be irrational and unproblematic at the same time. It is suggested that these features are central to contemporary drug discourse, and that they probably hinder public understanding of why people use heroin and therefore contribute to keep users stigmatised.
Risk and responsibilization
2019. Mats Ekendahl, Josefin Månsson, Patrik Karlsson. DrugsArticle
There is a lack of research on how youth make sense of substance abuse treatment. The aim of this article was to explore how young people in Stockholm, Sweden, perceive outpatient treatment for cannabis use, position themselves as subjects in relation to it, and how they respond to staff’s appeals to rationality and responsible action. The data, consisting of 18 interviews with clients recruited from six treatment centers, were explored using narrative and thematic analysis. Results show that the young clients understood their histories in a responsibilized way where the risk information about cannabis they received was considered crucial. Those who resisted treatment rejected cannabis problematizations by staff, did not value interventions and felt that they had control over their use. Those who complied with treatment said that cannabis problematizations helped them acknowledge their own difficulties, handle substance dependence and mature. We conclude that treatment resistance among young cannabis users would perhaps be prevented if the adult world acknowledged that some believe it is rational and responsible to use cannabis. While the criminal offense of substance use is often expiated through ‘treatment’ in Sweden, young clients establishing a substance use identity could possibly be avoided if cannabis was not equated with risk.
Substansbruksproblem bör få vara komplexa, precis som andra mänskliga bekymmer
2020. Mats Ekendahl. Till det sociala arbetets försvar!, 81-94Chapter
Time to Change
2007. Mats Ekendahl. Addiction Research and Theory 15 (3), 247-261Article
This exploratory study examines whether the attitudes towards change and treatment of untreated non-abstinent substance abusers differ from those of patients undergoing treatment in residential care. The sample (n=97) consists of untreated, voluntarily and compulsorily treated substance abusers who completed a questionnaire in 2003. Attitudes were measured with scales on e.g. problem recognition, desire for help, treatment readiness and aspects of time perspectives, e.g. past, present and future orientation. The attitudes of the three groups -- untreated, voluntarily and compulsorily treated subjects -- differed with respect to lifestyle change. Factor analysis of the measures revealed one component of primary interest, general willingness to change. Results show that willingness to change was correlated with other attitudinal characteristics in the three groups. The stability of substance abusers’ motivation is discussed with the focus on different social contexts’ influence on change-compliant attitudes and behaviour.
Will and Skill
2007. Mats Ekendahl. European Addiction Research 13 (3), 148-155Article
Background/Aims: This exploratory study focus attitudes towards lifestyle change among untreated, voluntarily and compulsorily treated Swedish substance abusers (n=97). Methods: Attitudes were measured with scales on e.g. problem recognition, treatment readiness and the time perspective of future orientation. Subjects were categorised into four ‘addict-types’ according to their viewpoint on changing substance use habits, i.e. ‘less change willing’: non-addicts (n=16) and consonant addicts (n=32); ‘more change willing’: dissonant (n=13) and transient addicts (n=36). Results: It was shown that ‘less change willing’ subjects had experienced less dependence disorders and expressed less treatment demand and motivation than ‘more change willing’ subjects. A general measure of willingness to lifestyle change correlated with future orientation among ‘more change willing’ subjects. Conclusions: The study suggests that individuals’ time perspectives ought to be considered when trying to illuminate the process of change and understand what attitudes exercise positive influence on and are associated with successful lifestyle change-efforts. The consistency of substance abusers’ motivational structures over time and in different social contexts is discussed.
Why not treatment?
2006. Mats Ekendahl. Contemporary Drug Problems: An Interdisciplinary Quarterly 33 (4), 645-668Article
In this study a sample of non-abstinent untreated amphetamine users’ accounts of lifestyles, living conditions and efforts to change were described and analysed. The objective was to inductively identify the qualitative characteristics of their potential distance to the treatment system. The analysis focused how self presentations and descriptions of reality were related to views on treatment and lifestyle change. Results showed that respondents distanced themselves from the individuals and practices of several social contexts, which was interpreted as indicating a limbo between substance abuse and conventional life. Yet, to solve acute predicaments the substance abusers were confronted with the demands of the supposedly condemning treatment system. It is suggested in the article that the Swedish treatment system develop further ‘low threshold’ interventions that address life problems as identified by the clients themselves. This should enable less motivated substance abusers to acquire stable living conditions that may facilitate lifestyle change efforts.
2004. Mats Ekendahl.Other
EU citizens begging and sleeping rough in Swedish Urban Areas
2019. Mats Ekendahl, Patrik Karlsson, Renate Minas. Nordic Social Work ResearchArticle
EU citizens from Central and Eastern Europe travelling to cities in other countries to make a better living have become an issue of major political concern across Europe. This study explores how professionals from Swedish municipal social service organizations in urban areas construct the phenomenon of poor visiting EU citizens. The impact of social constructions on the practice and design of policies makes it important to analyse how target groups, such as poor visiting EU citizens, are characterized and what normative assumptions are made about them. The study is theoretically based on Schneider and Ingram’s work on ‘Social Constructions of Target Populations’. Interviews with social workers in the three largest cities in Sweden were conducted. The results suggest a clear ambivalence among interviewees regarding how to conceptualize EU citizens. They were careful not to highlight any subgroups, instead defining the group as consisting of different individuals with varying needs. While the interviewees constructed members of the target group in a way similar to what Schneider and Ingram describe as dependents, they also attributed them with some agency. We conclude that this may be a reflection of the political and organizational setting in which social work with poor visiting EU citizens is conducted in Sweden.
Show all publications by Mats Ekendahl at Stockholm University