1. Freedom of choice in substance abuse treatment. First data from a Swedish study Kerstin Stenius and Samira Radwan SoRAD, Stockholm university and Ersta-Sköndal

2. Freedom of choice and social rights Nordic model: collectively granted and extensive social rights. Universalism Freedom of choice: citizens’ participation in production and delivery, route to autonomy, empowerment. Right and duty to choose as an individual Linked to market solutions: choice between public and private. With (hopes for) shrinking welfare budgets How does this ideology effect different groups of citizens, inlcuding thte potentially undeserving poor?

3. What does freedom of choice require? Possibility to choose between clearly distinguishable alternatives Possibility to choose between alternatives that have different meaning for the user Autonomy: the individual shall have the possibility to reach what he/she defines as her desired results (for instance influence kind, amount and content of tx) (Bavetta 2004)

4. Data Three towns with established policy of freedom of choice Three groups of citizens: elderly with home care, young persons who have choosen high school and persons in substance abuse tx Structured interviews, personal interviews, focus groups, expert interviews and policy material Citizen groups experiences of choice Hypotheses: within all three groups, the possibility and wish to choose varies; the expereinced benefits of choice varies between and within groups; freedom of choice effects citizens’ participation and influence and thus their citizenship

5. Out-patientIn-patientTotal n%n%n% Västerås354655369040 Nacka283620134021 Helsingborg141876509040 Total77100151100228100 Table 1

6. Questions What are the consumers experiences of and attitudes to choice? Is there real choice for persons in substance abuse treatment? Are there different and distinguishable service alternatives? To what extent can the users influence the content or treatment, or exit from treatment?

7. Attitudes to choice 45 % very or rather satisfied with possibilities to choose tx, 25 % did not know. More satisfaction among outpatient and persons with higher incomes Almost 80 % very or rather important to choose between different providers of treatment

8. Possibilities to choose in general Totally agreeAgreeDisagreeDon’t know Total n All people with addictions have the same opportunities to choose treatment 22 %28 %35 %16 %220 Those with less income have equal opportunities to choose addiction treatment 29 %21 %32 %19 %215 Those who are disabled or seriously ill have equal opportunities to choose 23 %18 %22 %37 %218 Women have equal opportunities to choose addiction treatment as men 49 %20 %11 %20 %216 Those who do not speak Swedish have more difficult to choose addiction treatment. 18 %25 %9 %48 %215

9. Are there alternatives? If you think about treatment options in substance abuse treatment in your municipality, would you say that they are:

10. Waiting time 16 % had to wait more than 3 months for the treatment they needed (23 % in inpatient) 78 % in out-patient did not have to wait at all (35 % in inpatient)

11. Out-patientIn-patientTotal n%n%n% Only 1212761418236 2 or more233039276228 Don’t know334349338236 Total77100149100226100 Did you have alternatives? How many similar care places could you choose from when you started this treatment?

12. Where there real alternatives for you? Did you think there was a difference between what tx the providers offered? Out-pat In-pat Total

13. Information 60%: enough information to choose 36 % said the information about the tx place was in accvordance with how it was (49 % out- pat, 29 % inpat) Most important source of inf. was staff from municpality, tx providers, and internet for outpatient Nacka: more choice and more satisfied with information)

14. ”Autonomy” 40 % had chosen tx themselves (50 % out-pat, 30% inpat) 20 % had chosen together with social service staff (10 out- pat, 28 % inpat) Half of respondents would turn to tx staff if they were unsatisfied 60 % did not know whom to turn to if they wanted to formally complain over their tx If they had articulated critique (more common among inpat) it was more common than not that it had led to change ¼ had changed tx, a majority of them thought it was easy or fairly easy

15. Out-patientIn-patientTotal n%n%n The staff at the tx unit treats me well77144221 Totally agree9675 Agree425*** Disagree The staff takes into account my opinions and wishes about tx 76140216 Totally agree9169 Agree826** Disagree16 I get as much tx as I need 70137207 Totally agree7964 Agree1925 Disagree311 The staff perform their duties well77140217 Totally agree8874 Agree1020* Disagree16 I feel safe in my tx situation74139213 Totally agree8570 Agree1421 Disagree19* The care I get is better than I expected73125198 Totally agree6949 Agree2735** Disagree416 I have great opportunities to decide about my everyday life in the tx unit 65138203 Totally agree6955 Agree2234 Disagree911 As a whole, I am satisfied with the help / care I have76139215 Totally agree8371 Agree1622 Disagree17

16. The staff performs their duties well 77140217 Totally agree8874 Agree1020* Disagree16 I feel safe in my tx situation74139213 Totally agree8570 Agree1421 Disagree19* The care I get is better than I expected73125198 Totally agree6949 Agree2735** Disagree416 I have great opportunities to decide about my everyday life in the tx unit 65138203 Totally agree6955 Agree2234 Disagree911 As a whole, I am satisfied with the help / care I have 76139215 Totally agree8371 Agree1622

17. As a whole, I am satisfied with the help / care I have 76139215 Totally agree8371 Agree1622 Disagree17

18. Out-patientIn-patientTotal n%n%n I get a different kind of care than the one I need75139214 Totally agree18 Agree920* Disagree7359 Don’t know1613 I can’t influence the content of the care I have77139216 Totally agree1216 Agree2743* Disagree4732 Don’t know149 If I pictures the perfect addiction treatment then the one I have is very close to the ideal 75146221 Totally agree4336 Agree3936 Disagree717 Don’t know1211

19. Conclusions 1/3 had a real choice – the majority did not know if there was a diff. Bewteen alternative or did not choose 40 % did not think they had enough information (real and distingusihable choice) Autonomy. Diff beteen in- and outpatient. Outpat could more infleunce length and content. Tx staff or social workers were the natural patries to turn to for complaints – few knew about formal complaints

20. Cont. Uneven distribution of choice, benefits of choice and influence In longer interviews more examples of both possibilities to influence, mainly through good contacts with social service or tx staff, and presssures or dramatic lack of choice Substance abusers as a group not politically active Valfrihet as a concept does not clarify the real dilemmas for many in this group