Arguing the case: Committing pregnant substance abusers to compulsory care

Aims: To analyse how social services relate to compulsory care legislation in applications for compulsory care for substance abuse in cases involving pregnant women, given that such commitments cannot be made solely for the sake of the fetus/unborn child. Design: Applications for compulsory care to administrative courts involving pregnant women categorized according to how the pregnancy was presented or emphasized. Setting: Compulsory care for substance abuse in Sweden. Participants: 116 cases involving 107 individuals who were pregnant at the time of application for commitment to compulsory care between 2000 and 2009. Findings: In 43% of the cases the risks for both the woman and the fetus’/child’s health was emphasized. In 28% of the cases the applications were primarily for the sake of the fetus/child. In 17% of the cases the pregnancy was mentioned in a neutral manner, while in 8% of the cases the fact that the woman was abusing substances during pregnancy was presented as an indication of the severity of the problem. Conclusions: References were commonly made to the interests of the woman and the fetus/child as an entity, but social services also openly claimed the need for commitment primarily for the sake of the child. Arguments also mirrored the debate when legislation was first introduced; for example, that substance abuse during pregnancy is a clear indication of how serious the problem is, and how this situation may be hazardous to the woman’s mental health should she become the cause of severe and irrevocable harm to her child. Public policies and legislation have an important normative and symbolic value, but the journey from policy to practice may consist of a long and arduous implementation process where “great expectations in Washington are dashed in Oakland” (Pressman & Wildavsky, 1984). At the operational level, we often find a street-level bureaucrat working in public services face-to-face with partly nonvoluntary clientele. Despite the surrounding bureaucratic structures, they typically enjoy a large degree of independence in work associated with discretion in decision-making (Lipsky, 1980). They may even be seen as the final implementors of public policy (Kelly, 1994). But, as resources usually are scarce and the workload demanding, street-level bureaucrats tend to develop coping mechanisms to relieve their work situation (Lipsky, 1980). Decision-making in street-level bureaucracies has attracted the attention of many social scientists, and the specific study of discrepancies between “law in the books and law in practice” became the core issue in the sociology of law (Staaf, 2004). In Sweden, substance abuse has primarily been defined as a social problem, and commitments to compulsory care are in the hands of the street-level bureaucrats in the social services. Formally, the decision to apply for compulsory care rests with the municipal welfare boards, consisting of elected laypeople, which has meant that compulsory care became internalized in the Swedish welfare system (Palm & Stenius, 2002). Compulsory care was, however, highly politicized as part of the pursuit of a “drug-free society,” and welfare workers tended to oppose such coercive measures, actively and passively (Blomqvist, Palm, & Storbjörk, 2009; Nilssen, 2007; Tham, 1995; Wallander & Blomqvist, 2005). IJADR International Journal of Alcohol and Drug Research The Official Journal of the Kettil Bruun Society for Social and Epidemiological Research on Alcohol