Risk and responsibilization: resistance and compliance in Swedish treatment for youth cannabis use

Abstract

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.

Keywords:

• Cannabis
• youth
• treatment
• responsibilization
• risk
• Sweden
• MiniMaria

Introduction

In what has been characterized as an age of ‘manufactured uncertainty’ (Giddens, 1999), society has become increasingly concerned with risk. Young people seem to have a particularly important position in this context, and according to Kelly (2001), all youthful behavior can be framed in terms of risk if it disrupts the desired outcome of an entrepreneurial adult subject. However, certain behaviors are often classified as especially risky in jeopardizing the transition into a ‘normal’ adulthood; for example drug use. Despite extensive scholarly work on youth drug use motives (e.g. Bonar et al., 2017; Terry-McElrath, O'Malley, & Johnston, 2009), risk perceptions (e.g. Kilmer, Hunt, Lee, & Neighbors, 2007) and treatment retention and outcomes (Schroder, Sellman, Frampton, & Deering, 2009; Waldron & Turner, 2008), there is a lack of research on how youth ‘at-risk’ perceive and make sense of treatment for substance use (Järvinen & Ravn, 2015; Mitchell, Crawshaw, Bunton, & Green, 2001).

Internationally, cannabis use has become more accepted during recent years, which includes liberalization of policy in parts of Europe as well as North and South America (Pew Research Center, 2013; Rogeberg, 2015). Since the 1990s, it has also been claimed that illicit substance use is normalized in youth populations and those socio-cultural aspects are more important than individual pathologies in driving it. Based on longitudinal research in Britain, the so-called normalization thesis was proposed by Parker and colleagues, suggesting that recreational substance use among youth is no longer considered as deviant behavior conducted by a marginalized minority group but rather part of mainstream adolescence (Parker, Aldridge, & Measham, 1998). While the impact of this theory on research and prevention related to youth substance use is enormous (Sznitman & Taubman, 2016), critics have stressed that it over-emphasizes the role of agency (e.g. Shildrick, 2002), downplays social structures such as class (e.g. O’Gorman, 2016) and does not translate well in relation to different drugs and settings (Sandberg, 2012; Shildrick, 2016; Williams, 2016). In challenging the stigmatizing effects of traditional models based on pathology, low self-esteem and peer pressure, the perception of youth substance users as rational pleasure-seekers has legitimized interventions focused on individual risk management and personal responsibility that direct attention away from structural deficiencies (Measham & Shiner, 2009). This shift has occurred simultaneously with the development of neo-liberal ‘at-risk discourses’ that seek to responsibilize young people and transform individuals into self-reflexive, self-produced do-it-yourself projects (Hannah-Mofatt, 2016; Kelly, 2001, 2006; Kemshall, 2008, 2010). In addition to individualizing youth substance use, it has been argued that normalization is ‘misinterpreted to indicate that drug use is “normal” for young people’ (Shildrick, 2002, p. 46), and utilized to increase morale and punitive control measures (Blackman, 2004) and thus strengthen the case for prohibition (Blackman, 2007).

In Sweden, cannabis policy and treatment have become increasingly concerned with the negative effects international cannabis liberalization movements may have on young people (e.g. Gripenberg, Tengström, Andersson, & Skårner, 2015). In recent years youth cannabis use has warranted large-scale prevention campaigns as well as the development of local outpatient treatment centers (Ekendahl, Karlsson, & Månsson, 2018). Cannabis use is still relatively uncommon among young Swedes (Guttormsson & Leifman, 2016; Hibell et al., 2011). The rate of lifetime cannabis use among 16-year olds in Sweden is typically around 4–7%, and the European average for the same age group is 16% (ESPAD Group, 2016). Despite this, it is officially emphasized that cannabis use is particularly risky for young people and is a high-profile problem requiring attention and resources (Månsson, 2017; Törnqvist, 2009). Sweden’s management of young cannabis users is based politically on zero tolerance (Tham, 2012), professionally on assessments of risk and protective factors (Åström, Gumpert, Andershed, & Forster, 2017; Åström, Jergeby, Andershed, & Tengström, 2013), and on supportive family services rather than forceful child protection (Gilbert, Parton, & Skivenes, 2011; Healy, Lundström, & Sallnäs, 2011).

This policy approach, paired with survey data reporting no dramatic changes in prevalence rates or attitudes (The Swedish Council for Information on Alcohol & other Drugs, 2016), suggests that there is little evidence that youth substance use is normalized in Sweden on a broader scale. What we can see, however, are traces of moral regulation and individualization of problems within Swedish youth cannabis treatment. In a previous article, we argued that outpatient treatment staff legitimized interventions on moral grounds and viewed treatment as a crucial opportunity to provide valid risk information about cannabis to facilitate behavioral change in youth (Ekendahl et al., 2018). A complex form of governance surfaced in treatment that included several ‘technologies’ (Soneryd & Uggla, 2015), including responsibilization, moralization, and state regulation. Quitting cannabis and engaging in treatment is mandatory for young clients due to Swedish prohibitionist legislation. Despite this, the staff claimed to work hard at making them believe in the dangers of cannabis, become responsible and do the right thing, such as engaging in treatment. The treatment can thus be characterized as ‘tough love’ (Werth, 2013), including both coercive and supportive elements.

However, social policy based on individual risk management and responsibilization can create a segregation between the deserving and the undeserving, where human rights are conditioned on the maintenance of positive behavior (Kemshall, 2008; see also Goddard & Myers, 2017). For example, in studying risk management in youth-serving organizations in the US, Goddard (2012) concludes that practitioners made a difference between ‘dangerous youth’ and ‘youth in need’, where the first were seen as posing an inescapable threat to society and the second as eligible for guidance and change. Also, empirical research on youth offenders in Britain (Phoenix & Kelly, 2013) and in the US (Myers, 2017) shows that responsibilization in practice appears to indicate that young people receive little assistance from the penal system and are left to handle their own problems. Swedish research on secure care paints a somewhat more nuanced picture, where young women in this system see themselves as balancing between responsibility and vulnerability (Andersson Vogel, 2018).

It is important to examine youth perspectives on cannabis, risk and responsibilization in a national setting where penal, health and welfare interventions are characterized by social democratic, paternalistic and universalistic values (Moore, Fraser, Törrönen, & Tinghög, 2015), and where dominant discourse on illicit substance use limits the scope of rationality to only include abstention. In this article, we draw on interviews with young Swedes who have engaged in outpatient treatment for cannabis use that cater to young substance users and their families. We begin with the theoretical notion of responsibilization - a key technique of governance in youth penal systems (Goddard, 2012) - and explore how the young individuals position themselves as subjects in relation to the treatment. The aim is to examine how they articulate resistance to and compliance with treatment and how they perceive the way treatment staff ‘problematize’ cannabis as a dangerous substance. This allows us to identify the role of responsibilization in youth’s understandings and experiences of a (more or less) mandatory treatment that restricts their control, limits their actions and imposes information about the dangers of cannabis.

Theoretical framework

Risk is a dominating principle in public health and social welfare discourses. This is particularly evident in relation to young people. ‘Risk’ and ‘youth’ have almost become synonyms (Mitchell et al., 2001). Departing from Beck’s work on ‘risk society’ (Beck, 1992), a large amount of theoretical literature on risk has developed during the past three decades (e.g. Giddens, 1999; Kelly, 2001, 2006). Theorists argue that risk is increasingly individualized, meaning that people themselves are responsible for dealing with risks (Kelly, 2001). Influenced by Foucault’s work on governmentality (Burchell, Gordon, & Miller, 1991), scholars including Rose and Miller (1992, p. 17) have argued that risk is a technique for ‘governing at a distance’. Risk is also claimed to intersect with concepts such as responsibility and accountability (Trnka & Trundle, 2014). According to this perspective, the state is supposed to provide knowledge and information so that educated choices are made by citizens (Kemshall, 2002).

The concept of responsibility has changed meaning over time but is nowadays ‘often used to reference individual or collective accountability through judgments of one’s rational capacities, assessments of legal liabilities, and notions of moral blame’ (Trnka & Trundle, 2014, p. 137). It is closely linked to ideas of individual choice and autonomy (Trnka & Trundle, 2014). According to Rose (1999), governing is individualized through appeals to responsible consumption and lifestyles. As Kemshall (2008) has argued, the active, as opposed to the passive citizen, is in this society defined as the norm. She contends that this ideal is captured by the notion that people should manage risk by themselves and that they should accept this responsibility early in life. Following this, it can be argued that substance users assume a ‘risky identity’ in a society dominated by at-risk discourses (Kelly, 2001; Mitchell et al., 2001), where ‘each person [is] obliged to be prudent, responsible for their own destinies’ (Rose, 2000, p. 324).

As discussed by Myers (2017), responsibilization has been conceptualized and studied in various ways, and responsibility is according to Trnka and Trundle (2014) frequently used in both research and policy as ‘a set of specific techniques of constituting the self in relation to government and society at large’. Phoenix and Kelly (2013) also suggest that English and Welsh youth justice studies can be characterized as case-studies in neo-liberal governmentality due to the dominating focus on risk thinking and strategies of responsibilization that seek to transform the ‘young offender’ into a self-governing ‘young citizen’. They, however, consider these studies as top-down readings of governmentality approaches that lack a focus on the subjective experiences of social actors. They ask what happens when a targeted subject ‘works against prudentialism’ and ‘how young offenders themselves make sense of youth justice interventions’ (Phoenix & Kelly, 2013, p. 425). In this study, we, therefore, explore the subjective experiences of young people.

Material and methods

Sample

The study is based on 18 qualitative interviews with young clients who were recruited by staff at six outpatient treatment centers, called MiniMaria¹, in different municipalities (with diverse political, social and economic status) bordering on Stockholm, Sweden. Staff introduced the project to potential participants and forwarded phone numbers of those interested to the researchers who had no other involvement with treatment, staff or clients. Youth, who after initial contact expressed informed consent, chose between a face-to-face or a telephone interview. The sample is self-selected, and there is no representation of young people who have not attended treatment, were uninterested in the research project, or considered participation too time-consuming.

The sample consists of 12 men and 6 women between 16 and 24 years of age, with a mean age of 19 years. They all had been enrolled in treatment at one point, but all were not attending treatment at the time of interview. The main substance that all of them use/used was cannabis, although two of them had also used other drugs regularly (e.g. cocaine and heroin). Among the 16 that only used cannabis, 11 had also tried other substances on a few occasions but generally expressed a dislike for them. While their background profiles (e.g. socioeconomic status) were not formally assessed, the interviewees described their social situations as well as their substance use in different ways. Some mentioned troubled upbringings (e.g. being neglected, incarcerated and having substance using parents) along with a problematic use of a variety of substances. Others talked about their ‘normal’ background and relatively unproblematic cannabis use. It is difficult to generalize about the length of the treatment they had experienced, as some of the interviewees had only been to the treatment center on a few occasions during a short court-ordered period, while others had voluntary sporadic counselor contact including drug testing over a number of years. However, they all received the same treatment including substance abuse assessments, drug tests, cannabis information sessions and counseling inspired by Motivational Interviewing (MI) (Ekendahl et al., 2018). MI relies heavily on making the client explore the probable consequences of different acts (Rollnick & Miller, 1995), and it is wholly aligned with recent years’ tendency in social welfare to responsibilize clients by making them aware of and able to handle risks (Kelly, 2001; Kemshall, 2010).

Interviews

The 18 interviews were carried out by the researchers during the months September–December 2016. Half were conducted at various locations (e.g. researcher’s offices, meeting rooms, and libraries) and the remaining were conducted over the phone. A semi-structured interview guide was used that covered three themes: substance use patterns (e.g. ‘Can you talk about how you came in contact with drugs for the first time?’), experiences of treatment (e.g. ‘Can you describe the help you have experienced from the time your use was discovered until now?’), and opinions on drug policy and societal responses to illicit substance use (e.g. ‘Can you describe your view on Swedish drug policy?’). The interviews lasted ≍ 45 minutes each, and the audio-recorded material was transcribed verbatim by assistants.

Analysis

The analysis was done in three steps. To get an overview of the material and the position of the interviewees we initially read the transcriptions several times to firstly make a classification of participants according to their self-reported cannabis experiences. Through this person-centered analytical approach we could identify important events, relations and causes for drug use that were highlighted during interviews (see e.g. Järvinen & Ravn, 2015). This analysis suggested the existence of four distinct narratives that are described in the results section to give some context to the extracts.

By using a more meaning-centered approach we then examined coherent and prominent ways of talking about cannabis and treatment that were coded in the software program Nvivo. This resulted in 35 codes, including for example ‘cannabis use situations’, ‘dependence’, ‘police control’, ‘urine testing’, and ‘treatment methods’. Generally, the content of these codes illustrated instances where the interviewees either resisted or complied with treatment, and we, therefore, structured the analysis according to these two overarching themes.

Finally, to penetrate the material deeper we mapped how the interviewees accounted for issues related to responsibilization such as knowledge, risk management and decision making (Kemshall, 2002; Mitchell et al., 2001; Phoenix & Kelly, 2013). The Nvivo codes were thematically analyzed which allowed for sub-themes to emerge related to resistance and compliance. The sub-themes in the results section thus illustrate key examples of youth perspectives and ways they position themselves as active subjects in relation to treatment. Extended quotes are presented below from a few participants who were particularly outspoken and representative of the data as a whole. To get a more in-depth understanding of the interviewees and the position they are speaking from the initial narrative classification was combined with the main thematic structure in the results section. The extracts were translated from Swedish to English, which aimed to keep the original wording as exact as possible.

Ethics

The project adhered to ethical standards for qualitative social science research (Silverman, 2010). All interviewees were given a project information sheet upon recruitment by the treatment centers, containing potential risks and benefits of participation along with a clear statement that it was voluntary (and unrelated to treatment). When contacting participants, we verbally informed them of the project and reiterated their right to withdraw their consent at any time. As the participants were all 16 years and older we did not ask for parental consent (Heath, Brooks, Cleaver, & Ireland, 2009). In the extracts included in this article, the interviewees have been de-identified by changing names and omitting sensitive information. The organization MiniMaria has not been anonymized since it is one of its kind and has a status similar to other nationwide agencies such as the social services. The study was approved by the regional ethical vetting board in Stockholm (Registration number 2016/709-31/5).

Results

The narrative structure of the interviews

The interviewees’ accounts of their personal histories were classified in four key cannabis-related narratives. One typical way of describing cannabis use was through the ‘youth sin narrative’, which described a socially established young person who viewed past cannabis use as a foolish mistake. Another way to describe previous experiences was through the ‘problem-burdened narrative’, portraying a young person with a troubled background who displayed several deviant behaviors in addition to cannabis use. These two narratives were generally related to expressing compliance with treatment. A third narrative described a young person who really liked cannabis and did not see any problems with continued use, which was termed the ‘cannabis lifestyle narrative’. The fourth and least common one, the ‘indifference narrative’, described a young person who had experimented with the substance a few times and gotten caught, and now found cannabis uninteresting. The latter narratives were usually related to resistance to treatment.

Irrespective of what narrative the participants emphasized, they generally left out social factors as decisive in cannabis initiation and use, and concentrated their accounts on individual decision making and control. Troubled backgrounds and social problems were mentioned, but not as explanations for substance use. Interviewees generally said that they had chosen to start use, and that they were responsible for their behavior. As displayed by Jonathan who takes a clear stand against the weight of peer pressure:

Interviewer: How did that happen [trying cannabis]?

Jonathan: I was twelve. It was actually at an early age. And then it was like, I was hanging out with friends, and some people may see this as peer pressure or whatever, but it was actually my decision. Do you understand? It was something I wanted to try for myself. Something I chose.

Jonathan generally echoes the cannabis lifestyle narrative, which obviously not all participants did. Still, deliberation of use was an underlying theme among all interviewees, regardless of what narratives they drew on.

Resistance in treatment

Resistance is found in several interviews and relates to different aspects of treatment as well as social norms.

“This is the easiest way”

A recurring theme found in the data was when young people describe that they ‘use’ treatment as an instrument to keep parents and societal authorities content. Such as Fred, who describes himself as ‘a normal kid’ who hangs out with friends ‘just like everyone else’, with the only difference that he and his friends smoke cannabis. Fred draws on the cannabis lifestyle narrative and says that attending treatment does not serve the purpose of quitting cannabis for people like him.

Fred: It [treatment] is on my terms. I’m over 18, so I can basically do what I want. I can call now and end the whole thing. This is like an assessment. […] But we have done our own thing. Added some extra time, so I can just take urine tests sometimes, and sometimes we only have meetings. […] But the only reason it turned out like this is because of mum. This is the easiest way to take urine tests regularly. The meetings, we really don’t need to have them. Mum don’t want them, and I don’t care about them. I just think that it’s nice sometimes because it’s their [staff] routines. It’s how they do it.

Interviewer: Don’t they think it’s strange to meet you when you don’t want to? You don’t think like them, you don’t want to change. Isn’t that a strange situation to be in?

Fred: Well, change. I mean no, when we talk about it, it’s not like I say ‘I smoked cannabis last week, it’s not going to show on my urine test, but I’ll say it to you now..’ No, obviously I keep a straight face.

Fred portrays himself as in control of his situation although being in treatment; he has initiated the contact, he can end it, he ‘takes’ urine tests, and he accepts counseling because ‘it’s nice’. Fred also says that he manages to keep up his cannabis use during treatment and he is not willing to change. In his account, contact with treatment becomes rational in order to continue using cannabis without causing too much trouble. By accepting treatment and some treatment demands, and by expressing sympathy for his mother’s concern, he acknowledges and accepts the normative judgment of what he is doing. However, with his instrumental view on treatment, Fred resists seeing himself as being an object of others’ views and of social norms treating cannabis users as out of control and deviant. Due to the denial of this perspective, Fred becomes self-reliant, taking responsibility for his own use as well as his relationships.

“How should they keep me away from it”

A similar form of resistance is illustrated in the following extract where Kurt, also drawing on the cannabis lifestyle narrative, describes how he was mandated to treatment as a consequence of being caught by the police with traces of THC (tetrahydrocannabinol) in his urine.

Kurt: They [staff] were more like, what can you do to not keep on doing it [cannabis]? It was basically that question, but in different versions all the time. How they should keep me away from it. Which I did during spring, until the day I quit treatment. Because that day, I still think it’s funny, do you know what four-twenty is? […] April 20th, it’s like the international weed-smoking day. And I just couldn’t get over the irony that they released me from my urine tests the day before that. And all my buddies started calling me and were like ‘you have to smoke!’ And then I smoked, and during summer it happened a few times, but not so much. It has happened a bit more frequently the last few weeks. But it’s when I’ve had long free periods, with no school, free time and all that. Simply, when I’ve had nothing better to do.

Interviewer: But what do you think they would say about that at the treatment center if they knew?

Kurt: Well, they would be disappointed. I can see their faces right now. Because they have a very clear view that this is bad in every way. But I think cannabis, and this is always my counter-argument, I think that you become slow and stuff, but otherwise I see nothing dangerous about it besides it being illegal. That’s the greatest danger.

Kurt describes how staff tried to make him choose to stay away from cannabis, conveying that treatment is not framed as coercion. Although Kurt is aware of what social norms and staff expect from him, he resists this by taking up use the day after his ‘release’. Consequently, in a situation of external pressure he finds a way to display and articulate control. Throughout the extract, Kurt portrays himself as a responsible actor who can decide when it is reasonable to use cannabis (celebrate ‘four-twenty’, ‘nothing better to do’) and when it is not (during treatment and school hours). This is presented as a rational answer and counter-argument to the view that cannabis is ‘bad in every way’. While he refuses to change his mind about seeing cannabis as rather harmless, further into the interview he says that he hesitates to exhibit such opinions during treatment as any such talk that ‘slips through’ makes treatment more intrusive, for example by added urine tests.

Thus, both Fred and Kurt portray themselves as responsible risk managers, who ‘use’ treatment to hide and continue the use of cannabis they view as unproblematic and informed. While such reflexivity in identifying differing knowledge bases and courses of action is an encouraged goal of MI-inspired treatment (Rollnick & Miller, 1995), it is perceived as signs of problems, denial, and resistance in the treatment setting. Still, this resistance may not be visible to the staff as oppositional opinions are kept in silence, and in the end clients who complete retention but continue to use cannabis may be viewed as examples of successful treatment. Although these young people challenge the usefulness of treatment, they generally understand and accept why they are enrolled and do not describe resentment against staff or parents who put pressure on them. Thus, the meaning that these young people take from treatment seems to have little to do with the goal of the intervention, as the main message of their responsibilized stories is continued use.

“I was not dependent”

Another form of resistance is illustrated by Ella, who draws on the indifference narrative, and who says to have shun being characterized as substance dependent during treatment.

Ella: She [staff] usually asks me if I feel the need to smoke and if I want to, I mean, if I just hang around. And she asks me ‘If you lie in bed, do you feel the need to smoke?’ I mean, she asks a lot, and what she mostly says is that it damages the brain. We have talked about what happens with the body when you smoke. What it can look like if I’m dependent, how I can feel if I’m dependent. […] When I got caught, everyone accused me because they thought I was dependent. They said so. Then I told them ‘I’m not!’ And then they told me ‘Yes, we can tell, which means you are.’ ‘What, am I…?’ So I went and read. I read for myself about what it is to be dependent, to see, am I dependent or not? I wanted to be sure. Is it only I who think so? Am I right or are they? I wasn’t sure, because I was in minority.

Interviewer: What was your conclusion? Was it you or they who were right?

Ella: I reached the conclusion that I was not dependent, and I told them.

According to Ella, cannabis use is discussed during counseling as a matter of compulsion and not free will. The issue here appears not to be if or why Ella has used cannabis, but rather if she has felt an urge to do it and thereby can be classified as substance dependent. In this treatment experience, using cannabis is not framed as an activity where an agent chooses a substance, but as an infliction in which a substance damages someone’s brain and causes dependency. Ella also describes how she has perceived pressure to admit to being dependent on cannabis, and that she came to doubt her own beliefs. She then read up and concludes that her denial was right after all. Ella, Fred, and Kurt emphasize responsibility by relying on different knowledge claims than those presented in treatment.

Hektor, drawing on the cannabis lifestyle narrative, makes a similar description of resistance when he questions the idea that cannabis use should stop at treatment entry:

Hektor: It [urine testing] wasn’t fun. I mean, they are so advanced now, they see the [THC] count go up and down. Not only 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 positive or 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 when I came in for a meeting: ‘You’ve had a relapse!’ Oh my god, such a hassle. I just smoked a joint.

Hektor illustrates how his everyday view on cannabis use meets the problematizations advocated in treatment. He emphasizes the silliness of denoting ‘smoked a joint’ with the clinical term ‘relapse’. Similarly, Ella and Hektor describe how staff tried to make them accept that they were dependent on cannabis, and that they resist this by presenting alternative stories of what cannabis means to them, and how they calculate risks.

Compliance in treatment

The material also yields instances when interviewees have internalized societal ideas about and staff problematizations of cannabis use.

“I noticed I was dependent”

One form of compliance is found in stories where interviewees accept that they are dependent on cannabis. This is illustrated by Albin, who draws on the youth sin narrative.

Albin: They [staff] have taught you why it’s better not to do it [cannabis] than to do it. And I’ve thought about why you become dependent. That the level of happiness rises, and then it sinks below what’s normal, below the normal level of happiness that I have now sitting here. You go below a certain point. He [staff] drew some graph showing me. And it confirmed that. […] He showed me a zero level on that normal endorphin curve. And then when you smoke, it becomes much higher, and after you end up below it. That is how I noticed I was dependent.

Albin describes it almost as a revelation when he, after receiving educational explanations, realized that his continued use of cannabis was a result of the substance itself. In this description, choices, actions, and emotions are shaped by the agency of the substance. Later on in the interview, this topic is revisited, and Albin describes that he thought he could control his use before coming to treatment, but that he is now convinced he cannot.

Interviewer: When your parents found out about you using cannabis, did you think at that point you had a problem?

Albin: No, at that time I didn’t realize it. And it was the same kind of thinking I had all along when I smoked ‘No, it’s cool, I’m not dependent, I can quit.’ Ok, now I can quit and it’s cool. But after a week of not smoking, or just after a few days I felt ‘Fuck, I want to smoke again, I’m tired, I’m slow, I want to get back to that level of happiness again.’ The happiness you had while smoking. So I realized pretty soon that I had been dependent, more or less anyway. Then after some time, maybe two weeks, it was like ‘Shit, I was really dependent!’

Albin emphasizes that treatment has been a turning point in how he views his past cannabis use; before everything was “cool” and afterward he was ‘dependent’. What becomes pivotal in this story is the knowledge passed on by staff about dependence and the brain, which is said to support him in making the right decision. The treatment center here becomes an ‘educator towards "good" risk choices’ (Kemshall, 2002, p. 43), and Albin is the perfect example of a well-educated citizen that makes the choices required by a government actor.

“I don’t want to be like that”

A similar description is presented by Cecilia, who draws on the problem-burdened narrative, and describes previous problems with aggression, self-harm and substance use. She says it was not until she attended this particular outpatient treatment that her substance use was given attention.

Cecilia: They [staff] went through how cannabis affects the body, brain, different functions. And I talked about my abuse. So I went there twice, or once a week, and we signed a bunch of papers and went through it. I got a booklet, and we worked with like different chapters every time. And just talked, and things fell into place for me. […] I knew that cannabis affected me mentally. Sometimes I thought I had a psychosis, like I was just stupid. I knew somehow that the drugs made me this way. But the more time that passed and I was sober, I was so sick of it, so it was easy for me to be sober. It was like the glass bulb over my head disappeared. I started seeing things differently. I started to see my own faults. What I had done and why. […] It was comforting to understand that, OK, this is what makes me be like that. And it made me even more motivated to stay sober. Oh my God, if it’s like this, and this is how it affects me. I don’t want to be like that.

Cecilia illustrates how the information disseminated during treatment makes her previous behaviors and feelings understandable, that cannabis transformed her into someone who she does not identify with or like. Cecilia is not as focused on dependence as Albin, but similar to him she acknowledges the agency of the substance and its consequences. Understanding that her bad behavior during cannabis use is not ‘real’, or her fault, but rather a lack of control is described as a relief and a revelation. Here too knowledge is pivotal. Cecilia describes that it was easy to become sober when staff explained what the substances’ effects were on her, and that it was easy to take responsibility and to create change with that knowledge.

Both Cecilia and Albin appear as perfect responsibilized citizens who have internalized treatment messages about cannabis, dependence and loss of control, and reached the conclusion that the only viable solution is abstinence. Their stories demonstrate instances where staff are successful in convincing clients that it is ‘better not to do it, than to do it’, and confidence in this makes the decision to quit easier.

Discussion

This study is set in a specific policy context dedicated to prohibition, which is important as a backdrop to how the material can be interpreted. The results show that the participants engaged in outpatient cannabis treatment both claimed to reject and comply with the treatment, whether or not this was mandatory or voluntary. Despite different ways of perceiving and handling their treatment experiences, the clients understood their personal histories in a responsibilized way where risk information and rationality were considered crucial (Kelly, 2001). The young persons in this study did not refer to ‘classic’ sociological explanations as to why people use illicit substances when they talked about cannabis and treatment. Unlike the young offenders in Phoenix and Kelly’s (2013, p. 427) study, our participants did not ‘relate the broader economic, ideological, political and social circumstances to their misdeeds’. And unlike the young cannabis users in Järvinen and Ravn’s (2015) study, we identified few accounts that explained current cannabis use through previous childhood experiences, social heritage, economic vulnerability, peer pressure or boredom. The interviewees rather showed signs of neoliberal responsibilization in making sense of their histories and future plans. While the Swedish welfare system aims at inclusion, and cannot be characterized as ‘welfare inaction’ (Myers, 2013), it is interesting that they described themselves as having sole responsibility for evaluating knowledge and deciding whether to continue or quit substance use. The participants claimed to know the risks with cannabis, use this knowledge in decision making, and could thus rationalize both resisting and complying with treatment.

The material covers instances when young people rejected the cannabis problematizations forwarded by staff, showing disinterest in treatment and claiming to have control over their cannabis use. It also covers instances when young people said that staff problematizations of cannabis use helped them acknowledge their own difficulties, take control over substance dependence and mature. This indicates that the way the participants make sense of their cannabis use is related to how they perceive treatment; for example, youth who echoed the cannabis lifestyle narrative and the indifference narrative were prone to reject treatment while those who spoke from a problem-burdened narrative or a youth sin narrative complied more with treatment.

Regardless of whether participants resisted or complied with treatment, and regardless of how their cannabis use was narrated, they accepted responsibility and understood why staff and the generalized adult world were concerned with their cannabis use. In this way, the ‘tough love’ (Werth, 2013), or the ‘moralization’ (Hier, 2008), they were subjected to appeared to make sense to them, either as symbols of the drug prohibitionism they rejected or as necessary tools in becoming drug-free. These findings recap the general tendency to place valid knowledge at the center stage in discussions about cannabis (Månsson, 2017). It is also clear that the interviewees praised the ‘entrepreneurial self’ (Kelly, 2006) in portraying themselves as well-educated citizens who act in accordance with their best interest and are responsible for their situations (Giddens, 1999; Kelly, 2001, 2006; Kemshall, 2002).

The young people in this study dealt with questions such as ‘who are the youth-at-risk’ and ‘what does it mean to be at-risk’ in their accounts, and it appears as if being responsibilized was not necessarily coupled with perceiving oneself as ‘at-risk’. According to this and previous studies (Ekendahl et al., 2018), this treatment setting presupposes that young people are rational, and that responsibilization is a prerequisite for individualized interventions targeting informed and deliberate action. The current study shows that only clients who internalized the label ‘at-risk’, who regretted previous cannabis use and complied with treatment were seen by staff as being responsible in the ‘right way’. They hence testified to the cornerstones of drug prohibitionism by claiming that substance use is a bad individual choice (unrelated to social structures and forces) that can and should be prevented through enlightenment about dangers and state-regulated penalties. Those who told another story said that they were considered to be treatment-resistant by staff. This appears problematic if the treatment centers are to provide ‘good’ individualized services and help all cannabis users. It appears effective, however, if the ambition is to place drug prohibitionism in a favorable light. When this political approach towards illicit substance use is coupled with a strong emphasis on neoliberal governance in the form of responsibilization, punishing and stigmatizing youth substance users becomes something they deserve (since they draw it on themselves) and not something that might be considered exaggerated or counter productive.

The results also show that the division between ‘dangerous youth’ and ‘youth in need’, as suggested by Goddard’s (2012) study of US youth-serving organizations, is key to the Swedish context too. By and large, all young Swedes who use cannabis are perceived by their surroundings as ‘dangerous youth’, because they disobey norms and legislation and their deviance may be followed by others. The participants unanimously stressed external pressure to acknowledge cannabis risks and quit using the substance. Only some portrayed themselves as ‘youth in need’, who benefit from extensive interventions and whose capacity to handle cannabis and act rationally is circumscribed.

The emphasis placed on both ‘dangerousness’ and ‘in need’ in Swedish youth treatment services suggests that clients who do not agree with the latter label will resist treatment and escape the system at first chance. Having been taught to take responsibility for their actions, their rejection of official cannabis problematizations may enhance feelings of being outcasts who seek danger and do not adhere to the rules. From a pessimistic viewpoint, we can assume that young persons who do not consider cannabis a crucial feature of life but who get caught using it (e.g. Ella above), may through engagement in treatment be forced to label themselves as ‘cannabis users’, which may enhance rather than lessen the importance of the substance in their lives.

In contrast with empirical evidence from youth studies in other contexts (e.g. Myers, 2017; Phoenix & Kelly, 2013), the participants in this study did not complain about being ‘on their own’ or forced to help themselves. It rather appears as if Swedish treatment for youth cannabis use stems from and illustrates an inclusive welfare state (Moore et al., 2015) that provides young people with resources, goodwill and a genuine interest in what they need to become responsible adults. Still, from the perspective of human rights and health care ethics it appears problematic that this treatment – and its narrow definition of responsibility and rationality – is provided to all young people that are caught using cannabis, regardless if they want it or not.

Limitations

As described above, all contacts with interviewees were passed on to us through MiniMaria, meaning that homeless, treatment-resistant or nonverbal young people were not represented in the sample. While different genders and quite a broad range of ages were included, we could not reach those who currently experienced turbulent life situations or were uncomfortable with the Swedish language. Also, the emphasis placed during interviews on decisions and accountability may be the result of social desirability to be mature and consistent, or of previous experiences of MI counseling based on weighing advantages and disadvantages (Rollnick & Miller, 1995). This being said, the results suggest that the young persons emphasized the importance of knowledge, responsibility, and control in their accounts of cannabis use and treatment. These findings are supported by previous research, and we believe that they are relevant in other treatment settings and contexts as well.

Conclusions

We conclude that it perhaps would be better if treatment interventions were more nuanced and did not equate cannabis use with risk. While youth cannabis use is a criminal offense in Sweden that is often expiated through ‘treatment’, the outcomes of this treatment would probably be enhanced if it targeted the social conditions that make young people choose a certain lifestyle. Services could then address cultural and community characteristics that provide individuals with incentives to use cannabis, and not the decisions that stem from such. We also conclude that treatment ought to be more sensitive to different narratives of what cannabis and ‘getting high’ can mean to young people. Pinpointing the importance of social conditions and cultural context (Hannah-Moffat, 2016) would also reveal that local drug prohibitionism can be cruel and confusing for young cannabis users. They grow up in a globalized world where cannabis policy is being liberalized, they acknowledge risk information about different substances, choose to use cannabis which they consider relatively safe, and are then lead by state agencies to believe that they are irresponsible risk-takers in need of treatment.

Acknowledgments

The authors would like to thank the anonymous reviewers for helpful comments that improved the article. Thanks also to Sinead Tobin who helped us with the language.

Disclosure statement

The authors report no conflict of interest. The authors alone are responsible for conclusions presented in the article.

Note

Additional information

Funding

This work was supported by the Swedish Council for Working Life and Social Research (FAS) under Grant number 2015‐00283.

Notes

1 The name MiniMaria stems from a regional healthcare agency focused on substance abuse treatment previously located in the surroundings of Mariatorget in Stockholm City.