Discussion

As the previous chapters and the country profiles have shown, the approaches to labour market integration of individuals with substance use problems have both similarities and differences. All the Nordic nations covered in this report have high employment rates, indicating a generally robust labour market. They also share adherence to the Nordic model of labour market regulation, which includes employee and employer organisations, wage agreements, and comprehensive legislation for workers’ protection. This model is characterised by cooperation between trade unions and employers’ organisations. All countries face substance use issues, with both alcohol and illicit drugs being a common problem. The prevalence of risky alcohol consumption and illicit drug use varies, but is a concern in all these nations. In summary, while these Nordic countries share commonalities such as high employment rates and substance use issues, there are significant differences in educational attainment, income inequality, geographic variations in unemployment, and substance use policies. These differences highlight the unique challenges and contexts faced by each country in their labour markets and efforts to address substance use problems.

This chapter presents the results of the case-oriented comparative analysis. In particular, the focal point of the analysis is the identification of any successful intervention and organisational settings for service delivery.

The overall aim of drug and alcohol policy in the Nordic countries is typically characterised by a comprehensive and balanced approach that focuses on both reducing substance-related harm and preventing substance use. In the Nordic countries, the current prevailing approach is to regard substance use problems primarily as health and, to some extent, social issues, rather than moral failings. Consequently, comprehensive support is provided to assist individuals in rebuilding their lives, including enhancing their employment prospects. These aims reflect the comprehensive and multidimensional approach to substance use treatment in the Nordic countries, which emphasises not only the reduction of substance use but also the improvement of overall health, wellbeing, and social integration of individuals affected by substance use problems.

As the country profiles showed, individuals with substance use problems have statutory rights to employment services in all Nordic countries. However, they do not possess any distinct statutory rights and are treated like any other target groups outside the labour market. This absence of particular rights can be disadvantageous, given that individuals with substance use problems have distinct needs that differentiate them from other target populations. Nevertheless, it can be argued that differentiating them from other groups may be highly challenging due to widespread comorbidity. In particular, it is estimated that a significant proportion of people with substance use problems also have one or more co-occurring mental health disorders (Castillo-Carniglia et al., 2019; Kingston et al., 2017).

The country profiles revealed that over the past decades, a series of reforms pertaining to employment services have taken place in several Nordic countries. These reforms encompass both substantive and organisational aspects. The objectives have been to achieve more comprehensive services, to increase the effectiveness of employment services, and to personalise the services. For example, the establishment and evolution of job centres in Denmark can be attributed to a series of labour market and welfare reforms that have taken place over the years. These reforms reflect Denmark’s proactive approach to addressing unemployment and labour force participation through a strong focus on active labour market policies and the work-first approach. This is closely related to conditional welfare measures, referring to a set of requirements, obligations, or conditions that individuals must meet to receive certain benefits or services related to employment and social welfare. In the utmost consequence, welfare conditionality may entail sanctions – withheld economic benefits or welfare services – in cases where the client has failed to comply with activity requirements. While Denmark is renowned for implementing one of the most stringent welfare conditionality frameworks, similar policies are also observed in other Nordic countries, such as Norway, Sweden, and Finland. For example, as seen in the Finnish case, the system can be rather punitive in the sense of harsh sanctions imposed upon those who have not met activity-related obligations. There is limited research on the effectiveness of such policies, and the existing evidence is divergent. While certain studies suggest that favourable outcomes may result from its prudent implementation (Dahl & Lima, 2016), others conclude that the policy as a whole is ineffective (Dwyer et al., 2020). Irrespective of the efficacy of welfare conditionality, numerous scholars have contended that it can have adverse impacts on the most marginalised segments of society, such as individuals grappling with substance use problems (see, for example, Fletcher & Flint, 2018; McNeill, 2020). In accordance with these alerting observations, it is recommended that the application of welfare conditionality measures targeting individuals with substance use problems be approached with caution or implemented in a restricted manner.

As mentioned previously, one of the most pronounced objectives of the reforms in the Nordic countries has been to address the fragmentation issues among sectors and service providers, and ultimately aiming to deliver more holistic services. However, fragmentation issues still represent a major obstacle in most Nordic countries, as is clearly demonstrated in, for example, the Finnish, Swedish, Norwegian, and Danish country profiles. Individuals with substance use problems constitute a vulnerable group requiring comprehensive services from multiple professionals, agencies, and sectors. The services must be coordinated to effectively assist these individuals’ transition to the labour market. Hence, most Nordic countries have a long way to go in addressing the issues related to fragmentation of services. Assessments of the labour and welfare administration reform in Norway have yielded varied outcomes (Erlien, 2017; Minas, 2014), but there are still grounds to posit that such one-stop shops can be a step in the right direction with respect to facilitating the provision of comprehensive services. Indeed, comprehensive services are not a categorical entity, and distinctions can be made among various degrees and dimensions of comprehensiveness. As such, there may be reason to recommend that other Nordic countries imitate the Norwegian model. Despite the abundance of research emphasising the significance of comprehensive services (Andvig & Karlsson, 2021; Bergheim & Rugkåsa, 2022; Frøyland et al., 2022), scholarly knowledge regarding the practical implementation and achievement of such services remains limited. There is thus a requirement of further research to determine the most effective approaches for enhancing the comprehensiveness of services.

The Nordic countries have long been regarded as models of comprehensive welfare states with strong public services. In recent decades, however, there has been a notable shift towards the privatisation of various public services, including employment services (Greer et al., 2017; Jantz et al., 2018). This trend has sparked significant debate and scrutiny, as it challenges the traditional Nordic welfare model.

Although most Nordic countries engage both public and private providers in delivering employment services, there is no uniform approach among them concerning the participation of private providers in this sector. Sweden and Denmark, for instance, have adopted relatively extensive privatisation measures, with a substantial share of employment services being outsourced to private agencies (Ennerberg, 2020; Greer et al., 2017; Jantz et al., 2018) (see elaborative accounts from the Swedish case). In slight contrast, Norway, Finland, Iceland, and Greenland have been more cautious in privatising these services, with a greater emphasis on maintaining public control (Leiren et al., 2020). Also, the Nordic countries differ in terms of which types of private providers of employment services are entrusted with delivering private services. One main distinction can be made between NGOs (non-governmental organisations, often non-profit and voluntary organisations operating independently of governmental control) and for-profit organisations. For example, Iceland, Finland, and Norway lean more towards NGOs, whereas Denmark and Sweden are known for their more extensive use of for-profit organisations in the delivery of employment services.

The involvement of private organisations in delivering employment services has sparked intense debates in the realm of public policy and social welfare, including employment services themselves. Proponents argue that private organisations bring innovation and efficiency to their delivery. Driven by competition and profit motives, these entities are incentivised to adopt modern technologies, streamline processes, and respond rapidly to changing labour market demands (Hermann & Flecker, 2013). Furthermore, the contractual framework of performance-based models, wherein providers receive compensation contingent upon their capacity to integrate unemployed individuals into the labour market, has been contended to bolster outcomes and streamline service delivery for greater efficiency (Crépon, 2018).

On the other hand, critics have raised numerous critical objections (Rehwald et al., 2017). For example, it has been maintained that the involvement of multiple private providers has the potential to exacerbate service fragmentation even further and lead to reduced coordination between stakeholders (Crépon, 2018). Individuals facing substance use problems may confront difficulties when navigating a complex network of service providers, potentially impeding their access to comprehensive support, as is evident in both the Finnish and Swedish contexts.

Another issue raised with respect to privatisation of employment services is the notion of cream-skimming and parking (Crépon, 2018). Whereas cream-skimming refers to the practice of selecting and prioritising the unemployed who are perceived as easier to place in employment, parking pertains to the passive or inadequate provision of services to the unemployed who face significant barriers to employment. Although creaming and parking can be an issue in the public sector as well, it is presumed to pose a more substantial problem when private actors are responsible for service provision (Crépon, 2018).

In light of the above discussions, what remains a challenge for the Nordic countries in their efforts to integrate individuals into the labour market is balancing the involvement of private and public providers. This challenge requires careful consideration of the potential benefits and drawbacks, coupled with robust regulatory frameworks to safeguard the interests of individuals with substance use problems and uphold the principles of the Nordic welfare model.

The primary impression derived from the analysis is that a wide variety of interventions are employed in the Nordic countries. However, as table 2 demonstrates, in terms of content, there is a significant overlap between the interventions. Most of these interventions are not specifically tailored for individuals with substance use problems. Several countries employ simplistic, broad categorisations of users/clients/citizens that do not encompass the complexity of users’ needs, such as those of individuals with substance use problems. For instance, in Denmark, they are often placed in the category ‘ready for activity’. Similarly, in Sweden, they are categorised as disabled, in Finland as individuals with partial work ability, and in Norway they are assigned to the category of reduced work capacity. These categories are very broad and are intended to guide the selection of interventions. Consequently, interventions may not always be well-targeted within these broad categories, which consist of highly heterogeneous groups of individuals.

The analysis further demonstrates that many interventions take place at the local level, initiated by local and regional entities such as individual municipalities/regions or private organisations in certain regions. They are often not implemented nationwide. In addition, a scarcity of evaluations and research regarding the effects of the various interventions is obvious. This lack of evaluations can be particularly problematic given that much of the activity occurs at the local level. Despite considerable innovation potentially occurring at the local level, the capacity for knowledge acquisition and sharing is hampered by the limited assessment of diverse interventions. One notable exception here might be the Finnish Centre of Expertise for Social Enterprises, which aims to collect, evaluate, and disseminate good practices for promoting employment (see more detailed information in the country profile of Finland). As the centre was established as late as 2021, it is too early to assess its impact. However, such expertise centres might indeed serve as a model for other Nordic countries to follow.

Finally, another main impression derived from the analysis is the shift from train-then-place to place-then-train. Swift placement in ordinary employment constitutes the core of the IPS intervention (individual placement and support), but there are several other recent intervention initiatives that emphasise the prompt integration into ordinary workplaces. Research from both Nordic and non-Nordic regions concludes that these interventions have positive effects on the labour market integration of marginalised groups of individuals (Frederick & VanderWeele, 2019; Harrison et al., 2020; Probyn et al., 2021; Rosenheck et al., 2017).

Even though there are some universal characteristics describing people with substance use problems as a group, it is important to bear in mind the significant variations among them. Some have lived a long life with substance use problems; they never finished school or have never really been included in ordinary work life. Others are young and could still be able to follow a more standard life cycle and be a part of ordinary work life. Others have education and/or work experience. Additionally, variations arise based on the specific substances individuals use. Those who use illicit substances encounter distinct issues compared to those who use legal substances such as alcohol. Users of illicit substances may experience additional complications, such as legal consequences, social stigma, and unintended consequences of drug policies (Moskalewicz et al., 2021).  

The variety among people with substance use problems is to a certain degree reflected in the existing interventions. While some interventions are ambitious on behalf of the participants and aim to be part of a change in the direction of a new and sober lifestyle, others offer occasional low-threshold work or work training as well as a community for people struggling. Broadly speaking the Nordic interventions reported could be placed in five categories: train-then-place, place-then-train, low-threshold jobs/activities, peer support/activities, and coordinative/organisational interventions.

An example of a train-then-place approach is the Islandic Grettistak programme. The main goal of the 18-month-long programme is to help participants regain full work capacity after rehabilitation. This is done through a broad process aiming at increasing the participants’ recovery capital index (which includes sobriety, health, social support, social skills, quality of life, financial factors, meaningful activity, housing, and housing security) (Þorleifsdóttir, 2021). In Iceland, people with substance use problems can also be offered support through Atvinnu- og virknimiðlun (AVM) when attempting to enter or re-enter the labour market. A small qualitative study indicates that participants had a positive impression of the service and found it helpful (Bjarnadóttir, 2022).

Most commonly, the train-then-place philosophy is reflected in interventions focusing on practical working skills. However, acknowledging that individuals without schooling or education have limited employability in today’s labour market, the Swedish Employment Service is increasingly matching unemployed individuals with education that leads to employment. The Employment Service provides support for primary and upper secondary level studies, as well as university studies, sometimes offering financial assistance and introductory courses to help individuals complete their studies (Arbetsförmedlingen, 2023a). This focus on formal education is interesting, given the typical characteristics of the Nordic labour market.

In Greenland, the interventions are dominated by the train-then-place philosophy. In the local Majoriaq centres, citizens have an action plan made which aims to bring them into employment or education. Educational upskilling courses help the clients to take a school-leaving exam, while practical upskilling is provided to the young or younger citizens who need to strengthen personal and social skills before they are ready to start work or an educational upskilling course. In addition, the home municipality of people in treatment for substance use problems must prepare an aftercare plan for interventions needed on work, housing, job training, and general follow-up after the treatment. The treatment centres map the users’ overall situation using a slightly modified version of the Addiction Severity Index (McLellan et al., 1980).

As mentioned earlier, during the last decade, there seems to have been a shift from train-then-place to place-then-train interventions, such as IPS. Various forms of individual placement and support are offered in all Nordic countries, except for Sweden and Greenland. The IPS intervention has been evaluated primarily outside the Nordic region, and shows promising results (Bond et al., 2020; Brinchmann et al., 2020; Fredrick & VanderWeele, 2019). There are also a few evaluations of the IPS intervention in the Nordic countries, demonstrating positive results (Bejerholm et al., 2015; Rotko et al., 2019; Sveinsdottir et al., 2020). However, these evaluations are small and less sufficient than those outside the Nordic countries. Further, some evaluations provide insights into the effectiveness of IPS in delivering positive outcomes for individuals grappling with substance use problems. In this respect, the ongoing ‘Hekta på jobb’ (Hooked on work) led by Oslo University Hospital represents an interesting case. The intervention offers people with substance use problems IPS in addition to ordinary treatment. The aim is to scientifically investigate how effectively the method helps patients in substance use treatment to get into work, as well as how applicable the method is for this patient group (Rognli et al., 2023). In Denmark, a previous try-out in four municipalities found that the participants who were offered IPS had an improved chance (by 13%) of obtaining a job compared to the control group.

In Finland, IPS interventions have been tested in five regions and will be extended to six new regions in the coming years. However, the intervention is aimed at people with mental health challenges, and even if it includes people with substance use problems, the results of the trials do not specify the situation of this group (Finnish Institute for Health and Welfare, 2023). A recent assessment of IPS work in Reykjavík showed that in 2022, 63% of people who gained competitive employment through the programme were still employed at the end of the year (internal review).

NGOs play a role as a supplement and partner to the public sector. For instance, in Sweden, Norway, and Finland NGOs provide low-threshold jobs/activities located between social and employment services. However, they also deliver more formal job training as well as more holistic interventions. In Finland, NGOs are also central in developing new interventions for people with substance use problems. The so-called Keijo model has been developed in co-operation between two non-profit employment coaching associations (Silta-Valmennusyhdistys and Valo-Valmennusyhdistys) and the Laurea University of Applied Sciences. Compared to other interventions, the model offers a longer period of training, and a key objective for the model has been to position the programme as part of the formal education system. The central idea is that people with a criminal background can function as peers to each other and, as experts by experience, be involved in developing services. Close cooperation with intermediate labour market operators is essential in the model (Salmi et al., 2020). 

For some people with a history of substance use problems, their experiences become an asset in a new career in peer support. This is formalised, for instance, in the Norwegian Erfaringsskolen, which offers training in peer support. The limited extant assessments show promising findings (Fonneland, 2022). Nevertheless, there is still a lack of thorough evaluations of the long-term effects of the arrangement (Recke, 2021). Another phenomenon are user-driven activities such as =Oslo, which represents a philosophy of socially marginalised people themselves organising interventions for change.

The need for service integration and cross-sectoral cooperation is a central aspect if people with substance use problems are to be integrated into society and the labour market. To address these (and other) challenges, the Work Capacity Programme was established in Finland in 2019. One aim of this ambitious four-years programme was to strengthen the work ability competencies of professionals and experts through work ability coordinators. So far, the work capacity coordinators have helped develop the skills of professionals in the field (Oosi et al., 2023). JobRus cooperation in Denmark between substance treatment and job centres focuses on young people in particular. The aim is to include individuals with substance use problems in working life and reduce problems related to substance use. An ongoing try-out is based on a successful pilot. 

So far, the various Nordic attempts to integrate people with substance use problems in the labour market provide few clear recommendations. One of the reasons might be the general lack of high-quality research evaluations focusing on this aspect, which makes it difficult to assess most of the ongoing interventions. Another challenge is the fact that people with substance use problems do not represent a category of their own in labour market statistics or in other public statistics. Instead, this group is mixed with other groups having challenges on the labour market and more generally. Even in specific interventions, people with substance use problems are often not separated as a category distinct from, for instance, people with mental disorders. Hence, when such interventions are evaluated, it can be hard to know the independent effect on the people with substance use problems.

In light of the limited number of evaluations and studies in this field, the country profiles might offer hope for potential change. For example, this can be seen in the Norwegian IPS project ‘Hekta på jobb’, the various evaluations of the Finnish Work Capacity Programme, and the Danish JobRus, which is based on a successful pilot. However, so far, significant public funding has been used on interventions with relatively unknown success rates. Given the general interest in evidence-based interventions and policy in the Nordic countries, this could be seen as an expression of a field not prioritised and characterised by good intentions and symbolic actions rather than a radical will to change the situation. The current scarcity of knowledge could lead to the export of interventions that for varied reasons are hyped but do not work as well as communicated and hoped for – or even worse, interventions that might have a negative influence on the lives of the people they aim to change in a positive direction.

Considering that a significant proportion of individuals dealing with substance use problems also struggle with concurrent health issues and a lack of formal qualifications, the goal of integrating a larger segment of this population into the ordinary labour market requires sustained, long-term efforts. The diverse array of challenges faced by individuals with substance use problems necessitates careful tailoring of interventions to suit each potential participant. While some clearly possess the potential to overcome their substance use problems and lead what society perceives as a conventional life with ordinary employment, others may fare better outside the typical labour market. Nevertheless, this latter group should still receive sufficient public support and access to activities aimed at stabilising their circumstances and enabling them to lead meaningful lives.