The right of people with substance use problems to the most advanced health care

Suggestion to the Ombudsman of Althingi to make an initiative review

The Statement can be accessed here in a PFD.

The statemnet in a PDF.Download

Introduction. 2

Status of Alcohol and drug prevention counsellors’ education. 3

Inquiries about the status of the education/training. 7

Plans to formalize counsellor education. 12

Marginalization in the welfare and health system.. 13

Quality and safety in treatment. 16

Appendix 1. Letter to the Quality and Supervisory Authority of Welfare. 19

Epilogue – August 2024. 20

References. 22

Introduction

This summer, the news broke that an agreement had been reached between SÁÁ[1] and the Continuing Education of the University of Akureyri, SMHA, that the latter would offer a course in Alcohol and drug prevention counselling this fall.[2]

The council of Rótin was very surprised by this news, which is not in accordance with the information that the authorities have given about the development of the education and in general about the future of this profession, which is a licensed health profession[3], despite in no way meeting the requirements for the education and training of health professionals in a modern healthcare system.

Rótin has since its foundation in 2013 lobbied for improved quality in services for people with substance use problems, and not least with regard to the education of those who provide treatment. The association has repeatedly drawn attention to the educational issues of Alcohol and drug prevention counsellors, which the authorities admit is inadequate, but no real improvements have taken place. Meanwhile, people with substance use problems are far from receiving services that promote the basic human rights that are included in the right „to enjoy the highest attainable standard of physical and mental health„,[4] as stated in the International Convention on Economic, Social and Cultural Rights, and „the most advanced health services available at any given time“ cf. Article 1 Paragraph 3 Act on patients’ rights law in Iceland no. 74 from the year 1997.[5] Also, whether it is guaranteed, in services for people with substance use problems funded by public funds, that everyone is „free of their thoughts, conscience and beliefs“ in accordance with Article 18 of the UN Universal Declaration on Human Rights[6]

In accordance with the aforementioned, Rótin now sends this suggestion to the Ombudsman of Althingi to start an initiative review of the quality of treatment and services for people with substance use problems in accordance with human rights and the right to health care.

Overview of main points

The legal basis for the study of alcohol and drug prevention counsellors is unclear, but it is clear that the Directorate of Healthhas the task of evaluating what is a valid education for the profession
Rótin has sent an inquiry to the chairman of the University Council of the University of Akureyri to find out what the legal status of the University of Akureyri’s Continuing Education SMHA is
The Medical Director at the only entity that offers internships, SÁÁ, is on the National Medical Board’s professional council for alcohol and drug prevention counsellors
Counsellors and counsellor trainees carry out most treatment work in the country, with the exception of Landspítali – The National and University Hospital of Iceland
The training/education of counsellors corresponds to approx. 15 secondary school credits, based on 300 lessons, matriculation certificate is not required
It is unclear to which study level the education/training belongs
It is unique in the health care system that a profession with so little education has so much responsibility for the treatment of patients, many of whom struggle with multifaceted and complex problems
Counsellors, who have no academic training, have assumed an incredible amount of responsibility for the well-being of patients with substance use problems
The Association of Alcohol and Drug Prevention Counsellors have hopes for the education to be offered at an accredited „educational institution in order to be able to get the education evaluated for credits, increase connections with the academic community and other professions“

Status of Alcohol and drug prevention counsellors’ education

The Directorate of Health is responsible for evaluating what is a valid education according to regulation 1106/2012, on the education, rights and duties of alcohol and drug prevention counsellors, and conditions for obtaining a work permit:

The Directorate of Health makes recommendations, in consultation with organizations that provide education in alcohol and drug prevention counselling, as well as the Directorate of Health council of specialists for Alcohol and Drug Prevention Counsellors and others deemed competent by the Directorate of Health, on the necessary education for alcohol and drug prevention counsellors and how it should be conducted. The Directorate of Health shall send the proposals to the minister for confirmation. [7]

It should be noted that the Medical Director at the only entity that offers internships for councillors, SÁÁ, is on the Directorate of Health council of specialists for Alcohol and Drug Prevention Counsellors, and this must be considered unfortunate. [8] It is clear that the stakeholder who hires alcohol and drug prevention counsellors, SÁÁ, has different interests than e.g. those who receive the services of the profession, who are not represented in the professional council.

The news that SÁÁ has negotiated an unprecedented agreement with SMHA was a surprise for the council of Rótin, not least in view of the fact that the Minister of Health has announced that the program should be moved to university level.[9] With the arrangement announced, it is clear that the repeatedly proclaimed reforms of councillor education, there is no revision of the regulation.

From the limited information given about the education program on SMHA’s website, it can be deduced that there is a 300-hour course available, however, there are only 13 lectures on the program for the first semester and the course description is only published for the first of three semesters. There are no prerequisites to enter the course, you do not need to have a high school diploma, e.g. and you can only do an internship at SÁÁ. However, to get into an internship there, you need a high school diploma.[10] There is no discussion of assessment or workload in the course, and it is not stated how the course is classified in other respects within the laws and regulations on education in Iceland, and therefore it is not clear at which school level this education is. Rótin has requested information about the administrative status of SMHA from the chairman of the University Council of the University of Akureyri, because as the program is advertised, it is difficult to see if it can be classified under the provisions on continuing education by universities according to Articles 3 and 23 law on public universities.[11] SMHA education is also not on the National Education Agency’s list of recognized educational providers.[12]

In 2019, a job profile for alcohol and drug prevention counselling was created by the Employment Training Centre, but the job profile is the product of a competency analysis and contains a list of the competency elements that are most important to perform the job effectively, together with a description of the competency at the appropriate level. The qualifications for studying Alcohol and drug prevention counselling are generally on the third level of the qualification framework for Icelandic education, [13] which corresponds to a high school diploma or a vocational qualification. Matriculation is e.g. in the fourth step. [14]

It is worth bearing in mind that Alcohol and drug prevention councillors are key workers in the treatment of SÁÁ, as Þráinn Farestveit, who is the vice-chairman of the executive board of SÁÁ, points out in a recent article:

Alcohol and drug prevention counsellors form the core of the treatment work. It is on their shoulders to lead the psychosocial process involved in the treatment. Decades of experience have shown and proven that their guidance and expertise is the key to the success of those struggling with addiction. There are now 42 counsellors and counsellor trainees at SÁÁ, and there have never been more of them working for the organization. [15]

As can be seen from the councillor’s job description, in a few years old article, the councillors’ have a lot of responsibility and:

… the heat and weight of the treatment. They are closest to the patients and therefore have a lot of responsibility. They hold lectures, mostly provide group therapy and individual counselling regarding drug and gambling addiction. [16]

He adds that „alcohol and drug prevention counsellors work, among other things, in prevention and research“ and that their work involves „helping people make decisions about their future“.

Half of the counsellors working at SÁÁ are counselling students and therefore do not even have the limited education that the counselling program provides. [17]

Counsellors with no academic training have assumed an incredible amount of responsibility for the well-being and treatment of people with substance use problems. It is unique in the health care system that a profession with so little education has so much responsibility for the treatment of patients, many of whom struggle with multifaceted and complex problems. To get certified, counsellors only need to attend 300 lessons, which corresponds to about 15 credits at the secondary school level.

It should be noted that counsellors do not have the opportunity to complete their studies elsewhere than at SÁÁ. The staff turnover rate has been high and Rótin has been in contact with people who have dropped out of the education/training for various reasons, e.g. due to the “reign of terror” that characterized the workplace and is described in the statement of 57 employees, or the majority of the staff in 2020.[18] The former counsellor trainee Hilmar Hansson found a reason to publish a booklet about his experience, where he describes what he experiences as a „bullying workplace“.[19] Hilmar’s testimony resonates well with the accounts of other employees who have shared their experiences with Rótin.

The situation of the education of councillors is a great injustice towards the counsellors. In recent years most schools that are run by organisations and workplaces have closed down in recent years, e.g. the Police academy, that has moved to university level. Such schools are products of their time and often create a very large imbalance of power, at the student’s expense, together with the fact that there is often little renewal of knowledge within such systems. The counsellors themselves are hardly happy about the news of SÁÁ’s contracts with SMHA, as the chairman of the Association of Alcohol and Drug Prevention Counsellors, Oddur Sigurjónsson, writes in Sameyki’s 2022 annual report:

One of FÁR’s main projects in the last few semesters has been to bring the alcohol and drug prevention counsellor education/training, which SÁÁ now oversees, into an accredited educational institution in order to be able to get it evaluated for credits, increase relations with the academic community and other professions, and also to support that development that alcohol and drug counsellors can work more widely than at SÁÁ health institutions, but the vast majority of FÁR members work at SÁÁ. FÁR believes that increasing the scope of work of alcohol and drug prevention counsellors is a logical development and strengthens the basis of this important profession.[20]

Counsellors and trainees also had to put up with a situation where their supervisor, at the treatment hospital, Vogur, was simultaneously the chairman of their professional association, the Association of Alcohol and Drug Prevention Counsellors, and also the main educator of trainees. This situation lasted for about two decades. His brother-in-law was his superior, adding to the complication and lack of ethics.

The public sector has therefore not only failed people who seek treatment, but also the staff at the treatment centres by not being more robust in terms of regulations, quality requirements and monitoring of such important services for people in a vulnerable situation.

It seems that few, if any, of the counsellors working in the Icelandic treatment system have more education than the first of the three levels of education, which is not at the university level. In the US, however, many counsellors have university degrees, BA/BS, MA/MS and PhDs. This is discussed in the article „Experience or knowledge?“ More facts about counselling studies“ by Rótin’s council members.

Regulations on counsellors education/training regulations are based on models from the United States and Canada, and the requirements for counsellors appear to be based on the National Association of Alcoholism and Drug Abuse Counsellors (NACCDAC) counsellors training. Many Icelandic counsellors have been recognized by these organizations, that offer certification at three levels, National Certified Addiction Counsellor (NCAC) I, II and Master Addiction Counsellor (MAC).

The first level is comparable to the program recognized by the Directorate of Health. The second level is for those with a BA/BS degree and the third level is for people with an MA/MS degree in health, social sciences or other related disciplines. The difference between the situation in Iceland and in the United States is that there seems that counsellors generally have no more education than the first level. In the United States, however, the majority of counsellors have a university degree. [21]

An American study on why it is difficult to implement new evidence-based methods in services for people with drug problems, found that treatment staff who support the 12-step approach, from which the counsellors profession arose, do have difficulty in adopting new methods that contradict the 12 steps:

… providers that support traditional twelve-step approaches, have longer tenure in the field, and identify as being in recovery, may be more resistant to implementation of new interventions.[22]

The treatment at SÁÁ has been based on the Minnesota model, 12-step ideology, and for a long time it was a requirement that staff members should be active 12-steppers. When the process of recognition of councillors as health care professionals, by the Directorate of Health, is examined it clearly is based on the 12-step ideology and the much-debated brain disease concept. In a letter from Hjalti Björnsson, then chairman of the Association of Alcohol and Drug Prevention Councillors, to Jón Kristjánsson, then Minister of Health and Insurance, about the theoretical basis of alcohol counselling profession, he says it is the disease concept, the stage of the disease according to the Jellinek curve, and the 12-step ideology.[23]:

1 -Translation of text in image: Theoretical basis of alcohol counselling, counselling addicts, the disease concept and theories, stages of the disease, 12 step ideology AA, NA, GA, ALANON

Thus, most of SÁÁ’s employees have been active in 12-step work, since it was a requirement until a few years ago, and 12-step meetings are still part of the treatment. The theory that addiction is a brain disease has been held up with persuasive conviction at SÁÁ. The value of the brain disease theory has declined in recent years, as evidenced by the editorial words of Matilda Hellman, editor of the journal of Nordic Studies on Alcohol and Drugs, [24] last year, that the time has come to review the theory that addiction is a brain disease and that many influential scientists, including in neuroscience, have now pointed out how flimsy and relative the science on which the theory is based is and how little it has yielded in improving the treatment of people with substance abuse problems. [25]

Another evidence is the letter of 94 scientists to the journal Nature, which is discussed in Rótin’s report to the Minister of Health on women and addiction from 2017. 94 scientists wrote to the editor of the journal Nature to protest that the brain disease theory was kept alive in the magazine’s editorial, and the scientists’ statement says:

Substance abuse cannot be divorced from its social, psychological, cultural, political, legal and environmental contexts: it is not simply a consequence of brain malfunction. Such a myopic perspective undermines the enormous impact people’s circumstances and choices have on addictive behaviour. It trivializes the thoughts, emotions and behaviours of current and former addicts. It also belittles the significant effect that public-health campaigns and legislation exert on curbing substance abuse.[26]

Lance Dodes is one of those who have discussed the brain disease theory of addiction is, and in a translated article on the Root’s website, he discusses how dehumanizing this approach is, and in its conclusion, he says:

The neuroscientists at NIDA have done addicts and the addiction field a grave disservice by claiming their rat studies explain human addiction. To understand the compulsive symptoms we call addictions, we need to understand humans.[27]

Dr Jeffrey Foote, a psychologist and addiction specialist in the United States, has expressed the problem in the addiction treatment system thus that in few other disciplines, the least trained staff are left to take care of the most complex group:

In few other fields do we place some of the most difficult and complicated patients in the health-care system with some of the least trained folk among us.[28]

Inquiries about the status of the education/training

Reviewing some of the inquiries sent to authorities regarding the education of counsellors, Rótin sent the first one in October 2013, a query to the Office of the Directorate of Health:

The regulation on the education, rights and obligations of alcohol and drug prevention counsellors and the conditions for obtaining a work permit states:

“The Directorate of Health makes recommendations, in consultation with institutions that provide education in alcohol and drug prevention counselling, as well as The Directorate of Health’s Specialist Council for Alcohol and Drug Prevention Counsellors and others deemed competent by The Directorate of Health, on the necessary education for alcohol and drug prevention counsellors and how it should be arranged. The Directorate of Health shall send the proposals to the minister for confirmation.”

The Council of Rótin would like information on whether The Directorate of Health has made the above recommendations, and if so, we would like to receive them.

The answer Rótin received was as follows:

During the preparation of the regulation, the necessary to review the educational requirements for this profession emerged and that it would be suitable to consider the education of similar professions in our neighbouring countries. That work has not officially started, but it will be started. It is not possible to say at this time when that would be.[29]

As far as we know, this review has not taken place.

Rótin also sent a message to the Minister of Health and the Minister of Education in October 2013, which says:

Regulation 1106/2012 on the education, rights and obligations of alcohol and drug prevention counsellors, and the conditions for obtaining a work permit, states that the Directorate of Health issues a counsellor’s work permit and that the permit may be granted to those who have completed a program that the Directorate of Health deems valid.

During the investigation by the Directorate of Health, which issues licenses for health professions and thus alcohol and drug prevention counsellors, it was found that the office has not made any recommendations about the education and how it should be conducted, according to Article 3. of the regulation, but that the office considers it necessary to „review the educational requirements for this profession and take into account the education of similar professions in our neighbouring countries.“ Furthermore, it is stated that this work has not started.[30]

In a reply from the Minister of Education on January 10, 2014, he says:

The education of counsellors does not belong to the Ministry of Education and Culture, but rather the Directorate of Health, which belongs to the Ministry of Welfare. It is recommended that inquiries about the education of alcohol and drug prevention counsellors be directed to the Directorate of Health.[31]

The answer of the Ministry of Health says, among other things, that:

The education of counsellors does not take place at a specific school level, but at health institutions that offer addiction treatment, and that a review of the education has not started.
The education comes under the Ministry of Welfare in cooperation with the Directorate of Health, the Directorate of Health Specialist Council and institutions that provide treatment.
The Ministry of Welfare has no intention to advocate for the inclusion of education about violence and trauma and its effects on addiction, in the education of these health professionals.
The only requirement for teaching councillors is that the education/training is supervised by an MD. Those in charge of the teaching do not have to have any teaching qualifications. No decisions have been made about the future of education in this area.[32]

Rótin council members were told at a meeting at the Director of Health in 2015 that the authority had been opposed to alcohol and drug prevention counsellors should get certified as a health profession. According to what was stated at the meeting, it can be concluded that politicians have decided to make alcohol and drug prevention counsellors a licensed health profession in defiance of the advice of specialists in the administration.

In 2014, Sigríður Ingibjörg Ingadóttir, a member of parliament, sent two questions to Kristján Þór Júlíusson, the then Minister of Health, about the education/training of alcohol and drug prevention counsellors. The previous inquiry contained five questions: [33]

What is the theoretical basis for the education of alcohol and drug prevention counsellors, cf. Article 3 Act on health professionals, no. 34/2012?
Which educational institution did the minister consult with when regulation no. 1106/2012, on the education, rights and obligations of alcohol and drug prevention counsellors, and conditions for obtaining a work permit, cf. Paragraph 1 Article 5 Act no. 34/2012, which states that the minister must consult with the Directorate of Health, the relevant professional association and educational institution in Iceland when enacting such a regulation?
Which educational institution is responsible for teaching according to Number 2. Paragraph 4 Article 3 regulation no. 1106/2012?
At which health institutions does the internship take place according to Number 1. Paragraph 4 Article 3 of the regulation?
Is the number of lessons according to Numbers 2 and 3. Paragraph 4 Article 3, of the regulation, comparable to the number of lessons in the education of other health professions, according to Paragraph 1 Article 3 Act no. 34/2012?

The minister’s answers states that „The study of alcohol and drug prevention counsellors is based, among other things, on the professional requirements from NAADAC, The Association for Addiction Professionals, and that „The Directorate of Health has pointed out that it is necessary to revise the educational requirements for this profession and to take into account the education of similar professions in neighbouring countries og Iceland.“

Sigríður Ingibjörg followed up this inquiry in September of the same year with the following inquiry:

Are the educational requirements for alcohol and drug counsellors being reviewed in accordance with the recommendation of the National Medical Examiner about the need for such a review to take place that takes into account the education of similar classes in our neighbouring countries?[34]

The minister’s answer clearly states that it is necessary to revise the educational requirements for counsellors:

Revision of the education of alcohol and drug counsellors was discussed somewhat by the Directorate of Health Specialist Council for alcohol and drug prevention counsellors, especially in 2009 and 2010. Various ways were discussed, such as that the education would be at secondary school level and could be part of the units for the matriculation exam and build up in a similar way to paramedic training. It was then discussed that it was important to also offer studies at university level, e.g. diploma program in alcohol and drug prevention counselling. It could be a multidisciplinary study for health professions to specialize in the field. According to information from the Directorate of Health, it is necessary to revise the study requirements for alcohol and drug prevention counsellors, but these plans have been on hold for some time. No decisions have been made about at which school level the education would take place, but the Ministry of Education and Culture is the authority on secondary schools and universities.[35]

At the beginning of 2015, representatives of Rótin attended a meeting of the working group on alcohol and drug prevention and also sent proposals and comments on the recommendations of the working group, where the issue of education for counsellors is addressed and the following pointed out:

… the basis of good treatment must be the education and experience of those who work in treatment. Rótin has expressed concern that alcohol and drug counsellors who have no academic training have such a big responsibility for treatment as is the case. We have sent a message to the Minister of Welfare on this occasion and written articles about it.

Rótin also pointed to a report by CASA Colombia (The National Center on Addiction and Substance Use at Columbia University), which discussed the lack of quality control in the treatment sector in the United States, which the Icelandic one refers to, e.g. educational requirements of advisers:

In facilities that are subject to state regulation, the staffing requirements do not consistently mandate the involvement of professionals who can provide a full range of effective interventions (including pharmaceutical and psychosocial therapies), services rarely are required to reflect best practices and quality assurance requirements seldom stipulate that patient outcome data be collected, analyzed or made available to the public. For no other health condition are such exemptions from routine governmental oversight considered acceptable practice.[36]

Rótin also sent a report to the Minister of Health in 2017, stating on the training of consultants:

It is necessary to pay attention to the education of counsellors, and Rótin has sent several messages to the authorities about these matters. According to the previous minister’s answers, it is clear that:

The education of counsellors does not take place at a specific school level, but at health institutions that offer addiction treatment, and that a review of the education has not started.
The education comes under the Ministry of Welfare in cooperation with the Directorate of Health, the Directorate of Health Specialist Council and institutions that provide treatment.
The Ministry of Welfare has no intention to advocate for the inclusion of education about violence and trauma and its effects on addiction, in the education of these health professionals.
The only requirement for teaching councillors is that the education/training is supervised by an MD. Those in charge of the teaching do not have to have any teaching qualifications. No decisions have been made about the future of education in this area.

From the answer, it can be concluded that the matter is in disarray, the education does not belong to any school level and little or no demands are made on those who are in charge of teaching the counsellors. Therefore, it is important that the legal environment and quality control of alcohol and drug prevention counsellors’ education should be clarified and placed under a certain school level, and thus come under the Ministry of Education. Then a curriculum will be set for the education and appropriate educational requirements made for those who are in charge of teaching counsellors.[37]

In 2017, Þorsteinn Víglundsson, then Minister of Social Affairs and Equality, also received a report from Rótin, which discusses concerns about the state of the treatment system:

… therefore, it is extremely important to develop services for this group and ensure that it is trauma-informed and based on knowledge on and the development of addiction problems. As it is, the vast majority of employees of the treatment system, who are alcohol and drug counsellors, have an education that does not include any such training and does not, in other respects, comply with other qualifications granted by the Directorate of Health.

We at Rótin are constantly receiving stories from the addiction treatment system that reflect the reality that there are people with little education struggling with a complex problem. Many of these stories deal with women experiencing violence and harassment in the treatment system, mainly by men who are with them in treatment but also by men who work in treatment facilities. The stories that deal with the relationship between treatment staff and clients are unfortunately not rare, and they either start during the treatment or after it ends. These stories have now been confirmed in an investigation that Rótin is a part of and is still in progress. See: https://www.rotin.is/slaandi-nidurstodur/.[38]

It is also worth mentioning that Rótin has made serious comments on the treatment of girls by the Icelandic government in the „Report on justice and women’s experience of placement in Varpholt/ Laugalandi“ which we delivered to the Prime Minister, Katrín Jakobsdóttir, in February 2023 after a meeting with her and two women who were kept as girls in Varpholt/Laugalandi. [39] The report was also sent to the Quality and Supervisory Authority of Welfare[40] and other authorities. No educational requirements were made for the operators of treatment homes of the Children’s Protection Agency until 2017 or even later.

Plans to formalize counsellor education

To the list above, it can be added that in communication with the health authorities, at different points in time, the managers of Rótin have received information that the program should e.g. be a part of Keilir, educational center, Ármúlaskóli, Gymnasium – which has a health program – or at university level.

The story about where to place the education is, however, longer and in the report of the Institute of Social Sciences from the year 2004, where 12 jobs in social and health services are discussed; their position on the labour market, development, field of work, study paths, training and need for knowledge and skills, it is clear that it is believed that the work of alcohol and drug prevention counsellors will give way to university-educated experts, but it says:

As of September 1, 2004, Landspítali – National and University Hospital – has discontinued alcohol treatment according to the 12-step system. As a result, there is some uncertainty about the field of work of the counsellors who work there, but these changes will probably mean that treatment will move to a greater extent than before into outpatient clinics and then under the supervision of psychologists.[41]

The report also points out that „Counsellors would benefit from having a matriculation certificate …“ (p. 103), so it has been clear for a long time that the educational requirements for the profession need to be increased, but unfortunately very little has happened in that direction 19 years later. In the quote it is also visible that the work of a counsellor is inextricably linked to 12-steps of Alcoholics Anonymous. The role of counsellor arose as an institutionalized „sponsor“ or personal leader within a 12-step organization. The position of consultants in the health care system goes against both the scientific requirements of the health care system and, on the other hand, such institutionalization is contrary to the traditions of the AA organization as well as the human rights of freedom from religion and thought control.[42]

In the annual report of Sameyki – labour union – in 2009, it is stated that work was done to develop the education in cooperation with SÁÁ, but there is the following clause:

Alcohol and drug prevention counsellors

Starfsmennt undertook a collaboration with SÁÁ during the year with the aim of continuing developing training for alcohol and drug prevention counsellors. The aim was to develop the SÁÁ education for a larger target group, e.g. for the employees of Landspítali’s psychiatric department, but no progress was made on the issue, i.e. because a formal study was being designed by other parties and it was decided to wait for the results of that group to avoid duplication. However, the staff managed one study session during the fall semester in which 20 employees participated. It is considered urgent to coordinate the education of this group in a broad collaboration of all interested parties to increase transparency, clarity and efficiency, and therefore an agreement is requested.[43]

As stated in the annual report, a group was working on planning the future of the education, but it is obvious that nothing has come out of those plans. It is also important to state that it was considered necessary to coordinate the education in a broad collaboration, but it is exactly the opposite of what happened at the beginning of the summer of 2023 when the board of SÁÁ negotiated with SMHA to host the theoretical part of the education, without apparent consultation with anyone.

A news report from February 2022 raised hopes that the case was now finally making good progress and was on its way to the university level, but it says:

The ministry’s response states that qualification requirements and a job profile for alcohol and drug prevention counsellors have been formulated, which the ministry has handed over to the University of Iceland for the preparation of the curriculum. The University’s interest in establishing the education is there, subject to its funding.

„The Ministry of Health and the Ministry of Social Affairs have collaborated on this issue, as they agree on the goal, and both ministries have agreed to support the university so that the education can be prepared and launched,“ says the answer.

The ministry has also examined SÁÁ’s position on changes to the program, and it is positive.

“The next step of the Ministry of Health is to contact the Ministry of University Affairs, to obtain information about the status of this case and the possible funding of the study program in the future.”[44]

The job profile mentioned earlier, however, does not place the education at university level, but at the third level of the Icelandic education qualification framework, [45] which corresponds to a high school diploma or a vocational qualification, but a matriculation degree is e.g. on the fourth step. Where the location of the education at SMHA places it is not clear, since a matriculation degree is not required for the program, it is however clear that it is not at university level.

Marginalization in the welfare and health system

Without going into detail about the history of services for people with substance use problems, there is a long history of marginalization within the health service. Hildigunnur Ólafsdóttir tells this story in her doctoral thesis on the AA organization in Iceland. [46] The law on health care is intended to set standards for services, while the administration has to implement them, but Hildigunnar points out that the organization of drug and alcohol issues has deviated from this general rule and therefore a special law on drug treatment has been enacted. The reasons she mentions are both the negative attitude of professionals towards serving this group and, on the other hand, that it was necessary to guide these clients, who were not believed to know what was best for them, and therefore the public sector had to take responsibility for them.[47] In this way, people with substance use problems have long lived with a strong guardianship and punitive attitude, and it is, not the least, manifested in the model that has been dominant in Iceland’s treatment system for the last 45 years, the Minnesota model, which has also been called the Icelandic model. This path is in many ways spiritual and aims to make people better, but in general the goal of treatment in the mental health system is to make people feel better.

Services for people with substance use problems have long been very different from services for people with mental health problems, e.g. in that, in general, university-educated professionals work with people with mental problems, but in drug and alcohol treatment there are mainly counsellors. The exception to this is withdrawal treatment, where doctors and nurses are a part of the treatment staff, and treatment at Landspítali, which abandoned the Minnesota model in 2004.

In an article, written in 1990, Ólafsdóttir describes the difference between treatment for „alcohol abuse“ in the mental health system and at SÁÁ:

At the institutions of S.Á.Á. there is one dominant theory about alcoholism and its nature. In the mental health system, professionals with different qualifications have different theoretical attitudes towards alcohol problems. The specialists in the health system make the diagnosis. But in the other system it is practically the patient himself who decides whether he is an alcoholic or not. The professionals set clear boundaries between themselves and the patients. In the Minnesota model, such boundaries are much more blurred, since most of the staff members are inactive alcoholics. This leads to empathy and solidarity between everyone in the system. The workers are role models, but the goal is precisely for the alcoholic to mold into the role of the inactive alcoholic. This socialization is based on the traditions of the AA organization. The new role has to be learned, and people also have to learn special terminology. The aim is for the alcoholics to come out of the treatment as „new men“. In addition, there are roles for spouses and children that people can train in Al-Anon and Alateen. The goal of treatment in the hands of professionals, however, is to bring the patient back into society, to make him the way he was before drinking became a problem.

The Minnesota model has various democratic characteristics and reminds in some respects of the „therapeutic community“. But this is an inflexible system, where people must embrace its ideology or stand outside the system. Seen in this light, it is not as democratic as the mental health system, which has more scope for explanations of alcohol problems and a wider range of treatment options. [48]

It is safe to say that much of what Hildigunnur describes still applies in the Icelandic treatment system, where all treatment except the one provided at Landspítali is based on this inflexible system that she describes. When you look at the stories of people who have sought treatment, they are often similar. People are taught to understand themselves within the narrow framework offered by the ideology of the treatment system. People often come out of treatment convinced that they have a chronic brain disease. The consistent stories of people who come out of treatment in the private/social treatment system tell us how little room people have to look at themselves and their history in an open way and seek their own way to self-understanding.

When these stories are then connected to raising money for the treatment organisations, new ethical questions come to the fore.

It is understandable that people come out of treatment with similar stories. The treatment is largely a lesson in what it is like to have the ‘brain disease’ of ‘alcoholism’. In her article, Hildigunnar Ólafsdóttir discusses how the theory of substance use as a disease is spread and maintained within the treatment system.

Perhaps too much has been made of the effectiveness of the disease model. It has been revealed that only a quarter of the public believes that alcoholism is a disease that the individual has no control over whether they get or not. Those who espouse this view are preferably those who have been in treatment, where this view has been taught.[49]

In this context, it is good to look at how common it is that the services of non-governmental organizations include a requirement to attend religious or other gatherings that involve ideological submission, such as belief in e.g. 12-step ideology, which is religious even though 12-step organizations don’t define themselves as religious organizations, and the disease-theory of addiction is often preached as unquestionable holy truth. These methods have little overlap with the general health system, where there is a strong emphasis on a scientific and evidence-based approach. Everyone shall be „free of their thoughts, conscience and religion“, and in accordance with Article 18. of UN Human rights declarations, the government should implement, in policy planning, not to buy such services, but make it a condition that there is no religious or ideological indoctrination in welfare and health services that benefit from public subsidies.[50]

The report of the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health specifically addresses biological theories of mental and psychiatric disorders. In the past, it was believed that the concept of disease would benefit people with mental health and addiction problems in the fight against stigma. It has not happened, and it has proved difficult to support the theories with strong scientific backing. However, they have led to a small-mindedness that works against the human rights of people with a complex compound problem where social conditions, health, both physical and mental, are intertwined in a way that cannot be separated.

18. The biomedical model regards neurobiological aspects and processes as the explanation for mental conditions and the basis for interventions. It was believed that biomedical explanations, such as “chemical imbalance”, would bring mental health closer to physical health and general medicine, gradually eliminating stigma. However, that has not happened and many of the concepts supporting the biomedical model in mental health have failed to be confirmed by further research. … Critics warn that the overexpansion of diagnostic categories encroaches upon human experience in a way that could lead to a narrowing acceptance of human diversity.

19. However, the field of mental health continues to be over-medicalized and the reductionist biomedical model, with support from psychiatry and the pharmaceutical industry, dominates clinical practice, policy, research agendas, medical education and investment in mental health around the world. The majority of mental health investments in low-, middle- and high-income countries disproportionately fund services based on the biomedical model of psychiatry.[51]

Dainius Pūras, Special Rapporteur on the right to health at the United Nations Office of the High Commissioner for Human Rights, says in a statement that:

The dominance of the biomedical model results in an overuse of medicalization and institutionalization, ignoring the social, political or existential context that contributes to a high prevalence of feelings of sadness, anxiety, fear and other manifestations of mental distress.[52]

Quality and safety in treatment

Many good suggestions were made in the Minister of Health’s report on services for alcohol and drug users in Iceland, which was presented to Alþingi during the 131^st legislative session of 2004–2005. Among other things there was reference to the Norwegian quality standards and criteria for treatment. Few of these proposals have been implemented, but it seems that the most powerful in the field of people with substance use problems have little benefit from promoting improvements in the education of those who work in the treatment of people with substance abuse problems, thereby improving the quality of services. In her master’s thesis in public administration, Þorgerður Ragnarsdóttir writes about the reasons why amendments to the Proposal for a parliamentary resolution for the formulation of a comprehensive policy on treatment institutions for alcohol and drug users, which was submitted to Alþingi in the spring of 2002,[53] were not implemented. Þorgerður’s results can be interpreted as meaning that the field was in the grip of stakeholders who did not see any benefit in an overall structure in their area of work:

It is interesting to consider whether the formulation of an overall policy is really beneficial in the long run. In the process of formulating the policy, many conflicting points of view have to be reconciled. In that process, the next step is to accommodate everyone. Some points of view will be on top, while others will be discounted. Members of parliament may care about the issue that the overall policy revolves around, but they presumably also care about their careers and can refrain from making unpopular decisions if it costs them votes. [54]

Our experience is that the organization of services to people with substance use problems are still held in the clutches of stakeholders who do not see the benefits in modern reforms. This is at the expense of the rights of people with alcohol and drug problems who feel that the authorities have not taken responsibility for ensuring the quality of services and thus the human rights of people with substance use problems.

Public bodies do often not have a clear criterion on which services should be purchased or what they should embody. Thus, e.g. some of the largest treatment centres in Iceland do not have managers who have a license from the Directorate of Health or suitable qualifications, and many people who work within the sector, have a degree from a school where various pseudo sciences, such as Neuro-Linguistic Programming, [55] are taught. In an article published in the Journal of Addictive Medicine about what works and what doesn’t in treatment, what is evidence-based and what isn’t, experts were given a list of 65 treatment methods and rated them on a Likert scale from „not at all discredited“ to „certainly discredited“. Neuro-Linguistic Programming is among the 11 methods that fell under the assessment of the experts to be „certainly discredited“.[56] Most people who work at the treatment centre in Krýsuvík have an education from the Counselling School.

The education of treatment staff is important to ensure both the quality and safety of those who seek treatment. So far, there is no data compiled by independent researchers on the quality of treatment in Iceland. The results of the service surveys are nowhere to be found, there does not seem to be a record of incidents at the treatment centres, [57] and for several years Rótin has been writing to the Directorate of Health about the registration of patients at treatment centres in the hospital accommodation register, which is required by law, but is not maintained in SÁÁ’s detox hospital Vogur.[58] In this way, the public sector does not seem to follow the laws and regulations that are in place to protect the interests of this group of patients.

In fact, the Directorate of Health conducted an audit of treatment centres in Iceland in 2016, and the conclusion was that few components passed the test. A partial assessment of Vogur shows that the housing is the only one that meets the requirements.

The performance of the treatment centre in terms of quality and safety is not visible. There is no quality manual, there are no written procedures regarding many aspects of the activity. For example, there are no written procedures regarding service at the constant observation care in Vogur. It is not stated whether service surveys have been conducted, but surveys have been conducted regarding educational lectures. Housing options are good both in Vogur and the outpatient department in Von, and well equipped for patients. Housing in Vík is a child of its time, but neat and well-maintained, but a new building is to be built for the activities there. [59]

Summary opinion – SÁÁ, Vogur

The result in the treatment centres in Krýsuvík and Hlaðgerðarkot was no better.

The evaluation of the Directorate of Health in 2016.

Summary opinion – Krýsuvík

Summary opinion – Hlaðgerðarkot

[60]

Despite these results and countless indications and proofs that it is necessary to make improvements in services for people with addiction problems, the authorities have not reacted quickly enough to the energetic battles of Rótin and others for improved quality in services for people with substance use problems.[61]

Appendix 1. Letter to the Quality and Supervisory Authority of Welfare

Letter to the Quality and Supervisory Authority of Welfare sent 6 April 2024.

As for today, 28 August 2024 Rótin has not received an answer.)

Good day.

In the contract of the Ministry of Social Affairs and Labor with the Treatment Home in Krýsuvík for services to those who need long-term support due to drug use, made on the basis of Article 40 of the Act on Public Finances, which states in paragraph 5:

In contracts for operational projects according to this article, i.a. define the scope and quality of the activities covered by the contract, contract period, conditions for contract payments, monitoring of their implementation and handling of disputes.

The agreement, Art. 2, states regarding the goal, that „when executing the contract, the contractor shall emphasize that the quality of the service is always a priority“.

It also says in parag. 4 Art. 3 of the contract:

The service must be provided by counsellors who have a recognized qualification in the field of substance abuse treatment with the assistance and under the guidance of a doctor or other specialized person if necessary.

An answer is requested as to whether the Quality and Monitoring Agency for Welfare recognizes education from Ráðgjafarskóli Íslands (Iceland’s Counselling School, private limited company). Most, if not all, of the counsellors working in Krýsuvík are educated at Iceland’s Counselling School, and the education provided there is not recognized by the Directorate of Health. Or is education in the Counselling School evaluated by other authorities?

The undergraduate program consists of 100 hours of structured lessons and 50 hours of homework and project work, there is no clinical experience in the program. The school’s website states that the program is recognized by the IC&RC:

The program at the school is recognized by the international organization IC&RC (The International Certification & Reciprocity Consortium). Students who graduate from Iceland’s Counselling School thereby gain the right to apply for international recognition (certificate) as an Alcohol & Other Drug Abuse Counsellor (AODA) from the IC&RC.

When looking at the IC&RC website, it is not easy to find out what is included in this certification unless you buy a manual that is 731 pages long. Does the Icelandic government, including GEV, recognize this certification?

The postgraduate course at the Counselling School consists of 80 one-hour lessons and 40 hours are for homework and project work. It teaches subjects such as NLP (Neuro Linguistic Programming), personality analysis, personality types and body language, which are not considered evidence-based knowledge and NLP is classified as pseudoscience.

Those who graduate from the Counselling School have a certificate from the European Certification Board, ECB, whose board includes three Icelanders, including the principal of the Counselling School.

The principal of the Counselling School does not have a university degree but a series of abbreviations, CMH, CHYP, PNLP, MPNLP. Looking them up reveals the following:

CMH = Certified Master Hypnotist (A title also issued by the UK Guild of Hypnotist Examiners, following both a written and practical examination)
CHyp = Certified Hypnotherapist (Issued by the UK Guild of Hypnotist Examiners for passing their exam)
NLP = Neuro-Linguistic Programming
PNLP = Certified NLP Practitioner
MPNLP = Master Practitioner of Neuro Linguistic Programming

All of these are short courses that were taken decades ago, if the news in the attachment is anything to go by, in non-traditional subjects that do little good for the education of people who work with the group that is struggling with one of the most complex problems of the health and welfare system.

Attached is a report on the concerns of real professionals that people who have no qualifications are advertising themselves as counsellors, where the principal of the Counselling School comes into play.

We also point to a report with a suggestion to the Parliamentary Ombudsman for an initiative investigation „on whether the services that people with drug problems receive in Iceland contribute to the fundamental human rights contained in the right „to enjoy physical and mental health to the highest possible extent“, as stated in the International Convention on Economic, Social and Cultural Rights, and „the most advanced health care available at any given time“ cf. Article 1 Parag. 3 Act on patients’ rights no. 74 from 1997. Also, whether care is taken to ensure that in services to people with substance use problems, everyone should be „free of their thoughts, conscience and beliefs“ in accordance with Article 18 og the Human rights declaration of the UN.

Epilogue – August 2024

The Icelandic treatment system and services to people with substance use problems are moving in the direction of human rights, but at a very slow pace.

Most treatment in Iceland is based on religion and ideology as well as the brain disease model of addiction which comes with various human rights and ethical problems as imposing diagnosis and the role of a patient on people with substance use problems. This is analysed in Hellman et al. book Addiction and the Brain. Knowledge, Beliefs and Ethical Considerations from a Social Perspective (2022).

We still need to make important changes to obtain that this group is the beneficiary of full human rights and where the obligations arising from human rights standards are met. Such as can be learned from the International Guidelines on Human Rights and Drug Policy and the obligations rising from them:[62]

Right to the highest attainable standard of health

Everyone has the right to enjoy the highest attainable standard of physical and mental health. This right applies equally in the context of drug laws, policies, and practices.

Drug dependence treatment

The right to health as applied to drug policy includes access to evidence-based drug dependence treatment on a voluntary basis.

In accordance with their right to health obligations, States should:

i. Ensure the availability and accessibility of drug treatment services that are acceptable, delivered in a scientifically sound and medically appropriate manner, and of good quality (that is, with a strong evidence base and independent oversight). This means that such services should also be adequately funded; appropriate for particular vulnerable or marginalised groups; compliant with fundamental rights (such as to privacy, bodily integrity, due process, and freedom from arbitrary detention), and respectful of human dignity.

Right to benefit from scientific progress and its applications

Everyone has the right to enjoy the benefits of scientific progress and its applications. This right applies equally in the context of drug use and dependence, as well as in development and criminal justice responses to the illicit drug trade.

Freedom of opinion, expression, and information

Everyone has the right to freedom of opinion and expression, which includes the right to seek, receive, and impart information and ideas of all kinds through any media of choice. It also includes the right to hold opinions, express ideas, and seek, receive, and impart information about drugs and drug policy.

It is also important in services to people with substance use problems and marginalised people is the freedom FROM religion and ideology in the services they seek. In Iceland this right is not met as it is.

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Þorgerður Ragnarsdóttir. 2006. Hvatar að mótun heildarstefnu um uppbyggingu og rekstur meðferðarstofnana. https://skemman.is/handle/1946/19303. Ragnarsdóttir was the secretary to the working group producing the report presented to Althingi during the 131st legislative session of 2004–2005.

Þráinn Farestsveit. 16. júní 2022. Ráðgjafarnir eru lykilfólk SÁÁ. Sjá: https://www.visir.is/g/20222276575d/rad-gjafarnir-eru-lykil-folk-saa.

[1] SÁÁ, The National Center of Addiction medicine, is by far biggest service provider in Iceland to people with substance use problems.

[2] Akureyri.net. 11.6.2023. Hefja kennslu í áfengis- og vímuefnaráðgjöf. Sjá: https://www.akureyri.net/is/moya/news/taka-vid-kennslu-i-afengis-og-vimuefnaradgjof.

[3] The Directorate of Health is responsible for the licencing.

[4] Alþjóðasamningur um efnahagsleg, félagsleg og menningarleg réttindi. 1979. Sjá: https://www.althingi.is/lagas/150b/1979010.2c4.html.

[5] Patients’ Rights Act, No. 74/1997, as amended by Act No. 77/2000, 40/2007, 41/2007, 112/2008, 55/2009, 162/2010, 126/2011, 34/2012, 44/2014 and 50/2019. See: https://www.government.is/library/04-Legislation/Patients%20Rights%20Act%20No%2074%201997_as%20amended%202021%20-%20Copy%20(1).pdf.

[6] UN Universal Declaration of Human Rights. See: https://www.un.org/en/about-us/universal-declaration-of-human-rights.

[7] Reglugerð um menntun, réttindi og skyldur áfengis- og vímuefnaráðgjafa og skilyrði til að hljóta starfsleyfi: https://island.is/reglugerdir/nr/1106-2012.

[8] Embætti landlæknis. 2.10.2023. Ráð og nefndir. Sjá: https://island.is/s/landlaeknir/rad-og-nefndir.

[9] Fréttablaðið. 3. febrúar 2022. Unnið að því að auka kröfur til áfengis- og vímuefnaráðgjafa. Sjá: https://timarit.is/files/51632165.

[10] Símenntun HA. 2023. Nám í fíkniráðgjöf – önn 1. Sjá: https://smha.is/namskeid/nam-i-afengis-og-vimuefnaradgjof-onn-1/.

[11] Lög um opinbera háskóla nr. 85 frá 12. júní 2008. Sjá: https://www.althingi.is/lagas/nuna/2008085.html.

[12] Menntamálastofnun. 2023. Viðurkenndir fræðsluaðilar. Sjá: https://mms.is/vidurkenndir-fraedsluadilar.

[13] Stjórnarráðið. Hæfnirammi um íslenska menntun. Sjá: https://www.stjornarradid.is/verkefni/menntamal/framhaldsskolar/haefnirammi-um-islenska-menntun/.

[14] Fræðslumiðstöð atvinnulífsins. 2019. Starfaprófíll áfengis- og vímuefnaráðgjafi. Framhaldsfræðsla. Sjá: https://frae.is/wp-content/uploads/2021/12/Afengis-og-vimuefnaradgjafi.pdf.

[15] Þráinn Farestsveit. 16. júní 2022. Ráðgjafarnir eru lykilfólk SÁÁ. Sjá: https://www.visir.is/g/20222276575d/rad-gjafarnir-eru-lykil-folk-saa.

[16] Magnús Einarsson. 2007. „Um starf áfengis- og vímuefnaráðgjafa“, í SÁÁ-blaðið, 1. issue, p. 19.

[17] Ríkisendurskoðun. Mars 2022. Geðheilbrigðisþjónusta Stefna – skipulag – kostnaður – árangur: Stjórnsýsluúttekt. Sjá: https://www.rikisend.is/reskjol/files/Skyrslur/2022-gedheilbrigdismal.pdf.

[18] Viðskiptablaðið. 22.6.2020. Þórarinn hafi verið með ógnarstjórn. Sjá: https://vb.is/frettir/thorarinn-hafi-verid-med-ognarstjorn/.

[19] Hilmar Hansson. 2013. Lítið kver um brennivín og fleira – vangaveltur miðaldra múrara sem vann á Vogi.

[20] Oddur Sigurjónsson. 2022. Félag áfengis- og vímuefnaráðgjafa, í ársskýrslu Sameykis 2022, bls. 37. Sjá: https://www.sameyki.is/library/Skrar-a-vef/2023/Sameyki%20ársskýrsla%202023.pdf.

[21] Rótin. 28. mars 2014. Reynsla eða þekking? Fleiri staðreyndir um ráðgjafanám. Sjá: https://www.rotin.is/reynsla-eda-thekking-fleiri-stadreyndir-um-radgjafanam/ og sjá einnig Staðreyndir um menntun áfengis- og fíkniráðgjafa: https://www.rotin.is/stadreyndir-um-menntun-afengis-og-fikniradgjafa/.

[22] Rieckmann og fl. 2012. The Substance Abuse Counseling Workforce: Education, Preparation and Certification, Sjá: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3486694/#R24. Ath. að breiðletrun í tilvitnuninni er Rótarinnar.

[23] Letter to Jóns Kristjánssonar, Monister of Health and Insurances. 16. maí 2005. Attachment 2: The councelling treining at SÁÁ.

[24] Hellman, M. 2022. New work on the brain and addiction. Nordic Studies on Alcohol and Drugs, 39/2, bls. 121-123. Sjá: https://doi.org/10.1177/14550725221092861.

[25] See a more detailed discussion of the brain disease theory in the Root’s resolution on harm reduction and decriminalization from May 5, 2023: https://www.rotin.is/alyktun-um-skadaminnkun-og-afglaepavaedingu/.

[26] Rótin. 2017. A report on women and addiction to the Minister of Health, see: https://www.rotin.is/greinargerd-til-heilbrigdisradherra/.

[27] Lance Dodes. 2020. Our Dangerous Obsession with Neurobiology. See: hhttps://rehabs.com/pro-talk/our-dangerous-obsession-with-neurobiology/. NIDA is the National Institute of Drug Abuse in the United States, which has led the group that maintains the theory of addiction as a biological problem.

[28] Fletcher, Anne M. 2013. Inside Rehab. The Surprising Truth About Addiction Treatment and How to Get Help That Works. Penguin Books, New York, bls. 390.

[29] Svar Embættis landlæknis til Rótarinnar 21. október 2013.

[30] Fyrirspurn Rótarinnar til ráðherra og Embættis um nám áfengis- og vímuefnaráðgjafa 27. október 2013: https://www.rotin.is/menntun-afengis-og-vimuefnaradgjafa/.

[31] Svar Mennta- og menningarmálaráðuneytis til Rótarinnar 10. janúar 2014. Tilv. MMR13100284/6.18.0-

[32] Svör ráðherra um ráðgjafanám. Sjá: https://www.rotin.is/svor-radherra-um-radgjafanam/.

[33] Alþingi. 10. apríl 2014. 951 fyrirspurn. Sjá: https://www.althingi.is/altext/143/s/0951.html.

[34] Alþingi. 22. september 2014. 147 fyrirspurn: Sjá: https://www.althingi.is/altext/144/s/0147.html.

[35] Alþingi. 15. október 2014. 286 svar: Sjá: https://www.althingi.is/altext/144/s/0286.html.

[36] National Center on Addiction and Substance Abuse við Columbia-háskóla. „Report on addiction treatment. 2012. Vefslóð: https://archive.org/stream/781862-casa-columbia-addiction-med/781862-casa-columbia-addiction-med_djvu.txt.

[37] Rótin. 27.6.2017. Greinargerð til heilbrigðisráðherra um konur og fíkn. Sjá: https://www.rotin.is/greinargerd-til-heilbrigdisradherra/.

[38] Rótin. 28.11.2017. Ósk um úttekt á áreitni á meðferðarstöðvum. Sjá: https://www.rotin.is/areitni-a-medferdarstodvum/.

[39] Rótin. 1.2.2023. Greinargerð um réttlæti og reynslu kvenna af vistun í Varpholti/Laugalandi. Til: Katrínar Jakobsdóttur, forsætisráðherra. Sjá: https://www.rotin.is/heimsokn-og-greinargerd-til-forsaetisradherra-vegna-varpholts/.

[40] See: https://island.is/en/o/gev.

[41] Hildur Björk Svavarsdóttir, Pétur Maack Þorsteinsson og Friðrik H. Jónsson. 2004. 12 störf í heilbrigðis- og félagsþjónustu : staða, starfssvið, námsleiðir, þekking og hæfni, bls. 18. Útg. Félagsvísindastofnun, sjá: https://www.stjornarradid.is/gogn/rit-og-skyrslur/stakt-rit/2004/11/15/12-storf-i-heilbrigdis-og-felagsthjonustu-stada-starfssvid-namsleidir-thekking-og-haefni/.

[42] AA-samtökin á Íslandi. 12 Erfðavenjur AA. Sjá: https://www.aa.is/12-erfdavenjur-aa.

[43] Starfsmennt. 2009. Annual report. See: https://www.smennt.is/library/Skrar/arsskyrslur-og-reikningar/Ársskýrsla%202009.pdf.

[44] Fréttablaðið. 3. febrúar 2022. Unnið að því að auka kröfur til áfengis- og vímuefnaráðgjafa. Sjá: https://timarit.is/files/51632165.

[45] Mennta – og barnamálaráðuneytið. 2023. Hæfnirammi um íslenska menntun. Sjá: https://www.stjornarradid.is/verkefni/menntamal/framhaldsskolar/haefnirammi-um-islenska-menntun/.

[46] Hildigunnur Ólafsdóttir. 2000. Alcoholics Anonymous in Iceland: From Marginality to Mainstream Culture. Bókin er aðgengileg á netinu: https://books.google.is/books/about/Alcoholics_Anonymous_in_Iceland.html?id=lX-Um4BanhsC&redir_esc=y.

[47] Sama heimild bls. 161.

[48][48] Hildigunnur Ólafsdóttir. Straumar í meðferð við áfengisvandamálum. 1990; 1., bls. 36. Aðgengilegt á vefnum: http://hirsla.lsh.is/lsh/bitstream/2336/99806/1/G1990-01-21-G2. pdf.

[49] Hildigunnur Ólafsdóttir. Straumar í meðferð við áfengisvandamálum. 1990; 1., bls. 37. Sjá: http://hirsla.lsh.is/lsh/bitstream/2336/99806/1/G1990-01-21-G2. pdf.

[50] Mannréttindayfirlýsing Sþ. Sjá: https://www.humanrights.is/is/mannrettindi-og-island/helstu-samningar-og-yfirlysingar/sameinudu-thjodirnar/mannrettindayfirlysing-sameinudu-thjodanna.

[51] UN Human Rights Council, Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, A/HRC/35/21, 28 March 2017, https://www.refworld.org/reference/themreport/unhrc/2017/en/116935.

[52] UNHRC. 2020. Statement by Mr Dainius Pūras, Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Sjá: https://www.ohchr.org/en/statements/2020/10/statement-mr-dainius-puras-special-rapporteur-right-everyone-enjoyment-highest.

[53] Skýrsla heilbrigðis- og tryggingamálaráðherra um meðferðarstofnanir. Sjá: https://www.althingi.is/altext/pdf/126/s/1255.pdf.

[54] Þorgerður Ragnarsdóttir. 2006. Hvatar að mótun heildarstefnu um uppbyggingu og rekstur meðferðarstofnana. https://skemman.is/handle/1946/19303. Ragnarsdóttir was the secretary to the working group producing the report presented to Althingi during the 131st legislative session of 2004–2005

[55] Ráðgjafarskólinn. Framhaldsnám í Ráðgjafarskólanum. Sjá: https://www.radgjafarskolinn.is/framhald.html.

[56] Norcross, J. C., Koocher, G. P., Fala, N. C., & Wexler, H. K. 2010. What does not work? Expert consensus on discredited treatments in the addictions. Journal of Addiction Medicine, 4(3), 174-180. Sjá:https://oldev.trubox.ca/wp-content/uploads/sites/37/2015/06/hlth4511_l8_whatdoesnotwork.pdf.

[57] Sjá samskipti Rótarinnar við Embætti landlæknis og Úrskurðarnefnd um upplýsingamál sem finna má í þessum lista: https://www.rotin.is/oryggi-kvenna-i-medferd-yfirlit/.

[58] Sjá tölvupóstsamskipti sem verða senda með erindinu.

[59] Embætti landlæknis. 2016. Hlutaúttekt. Meðferðarstofnanir SÁÁ. Sjá https://www.landlaeknir.is/utgefid-efni/skjal/item29702/.

[60] Sjá úttektir Embættis landlæknis frá árinu 2016: https://assets.ctfassets.net/8k0h54kbe6bj/5JubSPJakuS39kP7Dt3AA6/585aa8cbdc7f6e85ef67064e2d91e1c6/__ttektarsk__rsla_Kr__suv__k.pdf.pdf, https://assets.ctfassets.net/8k0h54kbe6bj/1t2rC5C7fY5gYDxqBcfwzr/5b55ef230ebc52d7f8989cb98c03dbbb/Hla__ger__arkot___ttektarsk__rsla.pdf.pdf og https://assets.ctfassets.net/8k0h54kbe6bj/u30XcwIYuuwOrhysxq2sx/a340a5d061868ce65ef2ec10defcb6d0/Sk__rsla_hluta__ttektar_hj___S____.pdf.pdf.

[61] Sjá lista yfir ýmis erindi Rótarinnar: https://www.rotin.is/oryggi-kvenna-i-medferd-yfirlit/.

[62] International Guidelines on Human Rights and Drug Policy. 2019. See: www.humanrights-drugpolicy.org and https://www.humanrights-drugpolicy.org/guidelines/obligations-arising-from-human-rights-standards/freedom-of-opinion-expression-and-information/.

6. 10. 2023

Rótin, félagasamtök – Rótin, NGO

Túngata 14

101 Reykjavík

Spokeswoman:

Kristín I. Pálsdóttir

kristin@rotin.is

Tel. +354-8939327