New research highlights the importance of social work in substance misuse

The Scottish Government has published a new report entitled, ‘Social work services and recovery from substance misuse: a review of the evidence’, which is accompanied by research findings. This research reviewed the available evidence on social work’s contribution to supporting recovery for those with problem drug and/or alcohol use. The review also collated the available evidence on workforce development in this area as well as reviewing what is known about social work roles and training.

This project was jointly commissioned by the Scottish Government, the Association of Directors of Social Work ( ADSW) and the Institute for Research and Innovation in Social Services ( IRISS). Its purpose was to review the evidence base to determine the contribution made by social work and social care to supporting people with alcohol and/or other drug problems. The findings were to be set within the context of the recovery based approach to working with substance use that is at the core of Scotland’s national drugs strategy.

In recent years, there has been a move away from treatment or harm reduction as a focus for working with those who have drug and/or alcohol problems toward a broader conception of “recovery”.

Scotland is at the forefront of this transformation. Recovery is a “process through which an individual is enabled to move-on from their problem drug use towards a drug-free life and become an active and contributing member of society” (Scottish Government, 2008).

The nature of recovery – including its start and end points – will vary from person to person and should be based on an individual’s needs and goals. A recovery focused professional provides “timely, sensitive, person-centred, evidence-based support that is appropriate and empathetic which empowers individuals to set their own recovery objectives, manage their own care, and sustain recovery.” (Scottish Government/ CoSLA, 2010).

This literature review considers the current evidence in relation to social work’s contribution to recovery focused approaches. It reviews what is known about social work roles and training, as well as the evidence of the effectiveness of social work interventions with people with problem drug and/or alcohol use.

Main Findings

• The values, theoretical models and ways of working with people which are considered typical of social work were consistent with recovery approaches. Despite this, there was relatively little research evidence for effective ways of working with problem drug and/or alcohol use from a social work perspective.
• The strongest body of evidence was in relation to ‘case management’. This indicated that the specialist co-ordination of services could have a positive impact, and that this was particularly likely to be true for service users with more serious problems. Key elements of effective case management included:
• A focus on developing and sustaining a relationship (most used specific methods for supporting this, most frequently motivational interviewing).
• A limited number of service users per worker.
• An emphasis on creatively engaging individuals, for example through out-of-hours work and interventions based in service users’ homes.
• Access to additional services rather than simply co-ordinating existing services.
• A key lesson was that effective case management required more than co-ordinating services. Instead, it involved building supportive and helping relationships based on skilled communication, patience in engagement and respect for the needs and strengths of service users.
• In addition to the findings on case management, there were a number of studies identifying promising social work contributions to helping people with drug and/or alcohol problems to recover. These included:
• Intensive interventions for families where children were at risk of entering care.
• Outreach services for homeless individuals with problem drug and/or alcohol use.
• Promising interventions for individuals where mental health issues co-exist with problem alcohol and/or other drug use.
• It was noteworthy that several areas, including older people, people with disabilities and children in care had virtually no research on the social work contribution to working with substance use problems.
• Despite the strong evidence for the potential difference that social work can make to supporting recovery, this review found that to-date the social work contribution has been insufficiently researched, whilst the evidence available suggests that social work, as a profession, has paid inadequate attention to ensuring practitioners have the skills and confidence to work with those affected by problem drug and/or alcohol use.

Background

Recovery approaches aim to support individuals in their journey away from problematic or dependent use towards becoming free of drug and/or alcohol problems. There is also a focus on helping individuals to make an active, positive and valued contribution to society. To achieve this, person-centred services that help people at every stage of the recovery journey are essential.

There are strong grounds for believing that social workers have a key role to play in supporting the recovery journey. Social workers already work with a wide-range of people who are often vulnerable to drug and/or alcohol problems. The values of social work – which emphasise service user choice and empowerment – are consistent with those of a recovery approach. Furthermore, the social work focus on social context and support is consistent both with helping people to make a positive contribution to society and with a wider conceptualisation of drug and alcohol problems that recognises them as being psycho-social issues, rather than framing them as matters of individual deviance or illness.

The Scottish Government, the Association of Directors of Social Work ( ADSW) and the Institute for Research and Innovation in Social Services ( IRISS) therefore commissioned this research to review what the evidence currently tells us about social work’s contribution and role in supporting recovery from problem drug and/or alcohol use.
Objectives

The research had three main objectives:

1. To review the evidence of the effectiveness of social work/social care interventions with people with substance use problems.
2. To collate the available evidence on social services’ workforce development in the area of substance use.
3. To gain an insight from the evidence base into the range of specific social work roles and functions with people who have substance use problems.

Method

The review for objective 1 was carried out using a rapid evidence assessment methodology. Extensive searches of electronic databases were carried out using key words aimed at identifying social work interventions relating to alcohol and/or drug issues. Articles that were not relevant and studies that were not sufficiently rigorous were excluded, which resulted in 57 articles being reviewed.

The reviews relating to workforce development and social work roles and functions used similar search strategies; however the limited empirical evidence required a more flexible approach to including studies. Studies were therefore identified and included if they appeared likely to be interesting or relevant. Forty-eight studies were included relating to workforce development and 25 looked at the role and functions of social workers.

Effective Interventions

The bulk of the studies reviewed related to forms of ‘case management’. Case management is a term covering a wide set of approaches to providing and co-ordinating appropriate service provision. Care management is a form of case management commonly used in Scotland and other parts of the United Kingdom. The type of case management reviewed in the literature varied enormously (from single 30-minute interviews to intensive services available 24-hours a day). The effectiveness of case management also varied a great deal, with several studies finding no impact, but a number identifying strong positive impacts. This highlights the importance of questions about what types of care management seem to work, for whom, in what contexts and why.

These are complicated questions to provide clear answers to. It was found that case management could produce positive outcomes, and this was particularly likely for those with more serious problems (such as homelessness, chaotic use during pregnancy or co-occurring mental health issues). In addition, the literature identified some key factors associated with positive results in evaluations of care management. Where substance use issues co-exist with other social or individual challenges, care management may therefore be particularly appropriate.

In addition to care management, there were several promising studies of specific social work interventions or services for people with substance use problems. This included families affected by serious parental substance use problems (particularly where children were at risk of entering care), homeless individuals and people with mental health issues). Across these areas, social work interventions were marked by a tendency to combine individual work to help people address their drug and/or alcohol use with attention to broader social issues, including support with housing, benefits, accessing health services or simply practical issues such as shopping. Overall, there were indications of relatively intensive services that reduced the need for children to enter care, reduced homelessness and improved health and substance use related outcomes. These provide promising starting points for developing specialist services in a Scottish context, though caution needs to be taken in adapting approaches for a Scottish context and any adaptations should be carefully evaluated.

Roles and Tasks

This literature review suggested that social workers are well placed to play an active role in supporting people with alcohol and other drug problems because of the profession’s holistic and ecological approach (which focuses on the person within their social context). It also suggested that an ongoing and intensive involvement with service users may often be an appropriate role for social workers despite the emphasis on short-term allocation in much current provision. However, attention needs to be paid to the challenges that social workers may face when working with problem alcohol and/or drug use, including lack of training, workers’ sense of legitimacy in addressing substance use issues and tensions between conflicting roles, such as care and control or personal and professional.

Workforce Development

The literature on workforce development found few strong empirical studies. Those that were found consistently highlighted that social workers receive insufficient training and support in developing their skills in relation to substance use. Studies suggested that training social workers can improve their attitudes, knowledge and practice in this area, though some found that changes are not always maintained and it is likely that ongoing supervision is a key factor in maintaining improvements. A second finding was that a range of barriers need to be overcome to ensure social workers are equipped for working with problem alcohol and/or other drug use. These include, in particular, ‘situational constraints’ created by organisations that do not consider working with substance use to be their focus and the challenge of providing training and skilled supervision when there is limited expertise within the workforce appeared important. Finally, where substance use knowledge was imparted through specialist workers both social workers and service users reported improvements in knowledge, skills and support.

Conclusions and Implications for Policy and Practice

The review supported the suggestion that social work can and should have a strong role to play in the move toward recovery focussed approaches to problem alcohol and/or other drug use. This was supported in theoretical contributions highlighting the fit between social work values and theories and those of the recovery approach. In addition, there was strong empirical evidence illustrating the positive contribution that social work can make both in case management and specialist intervention projects for those with more serious or complex needs.

In light of these positive messages, the consistent findings from the evidence reviewed about the lack of training and preparation for working with substance use for social work students and practitioners were disappointing. The lack of UK, and in particular Scottish, research on this topic was also evident.

The report concludes with a number of recommendations designed to allow the social work profession to play a full part in contributing to the move toward a recovery focus in response to Scotland’s drug and alcohol problems. In summary, these include suggestions relating to the development of the social work workforce nationally (eg around developing skills, training and supervision on substance use problems) and the identification and evaluation of the key elements of effective case/care management, social work interventions, services and training.

This document, along with full research report of the project, and further information about social and policy research commissioned and published on behalf of the Scottish Government, can be viewed on the Internet at: http://www.scotland.gov.uk/socialresearch .

If you have any further queries about social research, please contact: [email protected] or on 0131-244 7560.