6.1. This chapter discusses the evidence found in relation to the four key objectives of this research. These were to:
- Review the available evidence on the efficacy of social work and social care interventions in substance use treatment, care, rehabilitation and recovery
- Review the evidence on the distinct functions, roles, support and interventions provided by social work and social care professionals and their appropriate relationship with other interventions
- Collate information from the literature that would help the development of the workforce providing substance use services both in specialist services and in other social services such as mental health, criminal justice, children and families and community care
- Collate information in relation to 'what works' (including an assessment of the outcomes achieved) in non-Scottish contexts in order to inform innovative practice and debate about the transferability of such approaches to Scotland.
6.2. Given the links between the first and fourth objectives, these are discussed together followed by a discussion of objectives two and three. The discussion then offers some suggestions for future practice development, particularly in the context of the substance use recovery approach in Scotland.
Efficacy of social work and social care interventions
6.3. This was a challenging area to review primarily because the social work/social care contribution to substance use treatment was not always identified. There was also a dearth of evidence from the UK with the majority of the evidence and other literature stemming from North America. This, in turn, raises questions about its transferability to UK service contexts, and Scotland in particular.
6.4. In some respects the absences were as noteworthy as the evidence. There were few studies from the United Kingdom and none from Scotland. This suggests a systematic lack of research on the social work contribution to substance use services in these settings. A major practical issue that arises from this is the difficulty in interpreting findings carried out in other countries for understanding what "works" - or might work - in a Scottish context.
6.5. The second major absence was studies relating to older people, people with disabilities (physical or intellectual), children in care or those experiencing domestic violence. Given the importance of, and vulnerability to, substance use in all of these areas the lack of research is quite extraordinary. Even in the area of child and family social work only one UK study was identified that evaluated an intervention. This speaks to a systematic under-funding of social work and social care research (Marsh and Fisher 2005).
6.6. Nonetheless, despite this there was clear and consistent evidence that social work and social care can make an important and positive contribution to increasing the effectiveness of substance use treatment services. It was particularly striking that social work services were often successfully used with people with substance use problems and what are often considered to be challenging additional circumstances, such as those with a mental illness, those who are homeless or those using alcohol and/or other drugs during pregnancy.
6.7. The literature in this respect relates predominantly to versions of "case management". There were, in addition, many promising or interesting interventions that had been evaluated, often on a one-off basis. The effectiveness of case management has been the subject of extensive debate in the academic and practice community. In large part this is because of wide variations in what is meant by "case management" and related variations in findings about the effectiveness of the approach. A more appropriate approach than attempting to identify whether case management "works" at a general level is to begin to explore what types of case management work, for whom and in what contexts.
6.8. Summarising the literature reviewed in chapter 3 there were some overall themes emerging regarding effective case management approaches. In general:
- The form of case management offered needs to match the needs of the service users being worked with. In broad terms, the more complex and longstanding the needs of the service user group the more intensive and long-term the form of case management will need to be.
- The more serious the problems in the service user group, the more likely that case management will be beneficial. Thus, for homeless individuals, service users with co-existing substance use and psychiatric problems and pregnant drug users, versions of case management appeared particularly beneficial. For those with less complex problems, such as individuals leaving substance use treatment without additional issues, case management did not always affect outcomes. This highlights the complexity of providing services in relation to substance use and misuse because patterns of use, service users' needs and the best services for them vary.
- Approaches that focussed on developing and sustaining a relationship appeared more likely to be linked to positive outcomes than forms of case management which focussed on effective service coordination. This is important in understanding the ambiguous evidence on the effectiveness of case management, because the intervention being evaluated is often primarily an administrative coordination of services. On its own this appears to have little benefit. The studies that reported the best outcomes for service users had a form of case management that was strongly focussed on the development of an effective helping relationship. Services were then coordinated based on this relationship, which allowed the building of a trusting relationship, helped in the engagement of the service user with services, meant that workers had a better understanding of the needs of the service user and that allowed a more equal exploration of options.
6.9. In addition to a focus on relationship-based case management, common features of successful case management approaches included:
- A tendency to have a limited number of service users per worker
- An emphasis on creatively engaging people, for instance through out-of-hours work, interventions based in service users' homes or other places (such as soup kitchens) that they might attend
- Access to additional services rather than simply coordinating existing services
- Availability when needed, for instance through 24-hour on-call services or long-term consistent availability
- All emphasised skilful communication and engagement, and a large number based this on motivational interviewing or variations thereof.
Information in relation to 'what works' (including best practice examples)
6.10. In addition to some form of case management approach, a variety of specific social work interventions or services had promising results. Once again social work services dealt with people with the most pronounced and complex problems, and there were some examples of noteworthy successes being achieved with these groups. This section provides more information in relation to four studies from the results section. Studies were chosen where the interventions or services seemed to be:
- Of potential relevance to the Scottish practice context
- Consistent with a recovery approach
- Demonstrating potential effectiveness.
6.11. Bouis et al. (2007) and Whetten et al. (2006) report on a comprehensive drug and alcohol treatment package for individuals with a "triple diagnosis" of HIV, mental health issues and substance use problems (primarily related to illegal drugs). It is a noteworthy study because it focussed on a group for which few interventions have been proven to have a positive impact. It also took an approach that was consistent with the principles of social work, in working with the individual and their broader social situation. The service combined attention to building a relationship based on motivational interviewing principles and then working with the individual and their broader social context (including other services they received, housing and other issues). The study provides a good example of a successful application of a complex psycho-social intervention with a group often found not to use mainstream services.
6.12. A second study of interest looked at peer case management for service users with substance use problems and mental ill-health issues. Sells et al. (2006) reported on an innovative form of case management in which peers with histories of severe mental illness worked with service users. This approach appears particularly consistent with a recovery emphasis, with its focus on the importance of service user control around services. It appeared particularly helpful in engaging and creating a good working relationship. Key elements in making the intervention work included a limited case load and good supervision for peer case managers.
6.13. To date, the evidence on effective interventions for children affected by parental problem drug use and their families is limited. Two case studies from the literature appeared particularly interesting in this respect. First, Ryan et al. (2006, 2008) found that an extremely intensive approach which included intensive outreach and engagement and access to a range of services helped pregnant women during and after pregnancy. The intervention produced not only positive outcomes for the women but reduced the number of subsequent children born withdrawing from drugs. Given the significant social risks for such children, and the risk of them entering care, this is an approach that might be worth considering within a Scottish context.
6.14. Another service working with families affected by parental problem use of drugs or alcohol was evaluated by Forrester et al. (2008a). The study reported promising findings for an intensive service based in Wales aimed at families known to social services where there were serious concerns relating to parental alcohol or drug use. Of particular interest was the fact that the intervention appeared to reduce the time children spent in care and thus produced cost savings. Unlike other interventions - such as Family Drug and Alcohol Courts - this approach appears transferable to a Scottish context. The Option 2 service is providing the basis for broader system change across social care services in Wales which is currently underway.
6.15. While the studies identified cover a wide variety of presenting issues and describe a diverse range of interventions, there are some common themes. First, while the conventional literature on substance use problems has often dealt with the issue in isolation, in fact drug and/or alcohol problems are very likely to co-exist with a range of other circumstances, including domestic violence, mental health issues, poverty, child maltreatment and homelessness. Social work services are far more likely to be aimed at this complexity. Thus, while substance use treatment studies often exclude substantial numbers of individuals with additional or complex problems, social work interventions tend to be focussed on this very complexity. This highlights the importance of social work and social care for a recovery approach.
6.16. Second, people with complex problems require practitioners who have high levels of skill in engaging and working with them. Exceptional communication skills and positive attitudes to working with people who use alcohol and/or other drugs are crucial common features which allow practitioners to engage individuals who have often experienced stigma and multiple disadvantage over many years. These foundational relationship-based skills need to be complemented by an ability to keep working with people through patterns of behaviour change that may involve lapse and relapse and a focus on creating broader social changes for the individuals concerned. In particular, a number of studies focus on the importance of access to health care and housing.
6.17. Third, successful interventions are characterised by a relatively high level of intensity of input and protected or restricted caseloads. For instance, the Ryan et al. study involves workers working with no more than two families and Option 2 workers work with just one family at a time. Similarly in relation to case management, successful interventions with those with complex needs require a limited caseload and a supportive working environment.
Information that would help the development of the workforce
6.18. Given these key elements of effective social work provision for people with drug and/or alcohol problems, what are the lessons from the literature on the development of the social care workforce?
6.19. Most of the studies in this chapter explored training, from its impact on attitudes and knowledge to training needs, preparation for practice and curriculum design. The literature focuses exclusively on the social work population rather than the broader social care workforce suggesting a dearth of research looking at the latter group.
6.20. The current literature provides a clear message that social workers need to be trained in substance use and that social work education to date has failed to do this adequately and consistently. Of particular concern is the reported lack of knowledge of how to intervene to the extent that social workers know they are failing their service users (Hayden 2004, Galvani and Forrester 2008). Given the prevalence of substance use in social work caseloads, this situation should not be allowed to continue and social work education needs to improve quickly. The applicability of this finding to Scotland is difficult to establish. The focus of the Scottish Social Care Council's reviews of social work training is on meeting the standards set out in the Framework for Social Work Education in Scotland (Scottish Executive 2003) (personal communication, Smith 2010). As substance use is not mentioned in the Framework there is no review or monitoring of it. For social work educators looking to improve their education on this subject, attempts to develop materials targeting social work educators have recently been published by the Higher Education Academy for Social Policy and Social Work ( SWAP).
6.21. The reported success of training contexts that allow for networking and interdisciplinary understanding is worthy of note. While the evidence here suggests equivocal results for training in relation to knowledge and competence, particularly in the longer term, generally there was overall improvement in attitudes. The importance of attitudinal change should not be underestimated as it is likely to be the first step towards people engaging fully with the subject and on which further training and practice can then build.
6.22. The historical lack of attention to substance use in social work education apparent in the evidence appears to have resulted in educators who are not able to adequately offer training and supervision in substance use issues with one study suggesting training educators may be a helpful way of increasing input on social work programmes. For educators, individual social work staff and the policy frameworks that support both groups, engagement with the issue of substance use appears to be the crucial component. Engagement also appears to be a vital factor in the evidence-based interventions (as a key part of the outreach and case management tasks), as well as for social workers looking to develop their skills for practice, and for social work academics incorporating relevant training onto the curricula. Finally, the need for engagement with substance use as a legitimate role for social work practice or as a legitimate topic for social work education came through in a number of studies. The literature suggests that those who elected to undertake training or felt it was part of their role, benefitted most from it. This in turn suggests that there may be work to be done prior to delivering or receiving training which seeks to ensure both practitioners and social work academics understand, accept and are committed to training and working in this area, otherwise there may only be modest improvements in practice. At least as important is a practice context that is supportive of their work in this area, not one which is so "situationally constrained" (Lightfoot and Orford 1986) as to prohibit or restrict improved practice in this area.
6.23. A further key point is that, in delivering evidence-based interventions, training tends to be a means to engage and interest practitioners, but that lasting improvements in the skills of practitioners require direct supervision of practice. A training course can provide insight and motivation, but skill is improved through processes of doing and then receiving feedback - usually from those who have high levels of skill. This highlights the importance of systems that support excellent practice, rather than one-off training sessions. In the same way that the recovery approach points to a more long-term and ambitious focus on sustaining change for people with substance use problems, improving social work practice with substance use requires sustained focus on improved practice including monitoring and review.
6.24. The studies that were more focussed on the development of practice skills or exploring current practice highlighted the need for improved communication as a means of overcoming some of the barriers in effective engagement with people with substance use problems. Good communication by social workers cannot be assumed and while there may need to be more general improvement and emphasis in skill development, it may be that in the interim senior, or more experienced social workers, are identified to work with service users with problem alcohol and/or drug use, particularly where there are more complex and overlapping needs.
The distinct functions, roles, support and interventions provided by social work and social care professionals
6.25. There were no groups of studies evaluating distinct social work roles that clearly pointed to social workers having a particular role or function with people with substance use problems. This could be for a number of reasons:
- no distinct roles or functions have been identified for social workers working with substance use perhaps due to the primarily health and criminal justice led nature of responses to people with problem drug and/or alcohol use
- such roles or functions do exist but this is not reflected in the current literature
- the historical lack of engagement with substance use by the social work profession suggests that it is early days in terms of locating a specific role in the broader health dominated context of substance use service delivery.
6.26. However, the literature in this section emphasised the suitability of the social work profession's approach for supporting people with alcohol and drug problems due to its underpinning theories and principles. Social work is arguably a unique profession in its attention to the individual within both their immediate home environment and the wider socio-political context in which they live. This holistic approach to working with people underpins good practice in assessment and intervention processes. Further, its commitment to social justice and empowering processes make it a profession most suited to a care management approach. However the literature also identified some of the barriers to social work and social workers engaging with substance use issues at both organisational and individual levels.
6.27. Once again the need to educate and train social workers in order for them to see it as a legitimate part of their role and support them in helping service users effectively was a key theme emerging from the literature. This is not a new finding but its repetition in the literature is perhaps indicative of the many failed attempts in the previous 30 years to convince the social work profession and educators to embed substance use into the social work curriculum at qualifying and post qualifying levels (see Galvani 2007 for review). This, in turn, suggests that guidance and calls for change, unsupported by policies, effect little change. It also points to the fact that it is not just individual staff that need training but that there needs to be organisational commitment to supporting staff to work with substance use, particularly in light of the literature highlighting the challenges and potential personal and professional tensions that may emerge when working with people with substance use problems.
6.28. Among the roles identified in the literature but less commonly practised were those of educator and teacher in relation to substance use. This ranged from teaching people new skills to educating family members about substance use. These roles are the types of roles social workers are arguably already filling in other specialist areas of practice. However crucially in their application to working with people with substance problems this relies on social workers having a good knowledge of substance use, the types of intervention available and an understanding of what additional support will be required.
6.29. Importantly the literature reinforced the findings of the interventions search in terms of highlighting the need for a greater involvement for social work in supporting people with substance use problems, primarily in a case management or care coordination role, working with people throughout the various stages of behaviour change. This means adopting a role that begins with engagement and assessment and proceeds through to aftercare and coordination of other support services.
6.30. Community-based care management for people with alcohol and drug problems is already in operation in many authorities in Scotland (personal communication, Robertson 2010). While there is no known evidence on its effectiveness, the similarity of a number of its tasks and roles to key elements of case management is positive. Reviewing the extent to which the care management role in Scotland encompasses the roles and tasks identified here as being important is a possible way forward. So too is identifying the extent to which those in front line or supervisory positions have the training and skills to carry them out effectively.
Social work, the recovery approach and future directions for Scotland
6.31. Social work practice has a comfortable fit with the recovery agenda for substance use services in Scotland. The recovery approach presents a challenge for many substance use services to re-think their service delivery which has been dominated by individually focussed and professionally-led interventions for so long (Best et al. 2010). The emphasis in Scotland on recovery approaches offers a timely opportunity for the involvement of social work. Social work's prioritising of service user involvement, partnership work and a shift of power from professional as expert to service user as expert, make it well placed to support the principles and practice of the recovery approach. In its underlying principles of empowerment and advocacy, as well as its quest to be service user-centred and strengths focussed, social work has an easy fit with these new approaches within the substance use arena.
6.32. What is also needed to support change in, or development of, social care work with people who use alcohol and/or other drugs is a strong policy context. In many ways Scotland is ahead of the game. A number of key Scottish policy documents have recognised the importance of addressing the social implications of problem alcohol and/or drug use, alongside health concerns, and to ensure support goes beyond individualistic specialist treatment and reaches into families and communities (Audit Scotland 2009, Scottish Government 2008a, 2009). At the same time there is also political recognition within Scotland that "generic services" 2 play an equally important role in supporting people with alcohol and/or other drug problems (Scottish Government 2008a) which needs to be capitalised upon. The Social Work Inspection Agency's ( SWIA) (2010) recent report, Improving Social Work in Scotland, takes this further highlighting both the importance of addressing substance use in all social work services and also the likelihood of an increased need for an effective social work response in adult services in the future.
6.33. Social workers from a range of practice areas are frequently, if not daily, in contact with people with alcohol and/or other drug problems. They are supporting people who have highly complex needs and overlapping problems and circumstances. Further they are likely to be the main professionals working with such complexity as such overlapping problems are not usually addressed in specialist substance use services, particularly those that sit within health structures ( SWIA 2010). In Changing Lives: Report of the 21 st Century Social Work Review (Scottish Executive 2006) the then Scottish Executive set out the potential for developing new roles or growing existing ones. The findings of this review suggest both are needed in relation to social work interventions with people with substance use problems. It has once again highlighted the need to support all social workers, regardless of specialism, through education and training to ensure they engage with, then work with, the substance use problems of their service users. The framework and planning are already in place and, combined with leadership by the Association of Directors of Social Work ( ADSW) and its Standing Committee on Substance Misuse, Scotland has a head start. In the next chapter recommendations on how this progress might be maintained are set out.