by Eva Burrill, MSW, RSW
Introduction
Substance use spans the full spectrum of social work practice. Despite its universality, research has indicated that there are no Canadian practice guidelines or standards for working with people who use alcohol and/or drugs (PWUAD), and there is also concerning inconsistency in social work education curriculum in this regard (Smith,2022; Kelsall, 2019). In a preliminary effort to address this issue in our local context, this article proposes key practice guidelines for social work practice with PWUAD in Nova Scotia, toward the ultimate objective of developing a standard of care for social work practice with PWUAD.
Background
Social work practice with people who use alcohol and drugs has historically been steeped in individualistic approaches to behavioural and cultural change, harmfully ignoring the complex systems within which PWUAD are often situated (Kelsall, 2019). For instance, social work practice with PWUAD has traditionally focused on individualized approaches to abstinence and rehabilitation; substance use, and suspicion of substance use, have been used as a rationale for the removal of children from their families (particularly when it comes to Indigenous women) (Kelsall, 2019). The profession of social work in Canada continues to be vulnerable to oppressive practice with PWUAD due to the lack of standardized education and practice guidancein this area. Research indicates that not only do social workers demonstrate stigma-based attitudes toward PWUAD, many also believe that substance use is best addressed by other professionals (Brocato & Wagner, 2003) and therefore develop a “professional passivity” toward PWUAD (Tober, 1993, in Brocato & Wagner, 2003).
Harm reduction social work practice recognizes the historically harmful relationship between PWUAD and the social work profession and consciously moves toward repair, through practice that is evidence-informed and aligned with our principles and values.
What is it?
Harm reduction social work practice is a holistic alternative to individualistic, medical, and moral models of understanding addiction. It is an approach that understands addiction as a complex health issue with a high degree of psychosocial strain (Roberts et al., 2023), typically situated within complex interrelated systems. Harm reduction social work recognizes that most drug-related harms are caused by systems and structures that criminalize, marginalize, and oppress PWUAD, and are not solely a result of substances themselves. Recognizing the interconnected and systemic nature of harm, interventions are most successful when they address all levels of harm and follow the practice guidelines detailed below, rather than focusing solely on the substance.
Practice guidelines
- Ethics & values – Social work practice with PWUAD is rooted in a strong understanding of our historically oppressive relationship with PWUAD across all areas of practice and understands that intervention at all levels must work toward repair. Harm reduction and social work practice are aligned with respect to shared ethics and values, particularly the principles of self-determination, social justice, and respect for the inherence dignity and worth of all human beings (Bigler, 2005). Social work practice with PWUAD must be client-driven and collaborative.
- Knowledge – Social workers engaged in partnership with PWUAD must be familiar with the harm reduction options available to their clients (such as sterile equipment, overdose prevention kits, and Housing First programs), as well as the laws and policies applicable to the interventions and resources. Social workers must use evidence-informed approaches when working with PWUAD.
- Assessment – Social work recognizes that substance use impacts the biological, psychological, social, and spiritual; a thorough assessment and intervention plan must therefore take a biopsychosocial, person-in-environment approach (CSWE, 2015 & NASW, 2013). The objective of social work assessment and intervention with PWUAD is to understand the intersection of substance use and health, “prioritizing analyses of how context may facilitate or hinder patients’ ability to engage” (Kitchen & Brook, 2005 and Zerden et al., 2019, in Roberts et al, 2024). Harm reduction social work practice takes a strengths-based and resilience-focused approach to assessment and intervention (Rudzinski et al., 2017, in Marzell et al., 2024), recognizing that people use substances for a reason, and substance use can be adaptive. It understands that change to substance use is not always “possible or desirable” (Richert et al, 2023), and that analyses of readiness for change must be situated within the client’s unique context. Motivational work must never be coercive or mandatory and must be based on the client’s identified goals (Richert et al., 2023).
- Trauma-informed & anti-oppressive – People who have experienced adverse childhood events (ACEs) are disproportionately represented among PWUAD (Roberts et al, 2023), particularly among those with marginalized identities (Cummings et al., 2014 & McCarron et al., 2018, in Roberts et al., 2023). For instance, as a result of intergenerational trauma, continued colonialism, andoppression, indigenous peoples have an “increased vulnerability to drug-related harms” (Raynak et al., 2024). The integration of trauma-informed and anti-oppressive approaches to assessment and intervention are therefore core components of practice with PWUAD (CSWE, 2020), and central to reconciliation work (Raynak et al., 2024). As structural practitioners, social workers address the impact of trauma and oppression at all levels. For instance, they support clients to address the psychological impacts of oppression, while also challenging structural stigma, and advocating for the rights of PWUAD at a systems and societal level.
- Therapeutic alliance – Recognizing the integral nature of the therapeutic alliance to sustainably and effectively engaging PWUAD, social workers must prioritize factors that enhance the therapeutic alliance (Vakharia et al., 2017), such as: establishing low thresholds for service (Vakharia et al. 2017, Richert et al., 2023), taking a strengths and resiliency-based stance toward substance use, and taking a collaborative approach to assessment, goal planning, and intervention. Social workers understand that positioning the voices and expertise of PWUAD at the forefront of all intervention is an integral component of building strong and meaningful therapeutic alliance.
- Systems navigation – PWUAD often experience complex and interrelated forms of marginalization as a result of criminalization and stigma (Roberts, 2023). As structural practitioners, social workers must support PWUAD in navigating these complex and interrelated systemic structures.
- Advocacy & leadership – Social workers are uniquely situated to analyse and address the impact of bias and stigma on PWUAD. Social workers must continuously assess the impact of their own conditioning (personal and professional) on their perspectives of and approaches to working with PWUAD. They must ensure they use person-centred and non-stigmatizing language (CSWE, 2020). Social workers take on a position of leadership within their teams and organizations, drawing attention to the presence of bias and stigma in care, educating providers, and collaborating on the development of person-centred care plans. In keeping with the principles of harm reduction (National Harm Reduction Coalition, 2024), social workers must advocate for people with lived and living experience to have a meaningful voice in the development of programs and policies that impact them.
- Resources – Social work intervention must address the social determinants of health and, wherever possible, support clients to gain control over resources that help to reduce harms and enhance autonomy (Anbar et al., 2003). Social workers must also incorporate the knowledge and expertise of PWUAD at the micro, mezzo and macro levels of intervention.
- Documentation – Social workers must ensure that their clinical documentation reflects the complex biopsychosocial and structural realities of the client so as not to contribute to harmful stigma-based understandings of PWUAD. Social workers must also carefully attend to their position of power in clinical documentation, ensuring that they maintain the partnership perspective that is inherent to harm reduction practice.
- Supervision – Given the current politicization and criminalization of substance use, the complexity and multi-level nature of intervention, as well as the high degree of psychosocial strain experienced by PWUAD, social workers collaborating with PWUAD should regularly participate in clinical supervision. Supervision is a key resiliency factor in protecting social workers from moral strain. It also ensures a high level of clinical and ethical reasoning in an area of practice that has historically been misaligned with our professional values and ethics.
Closing
Social work’s historical relationship with PWUAD is deeply incongruent with our professional standards and values and has caused harm to PWUAD, particularly those in communities with whom we have already developed oppressive relationships. Not only is embracing a harm reduction approach to working with PWUAD fundamental to living our professional standards and promoting safe(r) social work practice, it is also an integral component of our responsibility toward reconciliation and repair. As structural practitioners, we are uniquely situated to offer a holistic, multi-systems approach that addresses the complex and interrelated systemic harms experienced by PWUAD. The adoption of a harm reduction standard of care serves as an integral step toward repair.
EVA BURRILL, RSW (Kjipuktuk) works as a Professional Practice Coordinator for Social Work with Nova Scotia Health in Central Zone. She currently serves as the Central Representative for NSCSW Council and is Chair of the NSCSW Professional Standards Committee. Eva has worked in the health system throughout her career, with a particular interest in harm reduction practice and advocating for the rights of PWUAD.
References
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