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

1. 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.
2. 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.
3. 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). 
4. 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. 
5. 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. 
6. 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.
7. 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.
8. 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. 
9. 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.
10. 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

Anbar, M., Buckland, D., Hope, S., Layland, L. & Peckham, M. (2003). Harm Reduction Policy for Social Work Practice: Policy Considerations for the Ontario College of Social Workers and Social Service Workers.

Bigler, M. (2005). Harm Reduction as a Practice and Prevention Model for Social Work. The Journal of Baccalaureate Social Work. Vol. 10, No. 2.

Brocato, J. & Wagner, E. (2003). Harm Reduction: A Social Work Practice Model and Social Justice Agenda. In Health & Social Work, Volume 28, Number 2. National Association of Social Work.

Council on Social Work Education (2015). CWSE Specialized Practice Curricular Guide for Substance Use Social Work Practice. Alexandria, Virginia. 

Kelsall, T. (2019). The Emergence of Harm Reduction in Canadian Social Work: Scoping Themes for Practice. [Master’s Thesis]. School of Social Work: McGill University. 

National Association of Social Workers (2013). Standards for Social Work Practice with Clients with Substance Use Disorders. 

Principles of Harm Reduction (2024). National Harm Reduction Coalition. Retrieved March 16, 2025, from Harm Reduction Principles | National Harm Reduction Coalition

Marzell, M., Acquavita, S., & Pirich, C. (2024). Harmonizing harm reduction: uniting varied perspectives for enhanced social work practice. Journal of Social Work Practice in the Addictions, 24:3, 333-338, DOI: 10.1080/1533256X.2024.2334217

Raynak, A., Wood, B., Mushquash, C., McLaughlin, B. (2024). Intravenous Drug Use in the Hospital Setting: Advancing Reconciliation for Indigenous Canadians Using In-Hospital Harm Reduction and Culturally Safe Care. Journal of Addictions. Oct-Dec 01;35(4):237-242. doi: 10.1097/JAN.0000000000000600. PMID: 39621502.

Richert, T., Stallwitz, A. & Nordgren, J. (2023). Harm reduction social work with people who use drugs: a qualitative interview study with social workers in harm reduction services in Sweden. Harm Reduction Journal, 20(146). https://doi.org/10.1186/s12954-023-00884-w

Roberts, K., Smith, E., Sousa, C., Young, J. E., Corley, A. G., Szczotka, D., … Hartoch, A. (2023). Centering persons who use drugs: addressing social determinants of health among patients hospitalized with substance use disorders. Social Work in Health Care, 63(1), 19–34. https://doi.org/10.1080/00981389.2023.2278777

Smith, C (2022). Notes on the conspicuous underrepresentation of harm reduction & substance use education in Canadian social work curricula. NSCSW Connections Magazine.

Vakharia, S.P., Little, J. (2017). Starting Where the Client Is: Harm Reduction Guidelines for Clinical Social Work Practice. Clinical Social Work Journal 45, 65–76. https://doi.org/10.1007/s10615-016-0584-3. 

Read more of Connection

• Developing a standard of care for social work practice with people who use alcohol and drugs
• Book review: Active Hope
• NSCSW Awards: A spotlight on our community
• Spotlight: 2024 Student Bursary Recipients
• Rethinking burnout through the lens of political critique

By Dominic Boyd, MSW, RSW

My on-line meditation group meets weekly, and we have been discussing global heating and related issues from a Buddhist perspective. Our first book was Thich Nach Hahn’s Zen and the Art of Saving the Planet. In 2024, we began  reading through and discussing Active Hope: How to Face the Mess We’re in without Going Crazy, by Joanna Macy and Chris Johnstone. Reading Active Hope offers strategies for engaging and for endurance, as does Green Social Work, by Lena Dominelli, and I highly recommend these books. I’ve felt inspired by these works, and our ongoing discussions, and hope other social workers will as well.

Active Hope focuses on the existential issue of our time: global warming, and calls on all of us to contribute whatever we can to solve this crisis. The process of active hope is differentiated from passive hope, wherein one might simply hope that things will get better, but not bother doing anything, out of the belief that there’s little to nothing that one can do. Macy and Johnstone take issue with such passivity and challenge the reader to engage by setting realistic goals and following through.

Part One outlines three possible perspectives of global heating: business as usual, where we passively continue on with our destructive ways; the great unraveling, which turns attention to the gradual collapse of ecosystems; and the great turning, where humans create a new world order that respects the planet and all life. The authors then describe how this great turning can be realized through a four-stage spiral process of reconnection.

1. Coming from gratitude: choosing to be grateful for our world, and acknowledging that we are part of nature, not above it.
2. Honouring our pain for the world: a steadfast commitment to see what is happening, why it is happening, and allowing ourselves to feel the pain and grief that results from the great unraveling.
3. Seeing with new eyes: seeing the interconnectedness of all life, seeing the need to build societies and economies that honor all life and create equality.
4. Going forth: actually engaging in the process of rebuilding with others who share this vision.

Part Two explores how we need to see ourselves, not as nuclear individuals, but as part of the human family and of our entire world. It exposes the myths of individualism that underpin our capitalist society and economy. It invites us to collaborate rather than dominate, and to co-create societies where we know our neighbours, value our connections and celebrate them, and feel supported and empowered in mutual ways. It challenges us to take the long view, to understand ourselves to be produced and sustained by living systems that our planet has developed over billions of years, and to see the danger of destroying that legacy within a few decades. We need to think in terms of what kind of world our descendants need, and what we can do to make sure it happens.

Part Three is about creating a vision and acting. The authors list how we can create inspiring visions, dare to believe that things are possible, build support, maintain energy and enthusiasm, and feel strengthened when facing uncertainty. I wish to focus on the first and last, in particular.

Creating a vision can be done using seven steps:

1. If you knew you could not fail, what would you most want to do for the healing of our world?
2. Specify a goal or project could you realistically aim for in the next twelve months?
3. What resources do you have within and around you that will help?
4. What resources, inner and outer, will you need to acquire? What might you need to learn/develop/obtain?
5. How might you stop yourself? What obstacles might you throw in your way?
6. How will you overcome these obstacles?
7. What step can you take in the next week, no matter how small, toward your goal?

Feeling strengthened is about acknowledging uncertainty when it occurs, embracing challenges, willingness to learn and grow, finding ways to connect with others and share power, and letting go of ego.

Reading this book has inspired me and provided me with tools I find useful. I have discovered that many of us are concerned but perhaps need a spark to get more engaged. Two elder members of my meditation group participate in discussion with their grandchildren, thus encouraging them. I have felt myself becoming more confident about raising these issues and have been working on bringing all 35 Community Health Boards in Nova Scotia to work together on them, and I spoke about them at a meeting of the NS Action Coalition for Community Wellbeing. Finally, I have been talking with other social workers about these issues and with Tyler Colbourne at the NSCSW, which led to the development of some learning opportunities to help social workers build commitment and action.

The new CASW Code of Ethics includes engagement with climate justice issues such as global heating. We social workers sometimes focus too narrowly on our work areas, but we have many skills we can utilize in addressing these challenges.

There are lots of people who are concerned about global heating, and all they might need is an idea, a suggestion, or a small task to help get involved. If you are one of them, I hope you will join the NSCSW’s workshops on this topic, view the recorded excerpts (and perhaps use them as a springboard for conversation with peers), or pick up one of these books yourself.

DOMINIC BOYD, RSW, has been in social work since 1986, with a background in community practice and social change/social justice.