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Syftet med den vetenskapliga genomlysningen var att undersöka hur, varför och under vilka förutsättningar HVB-hemmet Avstampet i Norr uppnår sina behandlingsresultat. Studien fokuserade på den primärbehandling mot missbruk enligt tolvstegsprogrammet och Recovery Dynamics som bedrivs vid Avstampet. Behandlingen är drog- och medicinfri. 

Studiens design byggde på en programteoriansats med inslag av en måluppfyllelsemodell. Programteoriansatsen användes för att ta fram en lokal och verksamhetsspecifik teori som beskriver, och i viss mån förklarar, hur och varför Avstampet uppnår sina behandlingsresultat. Med hjälp av en måluppfyllelseanalys granskades verksamhetens avsedda och uppnådda mål. Studiens teoretiska referensram bestod av KAIMeR-teorin och den kontextuella modellen vid terapeutisk behandling. Studiens data bygger på tre fokusgruppsintervjuer med personalen som genomfördes under perioden september 2019 till februari 2020.

Det övergripande resultat Avstampet eftersträvar är en långvarig stabil förändring och drogfrihet i klientens liv. Klienterna ska klara av motgångar och utmaningar utan att falla tillbaka i missbruk. I resultatbeskrivning kan man identifiera både kort- och långsiktiga resultat som kan ha en yt-, processuell- eller djupaspekt.  

Recovery Dynamics och manualbaserade insatser utgör centrala delar i behandlingen men kompletteras av informella och situationsanpassade insatser samt gruppinsatser. De informella insatserna baserar sig på medlevarskap och är oftast icke-uttalade. Fyra olika typer av informella insatser kunde identifieras: bemötande och omtanke, fysisk beröring, upplevelser och att agera pedagogiskt opedagogisk. Situationsanpassade insatser skräddarsys på basis av klienternas behov och de kan vara informella eller formella. Gruppinsatser grundar sig i den manualbaserade behandlingen där användningen av gruppsessioner är ett uttalat inslag.

I behandlingen ingår utomterapeutiska faktorer, dvs. behandlingselement som sker utanför Avstampets väggar. Klienterna deltar i AA/NA-möten som ordnas i närområdet. Personalen hjälper klienten med saker som hör till klienternas privatliv. Man uppmuntrar också både klienten och handläggaren att ha kontakt under tiden klienten är på behandlingshemmet. Dessutom är utomterapeutiska faktorer ”inbyggda” i tolvstegsbehandlingen, i och med att de sista stegen (efter primärbehandlingen) innebär att gå ut i samhället och stötta andra individer i aktivt missbruk.

Personalen har en klar uppfattning om vilka antaganden som styr behandlingen och som formar deras förhållningssätt till klienterna. Man utgår från att beroende är en sjukdom med fysiska, mentala och känslomässiga inslag och att behandlingen ska vara fri från mediciner och droger. Personalens handlingar utgår från ett relationellt förhållningssätt och medlevarskap och varje klient har en egen kontaktperson. Ett centralt antagande är att klienten ska lära sig nya verktyg under behandlingen, vilket personalen undervisar om, och att klienten förväntas ta ansvar för sin förändringsprocess, men med vägledning från Avstampet. Klienterna förväntas också stötta varandra under processen och delta i matchningsprocessen av nya klienter.  I studien identifierades fyra främjande kontextuella faktorer: 1) att det på Avstampet finns strikta regler och en tydlig vardagsstruktur som stödjer klienternas förändringsprocess; 2) verksamhetens småskalighet, dvs. att det endast finns 10 platser; 3) personalens starka sammanhållning, laganda och gemensamma synsätt på beroendevård och relationens betydelse för en lyckad behandling; 4) att personalen har god kännedom om, och förståelse för, den kontext klienterna kommer ifrån och att klientens livsvärld utanför behandlingshemmet beaktas vid behov under behandlingen. I studien identifierades inga kontextuella faktorer som direkt motverkar behandlingsresultaten. 

Aim: This study used 17 year of Swedish registry data (2003–2019) for 25,125 adults assessed for their severity of substance use to identify the baseline factors predicting the risk of being court-ordered into compulsory care and examine the association between admission to compulsory care and mortality risks due to alcohol- or drug-related causes.

Methods and materials: Addiction Severity Index (ASI) assessment data were linked to register data on demographic characteristics, compulsory care, and alcohol- and drug-related mortality. Cox regression models were used to identify baseline factors predictive of post-assessment admission to compulsory care in the 5 years post-substance use assessment. Discrete-time random-effect logistic regression models were used to examine the association between compulsory care duration and alcohol or drug-related mortality risks. Propensity score matching was used for validation.

Results: The first models identified that younger age, female gender, and ASI composite scores for drug use, mental health and employment were significantly associated with the risk of placement in compulsory care for drugs other than alcohol. Female gender and ASI composite scores for alcohol, drug use and employment were significantly associated with compulsory care treatment for alcohol use. The second models showed that older individuals and men were more likely to die due to alcohol-related causes, while younger individuals and men were more likely to die due to drug-related causes. Length of stay in compulsory care institutions significantly increased the likelihood of dying due to substance use-related causes. Propensity scores analyses confirmed the results.

Conclusion: In Sweden, a significant concern is the higher likelihood of women and young individuals to be court-ordered to compulsory care. Although compulsory care is often advocated as a life-saving intervention, our findings do not provide strong support for this claim. On the contrary, our findings show that admission to compulsory care is associated with a higher risk of substance use-related mortality. Factors such as compulsory care often not including any medical or psychological therapy, together with relapse and overdose after discharge, may be possible contributing factors to these findings.

Denna kvantitativa studie utvärderar kunskapsförändringar hos deltagare i EPI universitetskursen. Majoriteten av deltagarna var socialsekreterare inom miss-bruksområdet. Kursen resulterade i betydande förbättringar av deltagarnas kunskap, särskilt vad gäller insats- och vårdkontinuitetsmodeller samt använd-ning av motivationshöjande intervjutekniker. Kunskapen om äldre personer med beroendeproblem och fördelarna med ASI-uppföljningar för socialarbe-tare och klienter förbättrades också.

This quantitative study assesses knowledge improvement among partici-pants of the EPI university course. The majority were social workers in sub-stance abuse. The course led to significant enhancements in participants’ knowledge, particularly concerning intervention and care continuity and the use of motivational interview techniques. Knowledge about older individuals with substance dependencies and benefits of ASI follow-up interviews for social workers and clients also improved.

I det systematiserade arbetet med att följa upp hjälpbehov för personer med alkohol- eller narkotikaproblem har Addiction Severity Index uppföljnings-intervju (ASI U) en central funktion. I den här deskriptiva tvärsnittsstudien undersöker vi närmare hur demografiska, yrkesrelaterade och organisato-riska faktorer är relaterade till yrkesverksamma socionomers benägenhet att arbeta med ASI uppföljning. Studien omfattar 135 yrkesverksamma socionomer som arbetar med att utreda och följa upp hjälpbehov för personer med skadligt bruk eller beroende av alkohol eller narkotika. Bristande kompetens framträder som förenat med en lägre sannolikhet att arbeta med ASU upp-följning. För att öka medarbetares benägenhet att arbeta med ASU U bör chefer och andra personer i arbetsledande position ge medarbetare reella förutsättningar till fortbildning och vidareutbildning.

The theme of the symposium is how critical realism has been applied in social work research since the early 2000s. This symposium is strongly linked to the subtheme of Theory and practice in social work and more specific to theory development in social work. 

The aim of the symposium is to describe and discuss research where critical realism (CR) has been applied as a theoretical framework, and to inspire others to utilize CR in social work research. The first presentation is based on a systematic literature review of critical realism in social work research conducted between 2001 and 2022. The following two presentations concentrates on the CAIMeR-theory (Blom & Morén 2010; 2019), which is a general theory developed at Umeå University, based on CR, used for explaining client outcomes. The second presentation focuses on a revised version of the CAIMeR-theory. The third presentation demonstrates how the CAIMeR-theory underpinned and guided a small evaluation project. 

The presentations in the symposium will address central concepts of CR in different ways, and will altogether, serve as an introduction to critical realism and its use in social work research in different contexts.    

Critical realism, realist evaluation and social work research: A systematic review

Authors: Anu-Riina Svenlin & Didier Boost

Background: Critical Realism (CR), as a philosophy of science, was conceived by Roy Bhaskar (1979) as an alternative to empiricism and postmodernism; approaches which at the time had been dominating and dividing the social sciences. In social work, CR has been gaining momentum since Stan Houston (2001), Björn Blom and Stefan Morén (2003) convincingly argued how the paradigm can contribute to social work practice, research, and theory. Given the paradigm’s tendency to prioritize ontology over epistemology, CR has been applied in social work research in various ways, including realist evaluation (Kazi, 2003), in combination with grounded theory (Oliver, 2011), and the development of CAIMeR-theory (Blom & Morén, 2010). To further advance the use of CR, we argue that there is a need to analyze how CR and realist evaluation have contributed to the social work research.  

Method: In our review, we question (1) what is the motivation for using CR? (2) how is CR applied? (3) what empirical and theoretical contributions has been made to the body-of-knowledge? (4) which methodological issues are raised? To answer these questions a systematic review was conducted. Peer-reviewed articles (PsychInfo; Web of Science) relying on CR or realist evaluation between 2001 and 2022 were included. 

Findings and conclusion: The dataset will be analyzed in the spring 2023 and preliminary findings will be presented at the symposium. The results provide answers to the above-mentioned questions but allow also reflections on the strengths, weaknesses, and further prospects of using CR in social work research. 

The CAIMeR theory 2.0 – lessons learned and future prospects for evaluation in social work practice

Authors: Björn Blom, Didier Boost and Anu-Riina Svenlin

Background: The CAIMeR theory, developed for improving evaluation of social work practice, began to be outlined at Umeå University in the early 2000s. CAIMeR is a middle-range theory that primarily aims to explain how client outcomes arise. The theory is descriptive, in the sense that it stipulates the basic components of social work practice – Contexts, Actors, Interventions, Mechanisms, and Results – and how they interact. Furthermore, it is explanatory since it identifies generative mechanisms, and contextual conditions which underpin how change is realized in social work practice.

CAIMeR has been published in various versions and stages of development. The real impact, however, occurred after an international publication in 2010. Since then, CAIMeR has been used in research, evaluation, education and social work practice both in Sweden and in other countries (e.g. Australia, Belgium, Finland and Denmark).

Method: Throughout the years, the originators themselves (Björn Blom & Stefan Morén) and several other researchers have identified both advantages and weaknesses with the theory, and they have experimented with applying it in different contexts and welfare regimes. This called for a further development of the theory. We will present a revised version of the CAIMeR theory, which we accomplished by compiling different research experiences and analyzing pros and cons of applying the theory.

Findings and conclusion: The revised version includes e.g. new generative mechanisms, and a clarification and addition of contextual conditions. The result is a more usable theory that can guide researchers and social workers to obtain explanatory knowledge when evaluating social work practice.

How CAIMeR theory was used in the evaluation of a treatment center that conducts twelve-step treatment for substance use disorders

Authors: Marcus Blom-Nilsson, Robert Grahn, Anu-Riina Svenlin & Björn Blom

Background: We have carried out a pilot evaluation of a treatment center conducting treatment for substance use disorders with men aged 18 and over. The treatment is based on manual based twelve-step treatment, Recovery Dynamics.

The evaluation used a program theory approach with the goal of developing a local and organization-specific theory describing and explaining how and why the treatment center achieves outcomes. We have taken into account Contexts, Actors, Interventions, Mechanisms and Results by using the CAIMeR theory.

Method: Two types of data were used: 1) Focus group interviews with staff: i.e. semi-structured group interviews about prerequisites, interventions/processes and results. 2) Feedback group discussions: our observations and analysis have been discussed in meetings at the treatment center.

Findings and conclusion

The study shows:

• that Contexts, Interventions and Results are more multifaceted, and interact in a more complex way, than what the organization itself perceives,
• that informal support interventions (e.g. going fishing) seem to be more common and sometimes more important than the formal treatment interventions (e.g. group therapy),
• that a basic assumption in the treatment – ​​"that addiction is a chronic mental illness" – is reinforced and confirmed via the mechanism of the self-fulfilling prophecy. This is because it is built into the twelve-step treatment that the clients should have a lifelong contact with the non-profit AA/NA self-help movement, and they must themselves act as support for other addicts after treatment has ended.

Our presentation demonstrates how CAIMeR theory underpinned and guided evaluation process, data collection, analysis and presentation of results.

Background: Civil commitment for individuals with severe substance use is fairly common and a part of many treatment systems worldwide. In Sweden, individuals with severe substance use and experience with civil commitment are more likely to use higher levels of alcohol and drugs, to be younger, and be more socially marginalized compared to their counterparts. The study examined whether civil commitments for severe substance use increased the likelihood of imprisonment following the civil commitment.

Method: Baseline ASI-data merged with national registry data on prison sentences (2007 through 2016). Cox regression was used to estimate, for a Swedish sample of 12,044 adults assessed for risky substance use, the importance of having a history of civil commitment for severe substance use, controlling for age, gender and baseline assessment of ASI composite scores in seven areas (alcohol, drugs other than alcohol, legal, mental- and physical health, family & social relationships and employment) on the likelihood of future imprisonment.

Results: The regression showed that being a male, those with experience of civil commitment and elevated ASI composite scores for both legal and employment were significantly associated with imprisonment post-civil commitment. Civil commitment for severe substance use showed 1.29 (HR = 1.29, 95% CI: 1.03–1.49, p < 0.001) increased likelihood of imprisonment post-civil commitment.

Conclusion: Having been in treatment through civil commitment due to severe substance use was strongly associated with imprisonment post-civil commitment episode. This is concerning since civil commitment is supposed to mediate against the consequences of severe substance use and promote voluntary treatment participation. Those with severe substance use and a history of civil commitment are in need of a well-coordinated and integrated system of extensive aftercare services to reduce the likelihood of imprisonment.

Background: Treatment for substance use disorder (SUD), results, in general, in improvements in terms of both drug use and social functioning. However, there are clients who are in need of repeated treatment. The aim of this retrospective study was to identify, for adults in compulsory care for severe SUD, the association between reporting having experienced a risky psychosocial childhood and repeated entries into the Swedish compulsory care system for SUD.

Method: Hierarchical logistic regression and mediation analysis methods were used to analyse data from the Swedish National Board of Institutional Care (SiS) database. The sample included 2719 adults assessed at their compulsory care intake. The study examined the association between history of institutional care, family with SUD or psychiatric problem and repeated compulsory care entries as an adult controlling for main drug, age and gender.

Results: In the regression model the factor with the strongest association with repeated compulsory care intakes for SUD, was as a child having been in mandated institutional care (OR = 2.0 (1.60–2.51)). The proportion of the total effect that is mediated through LVU (law (1990:52) the care of young persons (special provisions) act) was 33% for SUD problems in family during childhood, 44% for psychiatric problems in family during childhood, and 38% for having been in foster care.

Conclusion: Having been in mandated institutional care as a youth was strongly associated with repeated compulsory care for SUD as an adult. This is concerning since receipt of services as a child is supposed to mediate against the consequences of risky childhood conditions. These adults, as a group, are in need of a well-coordinated and integrated system of extensive aftercare services to reduce the likelihood of re-entry into compulsory care for an SUD.

Objective: Both childhood and adult psychosocial stressors have been identified as links to both increased risk for substance use disorder (SUD) and increased risk of imprisonment. The aim of this retrospective study is to identify, for a sample of 14,914 adults who all were assessed for risky substance use or a SUD, the importance of having a history of psychosocial stressors compared to current addiction severity. The analyses control for age, gender and education on the likelihood of future imprisonment. 

Method: Baseline Addiction Severity Index data (ASI) were merged with national registry data on prison sentences from 2003 to 2016. In the analysis, a Cox regression was used to study the association between independent variables and the likelihood of future imprisonment. 

Results: In the regression, five variables showed significant association to increased risk of imprisonment: ASI drugs other than alcohol Composite Score (positive relationship), ASI alcohol Composite Score (negative relationship), age (younger), education (lower) and parental problems with drugs other than alcohol. The factor with strongest association with imprisonment was the ASI drugs other than alcohol Composite Score, which showed the highest HR = 10.63 (3.50–32.31) for women and HR = 5.52 (3.77–8.08) for men to predict the likelihood of imprisonment. 

Discussion: Research is needed on why individuals with history of psychosocial stressors have a higher likelihood of imprisonment compared to their counterparts. Findings indicate that a high ASI Composite Score for drugs other than alcohol are strong predictors of future criminality and criminal justice system involvement.