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Background and aim: Social workers regularly encounter clients affected by substance use disorders (SUD), yet training in evidence-based assessment and interventions remains limited. In Sweden, municipal social workers have statutory responsibility for SUD assessment, intervention planning and client follow-up which underscores the need for targeted professional education. This study aimed to: (i) describe social workers’ baseline self-assessed competence in evidence-based practices for SUD and its associations with demographic and professional characteristics, and; (ii) examine knowledge gains associated with completion of an evidence-based educational intervention.

Methods: A non-randomized pre–post design included 173 municipal social workers recruited from 64 municipalities across five cohorts (2021–2023). Baseline self-assessed competence was analyzed using ordinal logistic regression, and knowledge gains were assessed using module-specific pre–post items with paired t-tests with Cohen’s d.

Results: Baseline competence was rated as low to moderate, with professional experience predicting higher perceived competence. Substantial baseline knowledge gaps were observed, particularly in evidence-based psychosocial interventions and use of digital technology in assessment and planning of treatment. Knowledge increased significantly across all modules after training completion (d = 0.26–1.41). The largest knowledge gains were for modules on use of technology in the assessment and treatment-planning, biopsychosocial interventions, research-informed use of the assessment tool Addiction Severity Index (ASI), and the professional role in assessment and care planning. Score variability decreased across several modules.

Conclusion: Completion of an immersive, online, evidence-based training was associated with meaningful improvements in social workers’ knowledge related to substance use assessment, intervention planning, and use of technology. Although causal inference is limited by the non-randomized single-group pre–post design, the findings support the potential of scalable educational interventions to address competence gaps in substance use services even in organizations with high caseloads, workforce turnover, and limited training opportunities.

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. 

Artikeln ger en kort bakgrund om svensk missbruksvård. De forskningsprojekt vars resultat detta temanummer bygger på har uppstått utifrån denna förståelse. Förkortningarna EPI och ESTR får också sina förklaringar och beskrivs. Det finns en rad svar på rubrikens fråga. Det vanligaste är att det skulle behövas en generell ambitionshöjning, något som anses kräva mer resurser, vilket inte är så enkelt att ordna. Ett annat svar är att huvudmännens ansvar borde förtydligas, vilket redan en nu 12 år gammal offentlig utredning föreslog via ett samlat huvudmannaskap hos sjukvårdshuvudmannen för behandling vid missbruk och beroende (SOU 2011:35). En aktuell utredning föreslår samma sak (SOU 2023:5). Hur det verkligen blir återstår att se. Alldeles oberoende av reformer så finns det möjligheter till kvalitetsförbättringar och effektiviseringar genom att planera och följa upp de insatser som erbjuds brukarna på ett systematiskt sätt.

Changing patterns of addiction and increased psychiatric comorbidity pose new challenges for social services. As part of systematizing the work of assessing and investigating the need for help for people with alcohol or drug problems, use of the Addiction Severity Index is recommended. This descriptive quantitative study examines and compares how social workers and clients esti-mate the extent of a client’s problems in three areas: mental health, alcohol and drugs. Based on interviewer and client estimates, the study also examines whether the problems are estimated dif-ferently over time, from 2003 to 2017. The study includes ASI material for 15,005 people whose need for help for alcohol or drug problems has been investigated and assessed by the social services in 65 Swedish municipalities. The study shows that both clients and social workers estimate an increased problem level for the ASI domains of mental health and drugs. For alcohol, the trend is the opposite or is unchanged. Overall, interviewer as well as client estimates indicate an increased need for help and support for problems related to mental health and drug use, while the need for help and support for problems related to alcohol is unchanged or decreases over time among social service clients.

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.

Objective: Experiences of trauma, specifically sexual abuse, have been linked to both mental health and substance use disorders. This study used 14 years of Swedish health registry data to select a sample of adult men who reported frequent opioid use and assessed if those with a self-reported history of sexual abuse had a higher likelihood of hospitalization for a mental health disorder.

Methods: A Swedish longitudinal (2003–2017) registry study linked Addiction Severity Index (ASI) assessments completed with individuals who sought treatment for substance use disorders with data on hospitalizations for mental health disorders, and assessed associations with self-reported histories of sexual abuse among men who reported sustained and frequent use of opioids (n¼1862). Cox regression methods tested associations and controlled for age, and the7 ASI composite scores: family and social relationships, employment, alcohol use, drug use, legal, physical health, and mental health.

Results: The ASI composite score for mental health (hazard ratio[HR] 16.6, P<0.001) and a history of sexual abuse (HR 1.93,P<0.001) were associated with an elevated risk of future mental health hospitalization.

Conclusion: Both the ASI composite scores for mental health andself-reported history of sexual abuse reflected complex needs amongmen who used opioids and increased risk for mental health hospitalization.Treatment providers should strive to provide integrated careand address the negative aspects of victimization.

COVID-19 shocked health and economic systems leaving millions of people without employment and safety nets. The pandemic disproportionately affects people with substance use disorders (SUDs) due to the collision between SUDs and COVID-19. Comorbidities and risk environments for SUDs are likely risk factors for COVID-19. The pandemic, in turn, diminishes resources that people with SUD need for their recovery and well-being. This article presents an interdisciplinary and international perspective on how COVID-19 and the related systemic shock impact on individuals with SUDs directly and indirectly. We highlight a need to understand SUDs as biopsychosocial disorders and use evidence-based policies to destigmatize SUDs. We recommend a suite of multi-sectorial actions and strategies to strengthen, modernize and complement addiction care systems which will become resilient and responsive to future systemic shocks similar to the COVID-19 pandemic.