- Practitioners working with older people, adults with learning disabilities and physically disabled adults encounter AOD problems relatively infrequently compared with child protection or adult mental health fields. However, they face significant challenges when they do so.
- Many practitioners feel under-prepared and struggle with a lack of confidence in their practice with AOD issues.
- More clarity is needed concerning the role of these groups of practitioners when they encounter service users with AOD problems.
- Training that is able to respond to the specific challenges faced by different practitioner groups needs is desperately needed.
Dr Cherilyn Dance; Ms Debbie Allnock; Dr Sarah Galvani; Dr Aisha Hutchinson; The Tilda Goldberg Centre for Social Work and Social Care, University of Bedfordshire.
People who access social work and social care services frequently have multiple needs; difficulties with alcohol or other drugs (AOD) often feature. Using data from a previous survey conducted by the author and colleagues, the aim of this study was to examine the experiences of three groups of social work and social care practitioners in relation to their work with people who have problems with AOD use as well as their other social care needs. The practitioners’ areas of specialist practice were older people, physically disabled adults and adults with learning disabilities. The needs of these service user groups in relation to AOD use and the experiences of social care practitioners working with these issues have received little research attention to date. This study formed one strand of a programme of research that sought to identify not only practitioners’ needs but also the extent and nature of AOD education on qualifying social work programmes and in employer-led training.
The main analyses drew on qualitative and quantitative data available from a previous survey of practitioners’ experiences of working with AOD use (Galvani et al. 2011). Focusing on survey responses provided by practitioners in these three groups (total N=199) and data from four focus groups, the analysis aimed to:
- Examine the extent to which practitioners’ encountered AOD problems.
- Examine the practice responses and experiences of professionals when working with AOD use in these specialist areas of practice.
- Identify training needs related to AOD use which are specific to each of these three groups of service users.
- Explore practitioners’ perceptions of the barriers and facilitators to AOD services for these service user groups.
- Identify good practice or suggestions for service and practice development.
The sample comprised practitioners working with:
- Older people, including older people with mental health problems (OP(MH)) (total N=85)
- Adults with physical/sensory disabilities up to age 65 (PD) (total N=27
- Adults with physical/sensory disabilities including older people (PD, OP); (total N=62)
- Adults with learning disabilities (LD) (total N=25).
Practitioners’ encounters with alcohol and other drugs
On average, across all groups, practitioners reported approximately one in 20 (5%) of service users on their caseloads as having AOD problems (this ranged from 3.7% for practitioners in learning disability services to 9.9% for those working with physically disabled clients under the age of 65).
In all three areas of practice more workers reported frequent encounters with alcohol than was the case for illicit drugs (with 0-30% of practitioners frequently encountering alcohol, and 0-9% frequently coming across illicit drugs). Just over 20% of practitioners in physical disability teams (both groups) also reported frequent encounters with problematic use of prescription drugs.
Practice responses and experiences
Many practitioners reported finding it difficult to identify AOD problems. In attempting to do so, practitioners rely most heavily on their own observations of evidence of social harms resulting from AOD use and its impacts on service users lives.
There is real ambivalence about asking questions about AOD use, which often has to do with service users’ rights to make their own life-style choices – where they have the capacity to do so.
Issues around mental capacity were identified as a complex challenge in relation to work with the service user and with other professionals. In all groups the difficulty of balancing human rights and freedom of choice with a duty of care was mentioned.
Practitioners emphasise the importance a trusting relationship with service users in order to explore sensitive issues such as AOD use, but changes in service delivery mean less opportunity to develop rapport. Knowledge of skills and techniques to engage service users, even when encounters are brief, is essential.
Challenges in working with substance use and the importance of training
Challenges related to working directly with service users included concerns about threats to care packages when behaviour is unacceptable to paid carers, the reluctance of many service users to seek help to change their usage patterns and the complexities of managing ‘risk’ in the context of maintaining the service users AOD use.
With reference to working with specialist substance use services, practitioners across all groups identified a lack of services appropriate to the needs of their client group. In particular there was an expressed need for services to be able to engage with service users to help them reach a decision to change their behaviour.
Some practitioners expressed the view that they felt ‘isolated’ and that social care was frequently left to manage cases without adequate support from other services and this responsibility weighed heavily upon them.
Training in AOD was identified as being ‘very’ important for the majority of practitioners. They were particularly interested to know about types of intervention and treatment, assessing risk, working with specialist substance use workers and how to talk about AOD issues with service users.
Particular needs and issues for individual service user groups
Analysis of practice with each group of service users revealed particular issues.
There was concern about the potential increased vulnerability of people with learning disabilities in relation to risks of developing dependence and exploitation by others if using AODs problematically. There was also concern about their ability to understand advice about safe use and the implications of AOD use.
Practitioners working with physically disabled clients or those with sensory impairments identified many issues around access to, and appropriateness of, treatment services; concerns about the safe use of mobility and other aids while intoxicated; problematic information sharing – especially with regard to discovering that a disability is alcohol related – and a lack of support around reduction, rather than cessation, of AOD use.
Older people were reported to deny they have a problem and are often not able to cope with its impact. Practitioners reported difficulties in distinguishing between dementia and alcohol-related dementia as well as dementia compounding AOD related problems, e.g. the impact of dementia on appropriate use of prescription medications. Mobility problems among older people combined with drinking and the increased risk of falls was a major concern and again there were worries about the safe use of mobility devices and other aids and adaptations. Practitioners identified a lack of support groups for older AOD users and some believed that older people are being steered away from AOD services when their AOD use is problematic and placed in residential care.
Practitioners in all groups identified barriers to accessing specialist AOD services and a lack of specialist services able to offer an appropriate service to their client group. There were also concerns expressed about those with lower levels of need where thresholds for entitlement to a service might not be reached. Possible ways forward were identified by practitioners in terms of greater use of multi-disciplinary working, link workers across services and outreach. The knowledge exchange discussions suggested greater use of mentoring and imaginative approaches to training and self-directed learning.
The analyses presented suggest that the contexts practitioners work in and the challenges they face differ according to client group. Training needs to reflect this and be relevant to practitioners’ work situation.
Specialists in AOD use and specialists in the different fields of adults’ social care need to learn from each other and work together to offer a holistic service.
Practitioners in adult social care need to be better prepared to work with people with AOD problems but there needs to be consensus about what the role for social workers and other social care workers ought to be.
Specialist AOD services need to offer services that are accessible and appropriate to all service users regardless of age or [dis]ability.
Services are needed which can engage with service users who are not ready to engage with formal treatment.
There is a very real need to acknowledge the tensions inherent in considering mental capacity, the right to autonomy in life-style choices and where responsibility for those decisions should lie.
Practitioners working with service users with high levels of need and AOD problems need adequate support from managers.
AOD training needs to be relevant to the work that practitioners are engaged in and acknowledge the specific challenges in different areas of practice.
Practitioners particularly need methods for working with service users in circumstances where they do not have an opportunity to develop the type of relationships and rapport they would ideally like to develop.
This study has identified that practitioners working with older people, adults with learning disabilities and physically disabled adults encounter AOD problems relatively infrequently compared with child protection or adult mental health fields. However, they face significant challenges when they do so.
While practitioners face some similar challenges across the three service user groups, there are a number of challenges that vary according to the service user group and these need to be recognised and acknowledged. Many practitioners feel under-prepared for this work and struggle with a lack of confidence in their knowledge about AOD. This has to be balanced with their duty of care to, and respect for, an individual’s right to self-determination, each of which impacts on practitioners sense of entitlement to discuss AOD issues with service users.
The current mode of service delivery, case management, with its focus on signposting and referring on, limits the opportunities for practitioners to develop the sort of relationships with service users which would permit meaningful discussion of their AOD use. In addition, there is a lack of clarity about what is, or should be expected of adult social care practitioners with respect to problematic AOD use. Training that is able to respond to these needs and provide relevant and context specific learning is desperately needed.
This project is one strand of a three-strand project on the topic of substance use in social work education, training and practice. The full report Building Capacity, Bridging Gaps – Substance Use in Social Work Education, Training and Employment is available on the Alcohol Research UK website and at www.beds.ac.uk/goldbergcentre/resources.