Supporting recovery in social work with persons having co-occurring problems – clients’ and professionals’ perceptions

ABSTRACT

The study focus on how clients with co-occurring problems describe the importance of treatment factors for the recovery process and how these descriptions relates to professional descriptions. 40 client interviews and 15 interviews with professionals were conducted. Three major themes emerge in the results: medication, methods and the professionals.

The amount of contact with psychiatry and social services that these clients often have through the years can lead to a ‘learned passivity’ towards their own recovery process. Thus, an important task for the professionals is to break through passivity and isolation. This can be done by treating the client like an ‘ordinary fellow human’. Besides the actual professional tasks, small things seem to be important; greeting the person, paying respect when entering some one’s home, etc.

When a social network is missing, the professional can sometime fill this gap, but if this is to promote recovery, it seem important that the professional social network is used as a bridge to other social networks.

The professionals as a group, including the environment, emerge as important. Accordingly, to be supportive as a group, and be able to act like ‘social role models’, the professionals need to have working alliances also between themselves. The environment can also offer tools that can be used for socialization that interfere with the ‘learned passivity’ and instead includes and respects the client. This, together with the results highlighting the importance of creating safe milieus, confident and secure professionals, puts focus on how the professional work is organized.

KEYWORDS:

• Recovery process
• co-occuring problems
• client perspective
• social work

Introduction

Recovery from problems with alcohol and other drugs (AOD) is often described as a process influenced by internal, social, and treatment-related factors (Trulson and Hedin 2004; Ammon et al. 2008; Laudet and White 2008; Hibbert and Best 2011). Previous research shows that the conditions for recovery differ between individuals and groups of individuals (Ammon et al. 2008; Morgenstein et al. 2008; von Greiff and Skogens 2017) and these conditions can be related to the concept of recovery capital¹ (RC) (Cloud and Grandfield 2001, 2004, 2008). This article presents results from a Swedish research project focusing on recovery in a group that is common in social work: persons with co-occurring problems with AOD and mental health. It sets out to analyse how central participants in the treatment process – clients and professionals – perceive the relevance of treatment-related factors for the recovery process. Research focusing on the person’s own experience of both AOD and mental health problems is scarce (Carter, Fisher, and Isaac 2013; Cruce, Öjehagen, and Norström 2012; Ness, Borg, and Davidson 2014) but is stressed as important for gaining knowledge of factors that are important in their recovery process (Beredsford 2000; Davidson et al. 2001).

In previous studies in the present project, both clients (Skogens, von Greiff, and Topor 2018) and professionals (Topor, Skogens, and von Greiff 2018) have described the studied client group as marginalized (although there are individuals that do not completely fit into this definition), i.e. having low RC. The group often lack a social network and they live alone without contact with their native family. Also, they often lack employment and are in need of economic support and supported housing with access to staff. Moreover, the studied group often have a background of long and frequent contact with health and social services. While previous studies within the present project have focused on the clients’ descriptions of important internal and social factors or on prerequisites for professionals to support recovery processes for this client group, the aim of this study is to identify recovery supportive components in treatment of co-occurring mental health and AOD problems. The specific research question is how clients describe the importance of treatment factors for the recovery process and how these descriptions relate to professional descriptions of these factors.

Treatment-related factors among marginalized groups

Treatment factors that have been found to be important in previous research include provision of hope, knowledge, support, basic needs, and a therapeutic alliance. As mentioned above, the client group in focus, with experiences of co-occurring mental health and problems with AOD, can be described as having low RC and can therefore be defined as a marginalized group. This is a group often described as having worse outcomes compared to adults with mental health or AOD problems alone. For example they have higher rates of hospitalization, incarceration, unemployment, homelessness, and suicide (Green et al. 2007; Hilarski and Wodarski 2001; Hunt et al. 2013; Schmidt, Hesse, and Lykke 2011). With reference to (re)building RC, a more extensive system of support in addition to an intervention with focus on specific problems seems particularly important for marginalized clients. This implies a broader content to the treatment concept for those groups where employment, housing and strengthening of a social network need to be involved in the treatment setting. For example, Morgenstein et al. (2008) found that for individuals with social and health-related problems, besides AOD problems, treatment involving not only the latter problems was more effective. Since the majority of those clients tend to have more or less regular treatment contacts, often lasting for several years from childhood to adulthood, it seems relevant to gather knowledge on core elements of recovery supportive factors within treatment.

Previous research on treatment-related factors within the field of co-occurring AOD and mental health problems stresses the importance of the individual’s own participation in the recovery process. Thus, the responsibility lies first with the person in focus, and the professional’s role is to support individual possibilities and preconditions for recovery, and to give hope (Davidson and White 2007; Cabassa, Nicasio, and Whitley 2013; Mueser and Gingerich 2013; Roush et al. 2015). In order to inspire hope, the practitioner’s own hope is crucial when putting strategies for inspiring hope into action (Sælør et al. 2015) but how hope might be inspired cannot be answered in a general way (Herrestad et al. 2014). Furthermore, the professional’s role is to provide knowledge on mental health and AOD problems (Green et al. 2015; Roush et al. 2015; Pallaveshi et al. 2013) and to give non-judgmental support (Green et al. 2015). Having a social network that believes in the person and accepts them as they are, is important (Pallaveshi et al. 2013; Roush et al. 2015) and in this sense self-help groups can be vital (Laudet et al. 2000). The fundamental importance of relatively decent living conditions in terms of housing and financial security is stressed in some studies (Brekke et al. 2017; Elison et al. 2016) but is surprisingly rarely mentioned within the field of co-occurring AOD and mental health problems, conceivably because of its basic character.

In previous research on the importance of treatment of psychosocial problems, the therapeutic alliance is often emphasised (Wampold 2001; Dong-Min, Wampold, and Bolt 2006; Denhov and Topor 2012). However, studies with the same design as the present study have shown that this alliance can be described in different ways in different client groups. Clients with AOD problems and professionals working with group treatment describe the treatment group as an important tool for creating a sense of trust, confidence, acceptance and collaboration (von Greiff and Skogens 2014) – all central components of the treatment alliance concept (Martin, Garske, and Davis 2000; Lambert and Barley 2001). In studies on young adults with psychosocial problems, including problems with AOD, the therapeutic alliance is described in a more traditional way: as a relation between the individual treatment staff and the young adult (Skogens, von Greiff and Esch Ekström 2017). The importance of individual treatment in this group is explained by the need to strengthen two parallel and in part interrelated processes of change: the transition to adulthood and the recovery from psychosocial problems. The relationship ‘professional-client’ is similarly described as ‘parent-child’, a description that generally differs from research on other adults (see e.g. von Greiff and Skogens 2014). However, parallels can be drawn with adults with mental health problems where studies has described the relationship to the professional as similar to a friendship relationship (Ljungberg, Denhov, and Topor 2015). To act professionally and find a role where commitment and time are supportive elements and at the same time separate this role from the private person has been highlighted as a challenge. In order to handle this challenge a clear framework for the role of the professional is required, for example in terms of methods, and of organizational and professional context (Skogens, von Greiff, and Ekström 2017).

Method

Semi-structured interviews (Silverman 2013) with clients and professionals were conducted. A design aiming to gather data based on several shorter qualitative interviews, inspired by the approach used by Orford et al. (2006) and also used in previous projects by two of the authors in the project (von Greiff and Skogens 2012, 2017), was chosen.

Both in-patient and outpatient units in psychiatric care and AOD treatment were contacted for recruitment of participants. Eleven units were interested in taking part in the study (three supported housing, two in-patient treatment for AOD problems, three outpatient treatment for AOD problems, one peer support organization, two units for sheltered work/work training). Professionals in these units received written and verbal information about the study and were asked both if they were interested in participating themselves and if they could request the participation of former or actual clients perceived as having undergone a positive change related to their co-occurring problems. For the clients the main criteria for inclusion in the study were that they shared the perception of having started a positive change process. If a client accepted, their name and phone number or mail address were passed on to the researchers. The inclusion criterion for the professionals (in the article, treatment staff and professionals will be alternated) was experience of working with this group of clients.

Data collection

The data collection continued for eight months during the years 2016 and 2017. Since the invitation to take part in the study was distributed by professionals, we do not know to what extent clients declined to take part in the study. The interviewees chose the place for the interview; most were conducted at the treatment unit and some at the research team office. Before the interview started all participants were once again informed about the study and asked to complete an informed participation schedule.

The study was approved by the Regional Ethical Review Board in Stockholm (no. 2016/269–31/5).

Forty face-to-face interviews with clients were conducted. After initial questions on age, problems experienced, and their last professional contacts concerning these problems, the interviewed person (IP) was asked to talk about what they perceived as important for initiating and maintaining recovery, related both to their problems with AOD and mental health. The audio-recorded interview lasted for 20–40 minutes and resulted in a report of about 1000 words, based on the clients’ own words from the audio files. Excluded from the reports were ‘small talk’ or other parts that clearly did not connect to the study. To begin with, reports were written by all three authors and subsequently compared to validate content and form. After this initial validation procedure, the process was adjusted so that one author conducted the interview and another author listened to the audio recording and wrote the report. The interviewing author finally checked the report for accuracy.

The staff interviews concerned their professional work and thus were expected to be of a more general nature compared with the client interviews, where more unique descriptions of personal change processes were described. Since the content of interviews with the professionals was expected to be more homogenous, it was decided to conduct fewer, but longer and somewhat deeper interviews with the professionals than with clients. In total, 15 individual interviews with treatment staff were conducted, with the purpose of identifying core factors in their views on the quality of their own work. The staff were asked to describe their experience of treatment resulting in positive changes in the client, focusing on general changes, changes in way of life, social network, and physical and mental health. Conditions for qualitatively good treatment were highlighted in the interviews by relating to a broad range of factors such as personal qualities among the staff, the treatment method and the treatment context, but also to the characteristics and receptivity of individual clients. The interviews lasted about one hour and were audio-recorded. For each interview, a report of about 1500 words was written within 48 h, using the same procedure as with the client interviews.

Analysis

The focus of the analysis was the content of the interviews, therefore the material was analysed thematically (Braun and Clarke 2006) by coding the interview passages according to what was brought up. After re-listening to the interviews and scrutinizing the reports, the material was categorized and summarized. To address the main research questions, the material was categorized by internal, social and treatment factors. In the present article, treatment factors are analysed, primarily focusing on the client interviews. The material was summarised by picking relevant parts from each report. By iteratively analysing and compiling these in an increasingly condensed form, themes on an aggregated level were created, following a process of going back and forth between the reports and the emerging themes as described by Braun and Clarke (2006). The analysis of treatment-related factors in the client interviews resulted in several themes. Three core themes and a related sub-theme were used to re-analyse the interviews with professionals with the aim of highlighting how professionals reason around these themes. Nvivo, a software package for qualitative data analysis, was used to validate the condensed descriptions and thematisations made manually by returning to the reports and comparing the marked sentences on an individual level with the general descriptions on an aggregated level.

Methodological comments

In the narratives describing their own recovery process, each client stated the importance ascribed, in retrospect, to both internal and external events. These narratives are by definition selective and subjective perceptions, shaped by personal experiences and agendas as well as by cultural and social contexts – a subjectivity that indeed is a key element of the study since what the clients perceive as important also becomes important in the process of change (Humphreys and Wilbourne 2006; Hänninen and Koski-Jännes, 1999). By using the same design and method as in previous studies, comparisons with other groups are possible while still keeping the qualitative meaning of the investigated factors. Thus, we find the method suitable for the interactive, synergetic perspective applied in the study.

Results

All but one client described treatment as important for their recovery process. In the presentation of the results, below, common treatment factors in both clients’ and professionals’ interviews are presented through three overarching themes: medication, method and professionals. The theme concerning professionals is the most elaborated and is organised in subthemes including a subtheme that is related to treatment: support from peers. Initially, the two groups – clients and professionals – are briefly presented (for more detailed information, see Skogens, von Greiff, and Topor 2018; Topor, Skogens, and von Greiff 2018). The interviewees in the client group consisted of 13 women and 27 men between 26 and 62 years old (m = 43). Some type of drug abuse was the most common substance abuse problem (20) followed by alcohol problems (11) and mixed alcohol and drug abuse (9). The diagnosis mentioned by the clients were: Bipolar/Depression/Anxiety/Social Phobia/Psychosis (35), Neuropsychiatric Problems (ADD/ADHD/Asperger, 14), Unspecified (6) and PTSD (3).

The interviewed professionals, four men and 11 women between 39 and 61 years old (m = 51), had between eight and 28 years (m = 16) of experience in working with persons with co-occurring problems. They had diverse professional backgrounds such as social workers, home-helpers, doctors and unskilled nurses.

Quotes from clients are followed by numbers referring to a specific interviewee. Quotes from professionals are followed by letters.

Medication

Medication was highlighted as important by more than half of the clients (n = 25) and was commonly described as a prerequisite for a recovery process. Medication for mental health issues was the type most frequently mentioned, but in a few cases, it was related to problems with AOD. The descriptions of medication are characterised by short statements; about the importance of starting medication, or simply stating that they took their medication.

Although the majority of the clients stated that taking medication was important, single clients described the importance of stopping medication: I finished taking all these psycho-medications – then I became healthy (IP 37). One client even emphasized that the most important factor for maintaining a positive recovery process was to no longer take medication: My way through psychiatry and addiction treatment has been complete insanity – I should never have had all that medication (IP 12). Related to the theme of medication, it may be worth noting that only two clients mentioned that the diagnosis, in addition to leading to medication, also was important for the process of understanding oneself.

The treatment staff also mentioned the importance of medication in short statements: Medications are really important (IP C); Some need medication (IP K). Both the limited number of statements highlighting the importance of medicine (n = 4) and the lack of nuanced descriptions of the same, limit the possibility of further analysis. Thus, both clients and professionals described the importance of medication for the recovery process in a concise, but predominantly positive, way. However, they differed in the sense that medication was mentioned more rarely among the professionals than among the clients.

Treatment methods

When treatment as such was mentioned by the clients it often concerned the actual intervention, i.e. the treatment method used and how it was perceived as helpful. This was done by more than half of the group (n = 25). However, there were no patterns in the statements; rather, the statements consisted of a wide variety of actions where different methods were mentioned, for example; Electroconvulsive therapy (ECT), Motivational interviewing (MI), mindfulness, Acceptance and Commitment Therapy (ACT), Network therapy (NT), and Psychotherapy (PT) sessions. Cognitive behavioural therapy (CBT) and 12-step treatment were the most often mentioned methods, CBT always in positive terms: The most important is my conversation therapy, I receive different tools in the CBT therapy (IP 25). When 12-step treatment was mentioned, it was usually described as the importance of ‘working through the steps’ but some clients were wholly or partly sceptical towards 12-step treatment: I tried the 12-step treatment but it was too authoritative (IP 1).

Like the clients, the professional’s descriptions of specific methods concerned naming different methods rather than describing how these methods were used or how helpful they were. A little more than half (n = 8) highlighted being inspired by or using single and/or a combination of several methods: The MI-spirit – trying to accept and make them start changing (IP M); The MAPS-interview (IP G); Client centered, Rogerian//We have worked a lot with MI (we have coded interviews and received high fidelity) but (we have) also professionals using CBT that can create alliances (IP C).

Treatment staff

A majority of the clients (n = 27) highlighted the importance of the treatment staff for their recovery process. Many of the clients lacked a social network and for these, treatment staff could represent central social contacts that could link to other social relations within or outside the treatment context. In those cases, the function of the treatment staff could be described as bordering to being a social factor that went beyond their professional role. However, the key issue described here is that when professionals, as individuals or as groups, form social contacts, this was described as promoting a positive change process, for example by IPs establishing other social contacts and/or otherwise moving forward in their recovery process.

Treatment staff in the clients’ perspective – showing respect, creating a supportive environment and safety, being accessible

An overall theme in the descriptions of professional contacts was the response from the professionals. The descriptions varied but concerned the importance of being treated with respect for whoever you are: … I did not have to be social, they let me be, it was very important (IP3), and to be listened to: They made me feel like an important person (IP 34). The focus was often on descriptions that are commonly included in the concept of therapeutic alliance, that is, the staff inducing hope and mutual trust between client and staff: Trust, started to believe in the professional, the therapist, that someone wanted things to go well for you, believed in what they said (IP 33); They gave me a chance and believed in me… (IP 32) and involving the IP in a process: Experienced at XX (treatment unit) that the staff listened to me, what I thought of my illness. Allowed me to participate in the process, how I wanted to form my life. I was allowed to feel all emotions – sadness and anger. I was treated calmly, not in a confrontational manner. To be treated as a human being (IP 1). As stated in the previous quote, many descriptions related to, a sense of being seen and treated as a human, instead of as a patient: Here the staff have such a human approach. They understand you, they see you as a person, as a person who needs help (IP 28).

Sometimes, there were individual professionals who were described as important, but just as often the professionals were referred to as groups, as in the quotes from IP 3 and 34 above. Descriptions of the professionals as a group often seemed to be about them creating a supportive environment. That environment was certainly built up by the individual professionals, but it often seemed to be the environment itself that was most important.

One dimension that ran like a silver thread through the interviews with the professionals was the relationship between the individual professional and the organisations in which he or she worked. This concerns receiving and responding to the client, for example in how the professional acts: The response, that you have a good alliance, that the person trusts me in order to reach him. Knowledge is not enough, you have to see the person//meet the person where he or she is (IP F) and the importance of the group in creating an environment that can lay the foundations for an alliance: Everybody is nice and says hi, the reception is really important, saying hi, offering coffee.//We work on creating a good atmosphere, then it’s easier to open up, we care about the cosiness factor. A lot of alliance creation takes place during the coffee break, where things often come up… (IP E). The dimension was also expressed in descriptions of the importance of flexibility. This concerned the flexibility as a professional to adapt to the individual and, over time, often varying needs of a specific client, but also organisational conditions for flexibility: … immensely important to be flexible in our way of solving problems, the organisation is flexible: When psychiatry is accompanied by efforts from us then things happen (IP A).

The importance of feeling safe during treatment was central: Treatment staff you feel safe with, who you can talk to when feeling bad is really important (IP 31). There were also those who rather described the professionals in terms of straightforwardness, clarity and knowledge sharing: Met a doctor//he explained for me that it was life-threatening for me to inject (IP 5). However, IPs that highlighted directness and clarity and IPs that highlighted safety and confidence had one thing in common; they all related their descriptions to becoming more involved and active in the change process. Only one highlighted the staff’s own experience (of problems with AOD and/or mental health) as important.

The professionals were also described in terms of conversational partners, in therapeutic conversations but mainly in everyday conversations: Here you can find staff 24 hours a day to talk to, and it helps … Talk to the staff about everything and nothing (IP 4). The quote also highlights another central theme, accessibility. This theme was about the importance of the professionals being available both during and after treatment, but also that the contact was not automatically broken at relapse in AOD problems: They gave me a chance and believed in me. You can’t press an on-off button and you’re clean without being here for a week, so I had a relapse, was gone a week, then back, etc. Then stayed for four months – they held me. Then I felt safe, then I did not need it anymore (IP 32). The professionals were often described as important in terms of giving support and help with practical things: Help to clear (things up) (IP 11); He is super, helps me with curtains and so on, took me to Skansen (zoo), helps me pay the bills and so on (IP 35).

Treatment staff in the professionals’ perspective – building alliances

When the professionals described and reflected on ways to strengthen clients in their recovery process, it was often done in terms of ‘building an alliance’. It was about being responsive to and adapting to the client’s situation and needs in order to build the foundation for trust that could open up opportunities for supporting/helping the client using different tools/methods. As in the client’s descriptions, the professionals related the creation of trust to ability to convey faith, hope, security and the importance of being treated well. The meaning of these concepts was clarified when the professionals concretized how they work:/I/say hi, take off my shoes,² sit down in the kitchen and talk – it’s really important things. The details build up the whole relationship – it will be a real visit. I call and say that I am coming (even if we have an arranged time)//everything to get away from the sense of being a supervisor (IP M). It was about small details that convey a sense of being treated like an ordinary fellow human, instead of as a client/patient. By ‘seeing and listening’ to the client, the intention was to convey a sense of acceptance and trust: It’s about feeling accepted by us just the way they are. When they feel that we see them something happens.//We express curiosity and interest, we are not judging (IP A). The close relationship with the clients expressed by several professionals enabled the mediation of hope and individually adapted goals and was described as central to the recovery process: Finding a goal is important, finding hope. Finding something or this particular person//something to believe in, something to build on, something that is real like studies, something that leads forward (IP J). Some described building the alliance in terms of practical support (n = 4), especially at the beginning of the relationship. It was about following up on activities, sitting next to during contact with other authorities or as a professional expressed it: …offering a change (IP M).

Support from peers

The importance of the social network was central, and support from family and friends was analysed in a previous article based on the same material (Skogens, von Greiff, and Topor 2018). In the present article the focus was on peers with similar problems as a source for support. Even though several of the clients participated in some kind of group treatment only a few mentioned the treatment group, as a group or in terms of individual participants: Here everyone was open and kind to each other, they even gave each other hugs (IP 7). On the other hand, meeting places outside the treatment context were often mentioned, such as meeting places related to psychiatry or AA/NA meetings that complemented the function of support and context. Many described these supportive activities as their social network, offering a community that provided motivation, support and hope: A community where one can be oneself but not alone (IP 29): I have no family but have acquired a network of contacts in self-help programs – it has been crucial (IP 3).

When the treatment staff described the client group in treatment and/or the importance of peer support outside the treatment context (n = 5), it was about the group creating a sense of community and belonging that: …creates a security that makes you dare to grow and take space (IP F) but that they also said that the group could be a new social network that could provide practical help such as employment.

Discussion

All the interviewed clients in the project started a recovery process and made improvements related to their problems with AOD and/or mental health. The concept of recovery capital has been used to define the interviewed group as marginalised. However, it is important to point out two things; there are individual variations in the group regarding the extent and nature of marginalisation and since these clients had gone through a recovery process, their marginalised position had changed in a positive direction. During the interview, they described what they perceived as important for their positive change process. Descriptions of how their treatment contacts contributed to the process and how these descriptions relate to professional descriptions of the same themes were analysed in the present article. Three major themes emerged in the results: medication, treatment methods and the professionals.

The themes of medication and treatment methods were both analysed in the results. Medication was mentioned more often in the client interviews compared to the interviews with professionals. Specific methods were brought up to approximately the same extent in both client and professional interviews. The fact that both medications and methods were often mentioned but not with very wordy or long explanations was not interpreted to mean these themes were of less importance, but rather that the IPs did not consider it necessary to have elaborate explanations of why medication and methods were important. However, since the focus in the study was on factors pushing the recovery process forward, and, since the perspective was on social work rather than a medical perspective, the medication theme was viewed more as a basic prerequisite for a recovery process. There were descriptions of how medication was scaled down, introduced or changed, but besides these, the descriptions were not very salient in the recovery process.

As in previous studies, individual adjustments and flexibility in the treatment interventions was highlighted (Davidson and White 2007; Cabassa, Nicasio, and Whitley 2013; Mueser and Gingerich 2013; Roush et al. 2015). Especially, the possibility of returning to treatment after relapses or other failures and to get several chances was stressed, which puts demands on organisations to be prepared for and allow that. Security in terms of physical milieus and professionals that themselves feel confident and secure in their professional context are also factors that to a large extent are created through leadership and professional structures. Moreover, the theme treatment methods, relate to the organisational level. This theme mainly revealed that many differing methods were used which underline that a palette of different treatment methods are crucial in the professional work with this client group and thus, that professionals need both access to and ability to practice a variety of methods.

In the following, the discussion will focus on the role of the professionals in the clients’ recovery process.

Both the clients’ and the professionals’ descriptions of how the professionals were important for the process relate to therapeutic alliance. The concept was initially used in the field of psychotherapy (Wampold 2001; Lambert and Barley 2001; Martin, Garske, and Davis 2000) but has emerged as an important common factor for treatment in several other fields, such as treatment for AOD problems (Babor and Del Boca 2003) and mental health (Goldsmith et al. 2015). As pointed out earlier in the article, the creation of a therapeutic alliance cannot be described in a general way but may alter according to different groups (Herrestad et al. 2014; von Greiff and Skogens 2014). How creation of a therapeutic alliance was described in the study could be related to the specific investigated group. These clients could, on a group level, be characterised as having low RC in terms of social, physical and human capital, and thus, could be defined as a marginalised group. They were in a vulnerable situation in need of support for basic needs, which put demands on organisational and resource levels. In part, this support originates outside the actual treatment intervention and such support has been analysed in earlier publications from the project focusing on internal and social factors (Skogens, von Greiff, and Topor 2018). These supportive parts may be included in the interventions, for example, work in various forms where the client experiences the sense of doing a job that is needed and noticed. This is noted in previous studies emphasising that interventions with a broader focus than the actual problem are more beneficial for marginalised groups (Morgenstern et al. 2008; von Greiff and Skogens 2017).

The importance of inducing hope and of believing in change shown in previous research was confirmed (Sælør et al. 2015). The marginalisation of the present client group implied their vulnerability and fragility, both of which appeared in the emphasis on safety from both the clients and the professionals. The significance of creating safety through a respectful and affirmative relation between the professional and the client is stressed in previous studies (cf. Pallaveshi et al. 2013). However, the present study adds the professionals’ importance as a group in the sense that safety was also created through an environment produced on a collective level by the professionals.

Previous results published in the project have highlighted the importance of breaking the effects that long and numerous contacts with health and social services often have on the group in focus, i.e. a tendency of identifying themselves as clients and of becoming passive in meetings with authorities (Skogens, von Greiff, and Topor 2018). This leads for example to talking and acting during such meetings in a way perceived as expected instead of bringing forward central and important issues for oneself. The professionals in the study described the importance of breaking through this tendency. This was done by acting as a ‘fellow human’ in an ordinary way: offering coffee during meetings or in the waiting room, giving compliments on clothing or hairdo, and doing ordinary leisure things together. The clients’ descriptions of how the professionals were helpful in their recovery process confirm that this way of working is important. Whether the professionals were described as a group or individually, the experience of being respectfully met in an ordinary way was brought forward as central (Skogens, von Greiff, and Topor 2018).

In previous studies on marginalised groups, the treatment group has been emphasised as playing a part in the recovery process (von Greiff and Skogens 2014). In the present study, only a few of the clients with experience of group interventions mentioned the treatment group as important. However, peer groups were, in line with previous research (Laudet et al. 2000), often emphasised. This might be related to the identification as client and the effects of this described above. The stronger this identification is, the less likely it is to see other clients as actors who it is possible to relate to and accept help from. Later on in the recovery process, this identity becomes weaker, while the individual identity is strengthened and with this, the confidence in others in the same situation is strengthened. Thus, peer groups are perceived as important. In line with this are the descriptions of when the professionals constitute the clients’ social network, as a group or individually. When this was described as contributing to the recovery process, the most important aspect was that this had linked further to other social networks.

Strengths and limitations

A main strength in the study is the use of first person data. It has been pointed out that studies based on persons own experience of both AOD and mental health problems are important but scarce. Further, the individual perception of important factors in the process of change is probably included in the more complex concept of motivation, which, in turn, has been singled out as one of the most important factors for outcome of treatment in the AOD field (Cooney et al. 2003). By comparing data from the client interviews with data from professionals working with the clients in the same context, the credibility is strengthened.

The large number of interviews is a strength in the sense that it increases the possibility to grasp a variety of factors. On the other hand, the large number of interviews limits the possibilities for in-depth analysis of the nuances in the themes. The information on the clients’ problems in the AOD and the mental health field comes from the clients themselves and we have not analysed differences in significance in each problem, which might have revealed group differences. Moreover, since the interviewed group have made positive changes, this might mean that they have better prerequisites for change than others do.

The procedure of letting professionals select which clients to invite to participate means that problems connected to self-selection were avoided. As mentioned earlier under methodological comments, the interviews are subjective retrospective perceptions. The advantages with this is that the subjective perception is in itself important for a positive change process. In addition, since the interviewed clients have started and maintained a positive change, a retrospective perspective makes it possible to look back and evaluate what was important for this process. However, prospective studies would contribute with knowledge on if and how this perspective changes over time.

Conclusions

According to the results some suggestions can be made concerning the vulnerability of this group, compared to other marginalized groups, related to their often long and numerous contacts with health and social services. The amount of contact with psychiatry and social services that these clients often have through the years can lead to a ‘learned passivity’ towards their own recovery process. Thus, an important task for the professionals is to break through passivity and isolation. This can be done by treating the client in a way that can be labelled as very ordinary, like an ‘ordinary fellow human’. Some conclusions based on the results can be made according to this:

Besides the actual professional tasks (that of course varies according to profession), small things seem to be important; to greet the person, to pay respect when entering some one’s home, etc.

When a social network is missing, the professional sometime seem to fill this gap, but if this is to promote recovery, it seem important that the professional social network is used as a bridge to other social networks, for example to accompany someone to social events outside the treatment context.

As is brought forward in the results, the professionals as a group, including the environment, emerge as important. Accordingly, to be supportive as a group, and to be able to act like ‘social role models’, the professionals need to have working alliances also between themselves which means that concepts such as trust and confidence in each other are necessary between the members in the professional team. Further, the environment can also offer tools that can be used for socialization that interfere with the ‘learned passivity’ and instead includes and respects the client. Examples of this in the results are the offering of coffee in the waiting room, the receptionist saying hello, etc. This, together with the results highlighting the importance of creating safe milieus, confident and secure professionals, puts focus on how the professional work is organized.

Acknowledgments

This research was funded by the Swedish Research Council for Health, Working Life and Welfare (Grant # 2015-00699)

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the Swedish Research Counicil for Health, Working Life and Welfare [2015-00699].

Notes

1. There are different definitions and ways to operationalise RC (Hennesssy, 2017). However, the four central components are: social capital (a durable network providing emotional support with reciprocal obligations, trust), physical capital (economic and material capital), human capital (including skills, educational credentials, physical and mental health) and cultural capital (cultural norms, values and beliefs) (Cloud and Granfield 2008).

2. When Scandinavians do informal visits in the home of friends and relatives, taking their shoes of is a common habit. Thus, by doing this, the professional recognize that this is the clients home.