Balancing standards and flexibility – Preconditions for a recovery-based tool in a Swedish alcohol and drug treatment context

ABSTRACT

This article presents the outcome of the first phase in the development of a recovery capital-based assessment tool in a Swedish alcohol and drug treatment context. In the process of studying the potential usefulness of such a tool, other aspects besides psychometric properties and validity have been examined. The experience and knowledge of professionals in the Swedish alcohol and drug treatment context represent the empirical data. Five group interviews have been conducted with staff from different alcohol and drug treatment facilities in Sweden. The respondents were asked to discuss an outlined idea of a recovery capital-based assessment tool. The transcribed interviews were thematically analysed and divided into three themes: the impact and need for assessment and evaluation, the need for flexibility and simplicity, and the role of the professional. The findings indicate that there is a demand for a strength-based tool in the Swedish alcohol and drug treatment context. There was a divergence between the professionalism of the social work practitioners and the use of assessment tools. To meet this divergence, the professionals emphasized aspects such as simplicity and flexibility. The findings indicate that the conditions are favourable for the implementation of a recovery capital tool in a Swedish alcohol and drug treatment context, but certain questions remain unanswered. This requires further cooperation with professionals, and in particular provides them with the possibility to reflect on its usefulness and applicability, while applying it to their daily work and procedures.

KEYWORDS:

• AOD treatment
• recovery capital
• standardization
• social work practitioners
• assessment tool

Introduction

In many countries, the recovery model in the field of treatment related to alcohol and other drugs is increasingly being advocated (HM Government 2010; Inter-ministerial Group on Drugs 2012; Scottish Government 2008). The same trend is noticeable in the academic world where the term recovery is referred to more frequently than before. Besides including a reduction in substance use, the recovery model focuses on a more sustainable recovery and thus constitutes more than just sobriety. One argument that have carried this development forward is, for example, that treatment effects seem to decrease over time (Weisner et al. 2003). These arguments have resulted in the conclusion that different types of support, such as residential and employment-related support, should continue after the individual has ceased to use substances (Miller and Miller 2009).

Table 1. Outline of the participating AOD treatment facilities based on relevant characteristics (n = 22).

Group ID number^a (n^b)	Description of the main client group	In or outpatient treatment	Main methods	Current use of assessment tools	Individual or group treatment?
1 (6)	Clients from The Swedish Prison and Probation Service, and social services. Experienced long-lasting AOD problems. Mainly marginalized. Men only.	In and outpatient	Twelve-step programme and some CBT.	Assessment tool to measure outcome of treatment, 2–3 and 7 years post-discharge from treatment.	Group and individual. Mainly group treatment.
2 (5)	Clients from social services and psychiatric care. Gender-mixed.	Outpatient	Multiple treatment methods.	Besides certain treatment-specific assessments, they use what they call an ‘About me-emoji’ that they have created themselves.	Group and individual, based on type of treatment.
3 (4)	Clients from social services. Relatively integrated. Gender-mixed.	Outpatient	Motivational Interviewing (MI) and relapse prevention.	Breathalyser and questions to measure mental health (Previct).	Group and individual treatment. Mainly individual treatment.
4 (3)	Integrated client group. Private or employer financed treatment. Few clients from social services. Gender-mixed.	Outpatient	Twelve-step programme.	Assessment tool for treatment needs/planning. Evaluation of treatment/treatment facility.	Group treatment.
5 (4)	Mainly marginalized. Gender-mixed.	Outpatient	Multiple treatment methods.	Assessment tool to track changes over time.	Group and individual treatment.

^aFor ethical reasons, the names of the participating AOD treatment facilities have been replaced with ID numbers.

^bNumber of respondents in group interview.

To understand relevant factors in the recovery process, Cloud and Granfield (2008) developed the term referred to as recovery capital (RC). RC comprises four areas: social capital, human capital, cultural capital and physical capital. These four areas are used to explain the variation in different people’s ability to recover from alcohol and other drug (AOD)-related problems (Cloud and Granfield 2008). Research has shown that RC is theoretically and practically useful due to its ability to capture both personal attributes as well as context-related preconditions that may increase or decrease an individual’s chances and ability to recover from AOD-related problems (Best and Laudet 2010; Groshkova, Best, and White 2013; Morton, O’Reilly, and O’Brien 2016; Skogens and von Greiff 2016). Scientific progress concerning recovery and recovery capital has resulted in an ambition to quantify and measure an individual’s level of capital. This has led to the construction of a number of assessment tools which are said to identify crucial elements of an individual’s recovery process – information that further outlines the needs and barriers that must be considered for a successful recovery.

The practical and theoretical usefulness of RC has also been recognized in Sweden (Skogens, von Greiff, and Esch Ekström 2017; Skogens and von Greiff 2016; Topor, Skogens, and von Greiff 2018), suggesting that an assessment tool based on RC might be applicable in a Swedish treatment context, as it has been in other countries (Best et al. 2016; Burns and Marks 2013; Groshkova, Best, and White 2013). The ability that has been found to identify crucial elements of an individual’s recovery process, and by extension outlines an individual’s barriers and strengths, also corresponds to the core of evidence-based practice, and mainly the increasing demands for documentation and assessment (The National Board of Health and Welfare 2019, 23)

The paradoxical difficulty of applying standardized tools in the area of social work entails a challenge, where careful deliberations concerning applicability and demand are necessary. This article aims to present the outcome of the first phase in the development of an RC-based assessment tool in a Swedish AOD treatment context. In the process of studying the potential usefulness of such a tool, other aspects besides its psychometric properties and validity, have been considered important to examine. The area in which the tool is thought to operate have been the scientific object, and, accordingly, the experience and knowledge of professionals in the Swedish AOD treatment context have represented the empirical data. The findings in the article have been placed in the current debate that concerns evidence-based practice (EBP), standardized assessment tools, and have in particular added to the research on feasibility studies.

Background

Recovery is a wide construct. Currently, there is a lack of an unanimous definition of recovery, further generating consequences for the practical use of the term (The Betty Ford Institute Consensus Panel 2007; White 2007), but also how recovery is being used in a political context (Best et al. 2016; Laudet 2007; Neale, Nettleton, and Pickering 2013). Factors as abstinence/sobriety, personal development/identity change, lifestyle change, voluntarism, control, as well as different types of local or societal inclusion are frequently illuminated as important aspects in relation to recovery. Another question associated with the ongoing discussion concerning the definition is whether recovery should be viewed as a process or condition/outcome (Best et al. 2017; Corrigan et al. 2019; Laudet 2007; Topor et al. 2011; White 2007). Further, some distinctions can be made between the recovery developments noted in the areas of mental illness versus AOD (Corrigan et al. 2019).

As suggested, recovery is a wide construct that enables a variation of interpretations and definitions depending on scientific field. Recovery should be considered a self-evident part of AOD-related research. AOD research is however an interdisciplinary scientific subject, further implying that the use of recovery as a construct could vary based on the field. Although recovery in the AOD-field have generated the development of RC, RC have been found analytically useful also in the area of mental illness in terms of social capital (Corrigan et al. 2019; Pettersen et al. 2019; Topor et al. 2011). Thus, when a concept as RC is placed in a social work context, it can become a question of usability in a practical treatment environment.

The standardization project

The progress of quantifications of RC provides an example of the ambition of standards and standardizations, commonly associated with evidence-based practice (Björk 2017; Timmermans and Epstein 2010). Viewing RC as constructed with the ambition to illuminate the variation in different individuals’ recovery processes, a natural reaction would likely be to increase the amount of resources used to evaluate each client’s recovery progress individually. In Sweden, NBHW states in its guidelines that assessment tools are necessary to address the client’s treatment needs and analyse the outcomes of a specific treatment, as well as strengthening the relationship with the client and, by mapping out the progress, motivating the client to change (The National Board of Health and Welfare 2019). An increased demand for documentation in social work agencies has been noted (Björk 2017), and the NBHW has encouraged the social work agencies, and mainly AOD treatment agencies, to implement assessment tools (The National Board of Health and Welfare 2019, 23).

As with other organizations classified as human service organizations, the social services are obliged to approach the role of a caring actor dealing with personal and sensitive circumstances, and simultaneously adopt bureaucratic procedures and practices (Hasenfeld 2009). Organizations that include street-level bureaucrats (Lipsky 1969) entail a unique hierarchy, and above all a complex governance. The interactions with members of society entail individual adjustments, which in turn are considered difficult to regulate with specific rules and/or orders. It has been said that the unique structure of human service organizations leads to different ambitions, purposes and interests, at different levels of the organization (Abrahamson and Tryggvesson 2008). Accordingly, the standards applied are dependent on being legitimized, and this usually amounts to expert-classified information and knowledge (Grape, Blom, and Johansson 2006). Although street-level bureaucrats are at the bottom of the organizational hierarchy, their judgement of what the situation requires is considered the most valuable opinion (Johansson 2007).

The demand for documentation and standardization has increased simultaneously, and evidence-based practice has been referred to as a standardization project (Björk 2017), in which the development of assessment tools and standardized outcome measures are considered a crucial part (Björk 2013; Timmermans and Epstein 2010). The seemingly colliding interests of experts and social work practitioners¹ are an aspect that is likely to affect the applicability and usefulness of an assessment tool or other types of regulations. Thus, in order to address the applicability and usefulness, both interests would need to be considered when developing and implementing new assessment tools or other types of interventions.

Feasibility studies

A challenge associated with evidence-based practice is the paradoxical difficulty of applying standardizations in an area in which the measured conditions tend to vary based on a number of factors, as is often the case in several areas of social work (Bergmark, Bergmark, and Lundström 2011). This challenge has led to the development of a number of implementation and development perspectives that emphasize the importance of highlighting the practical environment, as well as alternative ways of developing interventions and assessment tools. One way to deal with the challenge mentioned is a more deliberate approach towards applying new interventions and/or assessment tools, as in, for example, the procedure seen in feasibility studies (Bowen et al. 2009; Morgan et al. 2018).

Previous research has highlighted the importance of examining other aspects than psychometric properties and validity when developing new interventions or tools in the area of social work (Björk 2017; Guberman et al. 2007; Skillmark and Denvall 2018; Spies, Delport, and le Roux 2015). On the subject of employing feasibility studies, Bowen et al. (2009) has outlined the core areas that ought to be addressed. These areas cover the implementation process, from the examination of its applicability to considerations concerning expansions of the specific intervention or tool. The feasibility study process may be divided into three main phases, characterized by the overall question it addresses. All phases are important to consider while determining whether an intervention or tool is appropriate, present article will however focus on the first phase known as ‘Can it work?’, and the areas acceptability, demand and implementation. Further, a common factor shared by the areas mentioned is the emphasis on the opinions of the target population (Bowen et al. 2009, 454).

Previous research on context-related implementation and the development of assessment tools

Although the majority of research projects addressing the implementation and development of assessment tools in the area of social work concerns psychometric properties and validity, a number of studies have been carried out with an emphasis on the practical environment. For example, the opinions of professionals concerning standardized assessment and the implementation processes have been highlighted (e.g., Guberman et al. 2007; Skillmark and Denvall 2018; Spies, Delport, and le Roux 2015). Resistance to standardization in the area of social science, along with its consequences, has been acknowledged by Timmermans and Epstein (2010) among others. In areas where professionals are considered experienced and competent enough to make decisions, standardizations may be perceived as unwelcome, unnecessary and harmful (Brunsson and Jacobsson 2002). Knaapen (2014) has argued that the standardization associated with EBP tends to reduce trust in, and undermine the ability and experience of, the professionals, and standards are said to be ‘expert knowledge stored in the form of rules’ (Johansson 2002). Other research with an emphasis on the practical environment includes the field of Science and Technology Studies (STS) and the term ‘situated standardization’ (Zuiderent-Jerak 2015). The STS field promotes an ethno-methodological perspective, where research is conducted in close association with the area it addresses, further emphasizing that every practice or organization is unique (Fernler 2012). Situated standardization emphasizes the importance of examining the feasibility of the tool or method in a practical environment as a crucial part in determining its applicability (Björk 2017). One addition provided by the term situated standardization is ‘invisible aspects’, which acknowledges the less pronounced aspects, namely the aspects addressing the tool in everyday work (Björk 2017).

Practice-related research

The Addiction Severity Index (ASI) is the most widely used evaluation tool in professional work with AOD problems (Abrahamson and Tryggvesson 2008; Spear, Brown, and Rawson 2005), and has accordingly received scientific attention. Research has addressed its psychometric properties and validity, and to some extent its applicability in a social service environment. Since its implementation in Sweden during the 1990s, both its usefulness (Spear, Brown, and Rawson 2005) and its suitability (Skogens 2012) in a social service environment have been put into question. Professionals working with the ASI state that the ASI creates legal certainty, structure and efficacy, but that it also constitutes disadvantages concerning the time it takes to fill out the index, as well as ethics, based on the relevance of the questions (Skogens 2012). Martinell and Barfoed (2014) states that the ASI tool is important for, and has the ability to affect, the interaction between social worker and client (Martinell Barfoed 2014). Further, research on clients’ perspective have shown that monitoring (Scott et al., 2005) and continuous feedback, which regular assessments provide, can help motivate client progress and contribute to recovery (Svendsen et al. 2020).

Another assessment-related implementation is the Swedish DOC system. The development of the Swedish DOC system started in the mid-1990s with a marked ‘bottom-up’ perspective, meaning that the tool was developed alongside professionals (Anderberg and Dahlberg 2009). DOC stands for documentation and evaluation regarding treatment of alcohol and drug abusers, and is distinguishable from tools such as the ASI in terms of its flexibility and its ability to account for the client’s entire life situation (Jenner and Segraeus 2005). An evaluation of the Swedish DOC system showed that the semi-structured interviews provided information that was useful for the professionals in terms of treatment evaluation and treatment needs, and that the documentation form fulfilled the demands of reliability and validity² (Anderberg and Dahlberg 2009). The opinions of professionals concerning the practical aspects of the documentation tool have, however, received little or no scientific attention.

Methods

Key informant group interviews

Five key informant group interviews with staff from different AOD treatment facilities were conducted. Each interview consisted of 3–6 members of staff representing five AOD treatment facilities, yielding a sample of 22 interviewed professionals (see table 1). With the ambition of attaining a variation in the type of client group, the participating treatment facilities were recruited based on their specific type of client group. Initially, the selected AOD treatment facilities were contacted, and given a brief introduction to the research project, and they were subsequently asked whether they were willing to participate in a group interview. If they were interested in participating, the contact person was asked to gather 3–6 other staff members interested in participating in the interview. None of the contacted treatment facilities declined to participate. Based on access and availability, all contacted AOD treatment facilities were located within an hour from Stockholm. The respondents were in charge of deciding where the interview would take place, and in all cases, the interview took place in a conference room at the specific facility, and lasted approximately one and a half hour. All three authors participated in all interviews, except one interview where only two of the authors were able to participate.

The interview guide was designed to answer the question ‘Can it work?’ with key terms such as acceptability, demand and implementation (Bowen et al. 2009). The corresponding author began the interview with a brief introduction of RC, including a brief verbal description of the different attempts to quantify the theoretical term. The presentation was followed by an open question concerning the respondents’ initial reaction to the proposed assessment tool, mainly in terms of usefulness and demand. Thus, the respondents were presented an outlined idea of an assessment tool, and not introduced to any specific tools nor measuring items. Depending on the respondents’ initial reaction, questions were asked regarding their opinions about how the tool should be formatted to best suit their daily working environment, as well as their opinion on its ability to highlight important factors in the recovery process. Another area that was addressed was how the proposed assessment tool might generally affect the client, and in particular the therapeutic relationship between professional and client. However, it should be noted that no clients participated in the group interviews. Thus, statements or opinions concerning the experience of the client are made through the eyes of the professional. Further, no conclusions can be made concerning experienced effects on the client.

Thematic analysis

Thematic analysis (Braun and Clarke 2006) was used to process the data material, which entailed an analytical process with the aim of identifying and organizing specific patterns in the material collected. All the interviews were recorded using standard recording equipment and later transcribed into written form by the corresponding author, who also conducted the early stage coding. Initially, the corresponding author read the written interviews a few times, and statements connected to acceptability, demand and implementation were noted. Thereafter, several meetings were held where the research group discussed the transcripts and identified patterns. The respondents’ reasoning concerning the outlined assessment tool were summarized and divided into different themes. The themes were the impact and need for assessment and evaluation, the need for flexibility and simplicity, and the role of the professional.

Findings

The impact and need for assessment and evaluation

All the respondents agreed on the importance of a strength-based, rather than a problem-focused, approach to recovery. The respondents in Group 2 stated that assessment tools could be seen as a symbol for the general approach to the treatment process:

“The assessment tool shapes the entire treatment process … it’s a testimony to the working method”. (Group 2)

This quote highlights the power of methods and tools used in a treatment context. The respondents agreed on the fact that an assessment tool has the power to influence the conversation climate and if it is not suitable, it can be a burden for the client as well as the professional. A more problem-focused approach was said to have a stigmatizing effect on the client. The strength-based aspect of the suggested assessment tool was thus identified as the strongest argument supporting the construction of the RC assessment tool. Another argument working in favour of the RC assessment tool was the ability to distinguish between different types of resources. This was seen by a vast majority of the respondents as a therapeutic way of sorting things out, and as a result it clarified which areas the client needed to work on and which existing resources the client could use.

“The people we’ve met have one big lump of anxiety, unease and concern regarding their life and helping them sorting out what is what brings it home to them”. (Group 3)

The ability to identify the resources was not only seen as important for the client’s recovery progress, it was also seen as important regarding the work of the professional:

“Respondent: I believe that it’s very important to raise the awareness both of those of us who work with the individuals to get a new point of view, and not least for the individual him or herself, things that you might take for granted and aren’t able to see. It becomes clear and verified. It’s not as if it’s not possible to do anyway, by focusing on resources. However, it’s easier if you work together with the client.

Interviewer: And you would consider this [RC assessment tool] as a method to do so?

Respondent: Yes.” (Group 3)

The excerpts above highlight that the respondents believe that the systematic approach might benefit both clients and professionals. This could imply that the need for a systematic approach and structure originates from other sources than only the demand for documentation and outcome measures commonly associated with evidence-based practice.

There was at least one respondent in each group who stated that they already had an evaluation tool similar to the one presented, or that they use a strength-based approach where they discussed these different types of resources with their client.

“ … what happens after treatment? We usually talk about these areas … so we’re already doing this, but not in a systematic way.” (Group 1)

“I believe that I already use this in treatment from the start, I use it to map out the needs, in, for example, group treatment.” (Group 2)

“You could say that we work according to these areas on different levels, depending on who we talk to. We use them [the areas] to highlight the parts we need to work on” (Group 4)

As illustrated in the excerpt above, the respondents mention that they already work according to the presented theoretical term, and some respondents even state that they already have an evaluation tool similar to the one we outlined.

“They [the clients] do what we call an ‘about me-emoji’. There’s an emoji in the middle with different areas surrounding it: my spare time, my hopes, my knowledge, my needs and so on. They do it at the beginning and at the end of their treatment, and we go back and look at it all the time. I also have other types of evaluation tools, one being the satisfaction circle. Have you seen that? You get to fill out how well an area works, say that one area represents spare time, you get to fill out that piece with a colour, based on how well that area is satisfied. They really enjoy doing this.” (Group 2)

Instead of using this as an argument for not implementing a new assessment tool, the respondents used ‘we’re already doing this’ as an argument to support the implementation of a new evaluation tool. When asked why they considered the RC assessment tool necessary, even though they said that they had a similar tool or method, some argued that they found it useful based on the demand for evidence-based practice:

“ … I’ve thought a lot about evaluation; I think that it’s very exciting … if you created a strength-focused resource evaluation tool, with evidence and university theories supporting it, I’d gladly change from the one we’re already using.” (Group 2, talking about the “about me-emoji”)

A respondent in Group 5 mentioned that at her previous place of work, she had tried a tool similar to the one we outlined. The respondent and her co-worker had developed a tool that covered areas similar to the ones included in RC, with the ambition of measuring change over time, and, in particular, not only evaluating the change based on aspects as sobriety. Instead of assessing different questions, the clients were asked to evaluate different areas in general. Due to the lack of support from managers and other co-workers, they decided not to continue to use the tool.

“It was an attempt to capture the complex reality we face. Some people succeed [in their recovery] while others fail, and we don’t know why. We can guess but we’re never really sure.” (Group 5)

The need for flexibility and simplicity

Each group emphasized that the tool should be easy to use, both for the client and for the professional. A complicated and time-consuming assessment tool would only increase the risk of not using it. As mentioned, the respondents in the different groups did not share the idea concerning how the evaluation tool should be formatted. A variation of suggestions were discussed where some argued in favour of a more therapy-focused assessment tool that the client and professional would fill in together during a therapeutic conversation, or one that the client filled in before entering the meeting, and that would then be used in the conversation between client and professional.

The discussion on the practical use of an RC assessment tool involved the applicability in different client groups. When asked whether the respondents believed that the applicability and usefulness of the tool would vary based on the client group, the vast majority stated that they imagined that it was useful, regardless of the client group. Some did, however, argue that it might not be appropriate to use when clients were active substance users, experiencing a great deal of anxiety or if they for any other reason had difficulty concentrating on the questions. Below is an excerpt highlighting an example:

“Interviewer: Can you imagine that this type of tool is more or less useful depending on the client group in which it’s applied?

Respondent 1: Maybe worse … that would be if they were active substance users … that they couldn’t focus on the questions …

Respondent 2: Or very depressed … then it might be difficult … maybe.

Respondent 1: But you could still work with it, because you could still see the strengths, because ‘you actually have this’ …

Respondent 2: So if you think like that you don’t have to exclude anyone.” (Group 3)

This conversation highlights the caveats of assessment tools in this field that are used systematically, and at the same time also underlines the importance of flexibility. The respondents acknowledge that there might be situations that do not allow for the tool to be used, but then state that it would not be a problem since, in their experience, they can always find something positive or a resource that is available. The same question in another interview provides a similar statement that further supports the importance of flexibility:

“It’s very situation and client-based, some have the capacity [talking about cognitive ability] and might actually find this useful, to clarify the progress. So yes, it would be useful in some situations for some clients.” (Group 2)

Others argued, with the emphasis on evaluation and assessment, that it could more or less replace problem-focused assessment tools such as the ASI, meaning that it would primarily be used to evaluate treatment needs and treatment outcomes:

“What if you could replace that damn ASI.” (Group 2)

Statements similar to the one above occurred in all the interviews. It is probably safe to assume that these types of statements are an expression of a negative attitude towards the ASI, and should not be mistaken for an argument in favour of the implementation of a recovery capital-based assessment tool. Strength-based assessment tools are presented as the opposite of problem-focused assessment tools. In a Swedish context, that means more or less that it is compared to the Addiction Severity Index (ASI), and as mentioned in previous sections, the ASI is associated with a few issues. A majority of the respondents expressed a dislike towards the ASI as a response to the question whether they thought a strength-based assessment tool would be useful or not. It is, at this stage, not safe to say whether the reaction is based on a substantial need for a strength-based assessment tool or whether it is just a negative attitude towards the ASI.

The role of the professional

Some of the respondents expressed concerns regarding their role in a situation where assessment tools was being used. One example illustrates the concerns regarding an addition of an assessment tool, in terms of figuring out what their role in the interaction is when including an assessment tool in their work:

“Who am I in this? Am I just supposed to strictly follow this? I deal with these questions in conversations already, I don’t know, it feels a bit systematic, I’m going to need more information” (Group 2)

Even though this group of respondents were a minority in the sample, their reaction highlights the need to develop the tool taking into account the opinions of those who are supposed to use it. The respondents did not completely agree on whether the systematic aspects were positive or negative. As stated in the quote above, one respondent suggested that the systematic aspect might mean that the social worker would get less time to make decisions and influence the therapeutic conversation. Another respondent added that it might affect the relationship between the client and the professional negatively – a crucial part in social work practice. Others argued that the systematic aspect was one of the main benefits of the tool and said that an RC assessment tool might even benefit the therapeutic alliance based on the notion that it is strength-based, and thereby provide a more humane evaluation of the client. The opinion that a recovery capital instrument might provide a more humane evaluation of the client was partly based on the notion that the discussion did not include ‘sad and bad things’ (Group 2). They further believed that a strength-based tool might be less stigmatizing for the client and as a result did not feel as if the social worker was the enemy. Altogether, these factors were assumed to contribute to the therapeutic alliance (Martin, Garske, and Davis 2000). Seeing that the evaluation tools and methods used in treatment are regarded as symbols for the general approach towards the clients, a strength-based tool is thought to improve the relationship, instead of generating a barrier between client and professional.

Those who were more sceptical towards the instrument stated that the strength-based approach was important and suggested that the tool should be more of a working method or guideline that might be helpful to the professional. This was considered especially useful for recently graduated social workers, as if the strength-based approach is based on knowledge you acquire as you interact with clients.

“ … it might be important, perhaps with recently graduated and new treatment staff to help them with the structure, but I’m primarily thinking about the client’s perspective, it [talking about the outlined assessment tool] is just too much.” (Group 2)

Discussion

Applicability in a Swedish AOD treatment context

A vast majority of the respondents had a positive attitude towards RC, both the general idea but also as a basis for an assessment tool. The ability to distinguish between different types of resources was, for example, highlighted as one of the more prominent benefits. When more detailed questions were raised, a more nuanced picture of their attitude emerged. Some mentioned that the systematic and standard aspects were something desirable, while others were more prone to highlight the negative aspects of assessment tools and standards in general. Respondents who promoted a new assessment tool as well as those generally against assessment tools agreed that the suggested instrument should be simple and flexible – a suggestion they believed would benefit both the client and the professional. The need for flexibility has been highlighted in previous research, where Timmermans and Epstein (2010) argue that the success of an implemented standardization is usually based on the extent of flexibility in the area in which it is implemented.

However, any interpretation of the statements made by the respondents has to be viewed while bearing a few important aspects in mind. The respondents were not able to comment on a specific assessment tool, instead they were asked about an “idea“. Consequently, it is not possible to say that the responses in the interview conform with their real attitude towards a specific instrument, and especially not their experience of using the RC assessment tool in their daily work – an aspect that has been highlighted as important in, for example, research on situated standardization (Björk 2017; Zuiderent-Jerak 2015). Lastly, the ASI was brought up a number of times as an example of an assessment tool that is not well suited for their working environment and their client interactions in their daily work. Hence, the request for an assessment tool that is simple and flexible could be interpreted as a manifestation of their dislike of the ASI. This further implies that the respondents would need to be introduced to a specific tool, and, not least, to evaluate the experience of using it in their daily work, before making any conclusions concerning the feasibility and applicability of the assessment tool in an AOD treatment context.

The role of the social work practitioner in a world of standardizations

Previous research has underlined challenges associated with the conflict between standardization and professionalism in social service organizations (Skillmark and Denvall 2018). Some statements in the interviews can be interpreted as an expression of this conflict. Social work practitioners, such as other street-level bureaucrats, encounter working tasks that include room for manoeuvre and situational adjustments, based on clients’ needs. In the meantime, the demands of evidence-based practice, and above all the expectations of documentation and evaluation this brings, may lead to a reduction of that particular room for manoeuvre, and in the end decrease the meaning of their professionalism. The statements that have been interpreted as highlighting this conflict have resulted in the conclusion that the recovery capital assessment tool would need to be constructed in such a way so as not to interfere with the room for manoeuvre and the ability to make situational adjustments. The conclusion drawn thereby resembles the conclusion from the previous section; if a new tool is to be added in the AOD treatment context, it needs to be flexible and not convey any doubt concerning the professionalism of the social work practitioner.

To summarize, previous research as well as the findings in this article have highlighted a divergence (Abrahamson and Tryggvesson 2008; Björk 2013, 2017; Brunsson and Jacobsson 2002; Skogens 2012; Timmermans and Epstein 2010) between the interests of professionals and the demands for documentation that a standardized approach entails (Hasenfeld 2009; The National Board of Health and Welfare 2019). The findings in the interviews have, however, provided key insights into possible ways this particular divergence can be handled. It is likely that implementation and developmental processes in the area of social work will always require trade-offs, such as the one between standardizations and the professionalism of the social work practitioners. As a result, the flexibility of the tool or method that is being implemented should be considered a crucial aspect concerning the consequences of the outlined divergence. However, present article have not provided any conclusions in terms of concrete examples of these potential solutions. Furthermore, the article have provided a first indication, but future research could preferably focus on supporting the development of solutions considering mentioned trade-off.

Legitimizing standards

Every group we interviewed stated that they already worked with a similar evaluation tool or approach in various ways, but that they at the same time, with few exceptions, expressed that they were interested in the instrument we suggested. When asked why they considered it useful, some said that they would like the method they were working with to be empirically tested and that they wanted something that could be used systematically, even though they expressed that the method or tool they were already using seemed to work pretty well. One respondent even developed a tool that she found useful, but due to the lack of support from managers and other co-workers, she found it difficult to continue using it. These statements can easily be related to the previously mentioned research that addresses the legitimation of standards (Grape, Blom, and Johansson 2006). Standards and standardizations are usually not coerced and will have to be rendered legitimate in other ways in order to be considered useful. The core of evidence-based practice consists of the ambition to provide non-harmful care, and to some extent to reduce arbitrary evaluations. It is difficult to interpret the respondents’ wishes for a tool that has been empirically tested, bearing in mind that they are convinced that the tool they are already using functions well. One interpretation could be that standards associated with evidence-based practice are in some way legitimized among the respondents, even though they are aware of the fact that they do not risk providing harmful care. The respondents, through their professional qualifications, arrived at the conclusion that the methods and tools they were using were not harmful, and in fact worked very well. Striving for evidence-based methods and tools might thus be defined as an external or governmental demand, but in the meantime so well integrated in social work practice that it is difficult to distinguish between the opinions of the street-level bureaucrat and the expert.

Limitations, the next step and concluding remarks

The scope of present article is limited to the experience and opinion of the professional. Although parts of the professionals’ opinions are based on interactions with clients on a daily basis, the client’s perspective is left unexplored. This further entails a client perspective described through the eyes of the professional, and it is not safe to say that these opinions are in line with the actual experiences of the client. Thus, future research should include a more prominent client perspective.

Present article has provided valuable insights as to how a potential RC-assessment tool should be formatted to be applicable in a Swedish treatment context, through the eyes of the professionals. In this early stage, the discussions came to focus on assessment and monitoring in general, as well as different opinions on the appropriate length and magnitude of tools integrated in treatment.

Further, the findings in this article are limited to opinions on the ‘idea’ of the assessment tool. It is thus necessary to conduct more research to determine the applicability in a practical environment. The next step involves further exploring the transferability of these internationally established assessment tools, in particular in terms of content, rather than shape and structure. Besides language, aspects as different social welfare models (Esping-Andersen 1990) and different cultural infrastructures (Timmermans and Epstein 2010) are likely to affect the applicability of the concept, and in particular the measurement items constructed to measure the specific concept. This entails further cooperation with professionals, and in particular provide them with the possibility of reflecting on interpretations of RC, as well as specific items designed to measure RC, to determine whether the importance of specific recovery resources remain when placed in a different cultural context with a noticeable different social welfare system.

To conclude, this article has provided a first glimpse at an attempt to develop a new assessment tool taking the practical environment it is thought to operate in into account. The findings indicate that the conditions are favourable to the implementation of an RC assessment tool in a Swedish AOD treatment context, but certain questions remain unanswered. The attitudes towards assessment tools in the area of social work are diverse and complex. Some argue that there is a need for systematization and standardizations, while others argue that these aspects reduce the importance of the professional. One of the questions that has emerged is whether these two perspectives are mutually exclusive, or whether it is possible to develop a tool that considers both perspectives.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. The terms ‘social work practitioners’ and ‘professionals’ will be used interchangeably.

2. Certain limitations were discovered concerning the accuracy in the self-assessed treatment needs as well as the self-reported consumption quantity (Anderberg and Dahlberg 2009).