Social work with people who use drugs during the Covid-19 pandemic - A mixed methods study

ABSTRACT

Measures to control the spread of Covid-19 are challenging social work practice in terms of difficulties to deliver services to vulnerable groups. The aim of this study was to investigate how the Covid-19 pandemic affected social work with people who use drugs regarding ways of working, quality of work, accessibility, and staff motivation. A mixed methods approach was used which included an online survey (n = 81), and three qualitative focus group sessions with social workers in the field of addiction. We analysed the quantitative data through frequency calculations, cross tabulations and Pearson’s χ² test, and the qualitative data with qualitative textual analysis. The demand for physical distancing challenged important principles of social work such as social closeness, trust and accessibility, and led to a difficult work environment and fewer opportunities to conduct high quality social work, as well as a reduced likelihood of vulnerable clients receiving adequate assistance. Altered practices concerning client meetings negatively affected assessments, working alliances as well as motivation and energy in social work practice. Social workers on the frontline became the ‘last outpost’ when other services shut down, and ‘digital bridges’ between clients and other social workers. Social workers faced a difficult trade-off between protecting themselves and clients from the risk of infection and providing support to a vulnerable group. There were also examples of new practices and lessons learned, for example, the introduction of ‘walks and talks’ with clients and an increased knowledge of how and when to use digital tools for communication.

KEYWORDS:

• Covid-19
• social work
• digitalization
• addiction
• working alliance

Introduction

The Covid-19 pandemic has had an intense impact on the global economy, public health and people’s everyday lives. Economic activity has decreased and unemployment has risen in many countries, which, in both the short and long term, risks affecting the health of populations and the ability of states to offer welfare services to all citizens (UNODC 2020). The first confirmed case of SARS-CoV-2 infection in Sweden was identified on the 31st of January 2020 and domestic spread of infection was identified in March. Sweden’s public health response to the Covid-19 pandemic has been characterized by an open approach with assumed citizen trust in the government and infection control measures, open public venues and hesitant introduction of restrictions (Kamerlin and Kasson 2020).

In the early phase of the pandemic, the UN (UNODC 2020) warned that the pandemic could significantly increase psychiatric problems, mental illness and the use of alcohol and other drugs. In the longer term, the Covid-19 pandemic may, through economic crises and changed patterns of drug consumption, increase poverty and reduce economic opportunities for already vulnerable groups. A deteriorating economic situation can lead to increased harmful drug use. Studies on the global financial crisis in 2008 show that many European countries cut back on the financing of drug treatment interventions (UNODC 2020). Depending on how the Covid-19 pandemic develop there is a risk that social work with people who use drugs (PWUD) might be affected negatively through reduced funding, despite potentially increased social problems.

People who use drugs are a particularly vulnerable group due to a high degree of problems related to mental and physical ill-health, crime, homelessness and socio-economic vulnerability (Degenhardt et al. 2017). There are indications that PWUD are more vulnerable to Covid-19 due to underlying diseases, lack of health literacy and societal stigmatization of drug use (Nordgren & Richert 2022). The group generally has a high prevalence of tobacco smoking, chronic lung diseases, and other health problems that may involve an impaired immune system (European Monitoring Centre for Drugs and Drug Addiction [EMCDDA] 2020). In situations when the health care and welfare system is in crisis, marginalized groups risk not receiving care of the same quality as others (van Boekel et al. 2013). PWUD generally have a great need for various social and health care services. This may, for example, apply to treatment interventions for addiction, health care, housing interventions and financial assistance. The range and organization of these types of intervention vary greatly between different countries and contexts, but the availability of interventions is also governed by factors such as stigma and society’s view of drug problems and how these should best be handled (van Boekel et al. 2013; Biancarelli et al. 2019; O’Keefe-Markman et al. 2020).

Various services focused on harm reduction for PWUD have been forced to limit opening hours and reorganize activities due to the Covid-19 pandemic (Bartholomew et al. 2020). This has meant poorer opportunities for arranging social meeting places, and reduced access to food, clothing and basic health care for an already vulnerable group (European Monitoring Centre for Drugs and Drug Addiction [EMCDDA] 2020). It is important for organizations that provide interventions for PWUD to ensure that staff are protected against infection. The Covid-19 pandemic created challenges regarding staff shortages, high workload and the closure or restriction of operations. Social work organizations must plan for how continuity in treatment and support can be ensured and, in many cases, the daily work must be changed, for example by reducing physical contact with clients and patients by switching to digital meetings (European Monitoring Centre for Drugs and Drug Addiction [EMCDDA] 2020).

This exploratory study is based on an online survey and three qualitative focus group sessions with social workers in Malmö, Sweden, working in the field of addiction. In Sweden, the responsibility for organizing addiction treatment is shared between the social services (responsible for prevention, social support, housing as well as non-medical treatment interventions), and the health care service (responsible for medically oriented interventions). This means that social work represents the profession that most help-seeking PWUD meet.

The aim of this study was to investigate how the Covid-19 pandemic affected social work with PWUD regarding ways of working, quality of work, accessibility, and staff motivation. The research questions analysed in this study are the following: 1) How did social work units and organizations targeting people who use drugs change their routines and working methods due to the Covid-19 pandemic? 2) Were different types of social work with PWUD affected in different ways?, 3) In which ways did a shift to physical distancing and digital meeting programmes affect the working alliance, quality and accessibility of social work?

Contextualizing social work during the pandemic

Challenges in social work

The Covid-19 pandemic has put strain on social workers as they must handle infection control, restrictions and an increased workload. Some important principles of social work are social closeness, trust, transparency, flexibility and accessibility (Payne 2011; Banks 2016). The handling of the Covid-19 pandemic with its demands for physical distancing and infection control challenges these principles and may affect social work in several ways.

Social work is a broad practice that can include therapeutic treatment work, outreach and preventive work, assessments of clients’ needs, decisions on treatment, housing and economic and social support, and structural social work aiming at social change and development (Coulshed and Orme 2012). Social work with PWUD can be linked to all these levels and is carried out by government institutions and civil society organizations. The possibility to redirect the work in relation to physical distancing requirements (such as using protective gear, limited opening hours, working from home) and their consequences thus may vary depending on what type of work is conducted and towards which target group of clients. It might for example be especially challenging to shift to physical distancing and digital meetings in frontline social work with older adults or outreach work with persons experiencing severe drug addiction problems and homelessness, when the work necessitates meeting clients daily and face to face.

Close interaction with clients is a central feature of most social work practice. Sociologist Randall Collins (2004) propose that reoccurring interactions with a shared focus can generate emotional energy. An important task for social workers who work with drug treatment is to facilitate changes for the client that enable the creation of emotional energy outside of drug use and related social networks. Additionally, regular meetings with clients should preferably themselves become energized with emotional energy, since ‘High levels of emotional energy in an individual consist of feelings of enthusiasm and confidence; low levels are manifested as apathy and depression’ (Collins 1993, 211). Emotional energy can thus be an important aspect of the creation of a working alliance between social worker and client.

The ability to create a close, collaborative and trusting relationship is central to social work and therapeutic treatment work and has been described as decisive for treatment outcome across various settings and client groups (Horvath et al. 2011). A rewarding treatment relationship usually presupposes a so-called working alliance or therapeutic alliance characterized by a strong bond between client and therapist, agreement on tasks directed towards improvement, and agreement on therapeutic goals. Reviews of therapist-based characteristics that contribute to the alliance have identified factors such as empathy, openness, warmth, genuineness, confidence, respect, flexibility, honesty, and use of self-disclosure to be important in this regard (Flückiger et al. 2018; Nienhuis et al. 2018).

Digitalization

A swift change to digital technology in social work practice due to physical distancing measures has been experienced as a paradigm shift and has entailed more discussions about the access to digital technology among clients and notions of confidentiality and privacy in social work (Mishna et al. 2021). The pandemic has also given rise to ethical challenges in social work, such as how to create and maintain a working alliance with the use of telephone conversations or digital technology, and how to assess and distribute resources and time in pandemic conditions where clients’ needs may be greater than before (Banks et al. 2020). In recent years, different types of internet-based methods for communication and treatment have gained ground in health care and social work. The term telehealth refers to the distribution of a wide range of health-related services and information via electronic information and telecommunication technologies. During the Covid-19 pandemic the telehealth model stands out as a strategy to enhance accessibility to services, reduction of barriers, and continued delivery of treatment to vulnerable groups such as PWUD (Kim and Tesmer 2021). In this way the Covid-19 pandemic has been a catalyst for the digitalization process that already has been gaining ground during the last decades (Amankwah-Amoah et al. 2021).

It is important to recognize that there are obstacles and risks associated with the use of technology in delivering services. Problems relate to lack of internet access, as well as ethical and privacy issues. Some vulnerable groups also may lack digital capital (i.e. accumulation of digital competencies) or experience ambivalence towards technology (Kim and Tesmer 2021). Concerns have also been raised about whether an adequate working alliance can be formed between therapist and client when therapy is delivered digitally rather than face-to face. One systematic literature review showed that the working alliance in videoconferencing therapy was inferior to face-to-face delivery, but that target symptom reduction was noninferior (Norwood et al. 2018). Studies of telehealth services for outpatient treatment for substance use disorder during the Covid-19 pandemic have reported mostly positive outcomes. Clients report satisfaction with individual telehealth therapy but are less supportive of group therapy (Sugarman et al. 2021), and providers report confidence in individual counselling but less confidence in telehealth group counselling and intake assessment (Mark et al. 2021). However, telehealth services for people who inject drugs is challenging due to low availability of mobile phones and internet access within this group (Delisle-Reda, Bruneau, and Martel-Laferrière 2022). The gradual shift to digital communication tools such as Microsoft Teams and Zoom in social work with PWUD can be interpreted as part of a general trend towards digitalization in social work. One risk in this development is that digital communication tools may impact negatively on therapeutic relationships, treatment quality and equality of access to services. However, digitalization in social work is associated with both problematic and fruitful developments for the practice and more knowledge is needed about how and when social workers in different kinds of services employ digital technology and to which groups of clients (Steiner 2020; Nordesjö, Scaramuzzino, and Ulmestig 2021).

Methods

In this exploratory study we used the city of Malmö as a local setting to study how the Covid-19 pandemic affected social work with PWUD during the early stage of the pandemic (i.e. from domestic spread in March of 2020 up to January of 2021). We employed a mixed methods framework that combined quantitative descriptive statistics and qualitative focus group interviews. Our approach to mixed methods was qualitatively driven (Hesse-Biber, Rodriquez, and Frost 2015), in that our core method was qualitative, while we used descriptive statistics as complimentary data. To study the impact of the Covid-19 pandemic on social work with PWUD, we launched an online survey and organized three focus groups with social workers in Malmö. By combining a mixed-methods survey gathering both quantitative and qualitative data, with qualitative focus groups interviews, we could describe general trends in variables and illustrate the details of the trends through qualitative data analysis.

Recruitment and procedure

Online survey

The survey focused on issues relating to social work with PWUD broadly and contained a section with both fixed and open-ended questions specifically about the Covid-19 pandemic. Information about the online survey was sent out by email to around 100 social workers who worked with PWUD in Malmö. Several reminders were also sent out by email. In a second wave of advertising, information about the survey was published on the intranet of Malmö municipality. The head of social work with addiction in Malmö estimated the number of staff working with PWUD at just over 100 persons. The 81 respondents who finalized the survey thus represent most of the social workers within the field of addiction in the city. The survey was launched on the 20th of May 2020 and was closed on the 20th of August 2020. We chose a short data collection period to obtain a snapshot of the effects of the pandemic at a relatively early stage. As such, the survey responses are cross-sectional and offer data on social work with PWUD during that specific period of the Covid-19 pandemic. The questions concerned how Covid-19 affected social work practice, how client meetings might have changed from face-to-face to digital, and measures implemented to minimize the risk of contracting the new virus.

The respondents were able to answer questions using a five-degree Likert scale with the options ‘Not at all’, ‘To a small extent’, ‘To some extent’, ‘To a large extent’ and ‘To a very large extent’. The respondents were encouraged to write longer free text answers as comments on the questions and we have focused on these in the qualitative analysis.

Focus group interviews

We conducted focus group interviews with participants representing social work units and low-threshold services in Malmö that offer services and treatment specifically to PWUD. The participants were recruited through an ongoing research and professional development network for social workers led by the authors. The focus group interviews were held via Zoom on the 18^th of May 2020, 2^nd of November 2020, and the 11^th of January 2021. The focus group in May aimed to supplement the parallel survey and to get an in-depth picture of the current situation. The focus groups in November and January aimed to discuss the results of the survey and examine the extent to which the situation had changed at a later stage of the pandemic. The questions about Covid-19 discussed in the focus groups were how the pandemic affected working methods, collaboration and the quality of work, and to what extent information, support and protective equipment were received in the workplace. The three focus groups were recorded and subsequently transcribed verbatim.

Participants

In total, 81 respondents answered the survey. Sixty-six respondents were female, 14 male and one non-binary. The age range was from 24 to 67, with a mean age of 39. Overall, the respondents of the survey were a group of experienced social workers where the majority had worked for several years. The number of years working specifically with PWUD ranged from 1 to 49, with a mean number of 9.71. There was a great breadth in the work areas represented, including staff at supported accommodation, outpatient treatment, institutional care, investigation units, low-threshold activities and outreach work teams.

The focus group consisted of people who work in the social services, low-threshold services, supported accommodation, the needle exchange programme, a civil society organization, the Church of Sweden, opioid substitution treatment and an out-patient treatment programme for younger PWUD. In total, ten professionals, three men and seven women, participated in the focus groups, with five of the participants present in all three focus groups. Throughout this text, we refer to the study participants who finalized the survey as respondents and the focus group participants as interviewees.

Analytical approach

The web survey was constructed and carried out using Artologik Survey&Report, and the data was subsequently exported into SPSS, where the statistical analyses were conducted. We analysed the data through frequency calculations and cross tabulations with pair-wise comparisons and Pearson’s χ² tests. These tests were conducted to analyse how common changes in social work practice were, and if these changes differed between different types of social work.

The free-text responses in the survey and the transcribed focus group interviews were analysed by employing central principles of qualitative textual analysis with the aim of interpreting meaning in the empirical material (Kvale and Brinkmann 2009). Coding was carried out in a three-step process. The first step consisted of reading all qualitative data to obtain a holistic view of the material. In the following step the material was categorized into broad themes based on significant topics brought up in the focus group sessions and reported survey. The themes were then jointly checked for consistency and how they related to each other. In the third step, we selected excerpts that represented these themes for inclusion in the results section, and translated those from Swedish to English.

Ethics

The project on which this study is based was approved by the Swedish Ethical Review Authority (Dnr 2019–06509). The survey respondents filled in the survey anonymously after providing informed consent. We have handled the free text answers with discretion, and we have removed or changed details that would identity a specific respondent. We have also anonymized both focus group interviewees and the survey respondents. The interviewees provided oral informed consent in each focus group session.

Results

The impact of Covid-19 on social work practice and organization

According to the respondents, the Covid-19 pandemic had resulted in several changes in social work with PWUD in the city of Malmö. The majority of the respondents in the survey, over 70%, stated that they to a large or very large extent changed their ways of working due to the pandemic.

As seen in Table 1, there were significant differences in perceived changes to social work practice depending on the type of social work conducted. A significantly higher proportion of those working with assessment/screening and treatment had to a large or very large extent changed their way of working compared with those working in outreach work or in low-threshold services.

Table 1. To what extent do you perceive that the current Covid-19 situation has changed the way you work? Pairwise comparison and Pearson’s chi-square test.

		Not at all, to a small or to some degree	To a large or very large degree		P-value
Type of work	Assessment/screening	21.7% (5)	78.3% (18)	100% (23)	0.004
	Outreach/low-threshold	66.7% (12)	33.3% (6)	100% (18)
	Assessment/screening	21.7% (5)	78.3% (18)	100% (23)	0.527
	Treatment work	15.4% (6)	84.6% (33)	100% (39)
	Outreach/low-threshold	66.7% (12)	33.3% (6)	100% (18)	<0.001
	Treatment work	15.4% (6)	84.6% (33)	100% (39)
Total		28.7% (23)	71.3% (57)	100% (80)

What the social workers experienced as the most intrusive change was the transition from physical client meetings to meetings via telephone or digital meeting programmes such as Microsoft Teams and Zoom. As can be seen in Table 2, the majority of the social workers, about 56%, stated that physical meetings with clients had to a large or very large extent been replaced by meetings by telephone or digital meeting programmes. However, the extent to which this change was reported differed depending on type of work. A significantly higher proportion of social workers who worked with assessment and screening had switched to digital or telephone meetings in comparison to social workers working with treatment or out-reach work/low threshold services.

Table 2. To what extent have physical meetings with clients been replaced with meetings by telephone or digital meeting programmes? Pairwise comparison and Pearson’s chi-square test.

			Not at all, to a small or to some degree		To a large or very large degree		P-value
Type of work	Assessment/screening			21.7% (5)	78.3% (18)	100% (23)	0.010
	Outreach/low-threshold			61.1% (11)	38.9% (7)	100% (18)
	Assessment/screening			21.7% (5)	78.3% (18)	100% (23)	0.029
	Treatment work			50.0% (19)	50.0% (19)	100% (38)
	Outreach/low-threshold			61.1% (11)	38.9% (7)	100% (18)	0.436
	Treatment work			50.0% (19)	50.0% (19)	100% (38)
Total		44.3% (35)			55.7% (44)	100% (79)

Free text comments from the survey and the discussions in the focus groups largely confirm the differences between different work units and show the characteristics of the changes. A central theme that both respondents and interviewees agreed with was that the Covid-19 pandemic had a negative effect on the work situation and on the possibility to offer adequate services to some client groups. Examples of the most common and fundamental changes include a transition from physical meetings to meetings via telephone or internet-based solutions, working from home to varying degrees, using protective gear, pausing certain activities, increased workload due to sick leave among colleagues, changes in work routines and opening hours, as well as difficulties in collaborating with other social welfare services. The following two quotes from the free text answers in the survey illustrate some of these changes:

Fear among staff and clients. More work tasks. Certain activities that cannot be carried out due to restrictions. Clients who are unable to participate in activities due to symptoms and who become isolated (respondent 19).

We also work more from home, which in many ways makes the work more cumbersome, and the availability [of services] for clients decreases (respondent 24).

The reduction in access to some services put additional pressure on low-threshold services that did not change their ways of working to engage with PWUD. In a discussion from one of the focus groups, it became clear that several of the staff in low-threshold services that worked closely to PWUD took an additional and large responsibility to help vulnerable clients during the Covid-19 pandemic. For example, a social worker at a low-threshold accommodation for PWUD said:

I mean, we struggle on as usual … . What we are trying to do is to keep our distance and we do not shake hands and we still do not allow people to come and visit. But everything else is the same.

Interviewer: Has there been a lot of discussion in the staff group about different views on how to handle this, for example about protection for yourselves and so on?

No, everyone is pretty much in agreement […] ‘We have to do it like this’. I mean, we are the only ones who meet these clients right now, us together with the outreach group sort of, so we have to do it. We go [with clients] to the tax office and get ID cards, we go to the hospital, health centers, everything (social worker at a low-threshold accommodation).

It is clear in this quote and in several other descriptions that frontline social workers, i.e. those who worked close to the clients in outreach and low-threshold services reported the fewest possibilities to change their work. A dilemma arose about the importance of infection control and physical distancing on the one hand, and clients’ need for help and support on the other. This occurred in a situation where many other community initiatives had limited accessibility. In some cases frontline social workers covered up for closed services and in other cases they became a link between clients and other services.

The social worker at a low-threshold accommodation in the quote above continued this line of thought:

If we speak about our client group, it’s just plain luck that we have them here at our place and that they are in contact with the outreach team. Otherwise, the authorities would never have been able to reach them by telephone or Teams, because they [the clients] seldom have their own phones and especially not smartphones that can use Skype. So all the time we have to sit by the computers with the clients and sometimes you feel a bit abandoned – we sit here with the client and it’s only us who meet the clients at the premises. Before, there was much closer cooperation with other units (social worker at a low-threshold accommodation).

This aspect of working closely with users and being one of a few units meeting these clients and patients was also recognized by a social worker at the needle exchange programme:

Because there are several other units that have closed down it is important that we are available to these patients. And we have been given more testing to do that normally the other units conduct. And we see the effects of some opioid substitution treatment clinics not running as normal, which means that they [the clients] come to us and ask for help with stuff that they perhaps wouldn’t have done otherwise. And they say that they come because those units have changed their way of working now. So we have more work to do (counselor at the needle exchange program).

Some of the social workers in voluntary organizations also experienced increased pressure in their services when homeless persons or older people who do not always have access to a computer or telephone had difficulty reaching various authorities or social work units. When services to a higher degree rely on digital meetings, there is a risk for greater inequality in access to treatment, which may impact on particularly vulnerable PWUD. A social worker at a voluntary organization that offers free lunches, social activities and support described how in some cases she also became a link between their older clients and other social welfare services when she assisted them in communicating via telephone and computer. These examples show how some frontline social workers became ‘digital bridges’ between their clients and other social work units. Clients with low degrees of digital capital needed the resources and digital services held by staff. Overall, there had been a clear increase in workload for frontline social workers and they reported that they were essentially the only professionals who physically met with PWUD.

The shift to digitalization – impacts on working alliance, treatment quality and motivation

The social workers experienced major concerns and problems with meetings by telephone or digital meeting programmes. A fundamental problem was that clients may lack a telephone or technical equipment, or lack knowledge of how to manage meetings via digital meeting programmes. This meant difficulties in ‘contacting vulnerable people who can be assumed to be in need of support’, and that some clients had ‘fallen away’ (respondent 3). Problems with one’s own technical equipment and poor internet connection were also highlighted as obstacles by some social workers. The fact that clients may be in environments (e.g. at home or on the bus) where other people are present can be problematic in terms of ability to focus, and from a confidentiality point of view because ‘you never know who is listening’. Some of these problems and concerns seem to have decreased gradually, as both social workers and clients gained more knowledge, became accustomed to digital meeting programmes, and developed strategies to deal with various obstacles. This was clear in the last focus group where interviewees described that they and colleagues had developed their knowledge and confidence in using digital meeting programmes, which may be interpreted as an increase in digital capital among social workers.

A few social workers stated that meetings via telephone or digital meeting programmes worked just as well as physical meetings and that the quality was not negatively affected. Positive aspects of digital meetings brought up was that they were generally shorter and more effective and that the client (or social worker) did not have to travel to a physical meeting. Most social workers found digital and telephone meetings to be disadvantageous and several expressed a fear that digital meetings may replace physical meetings as a standard after the pandemic, as this could mean economic savings. Three key areas in client contact were negatively affected when switching to such meetings: 1. assessing needs and making decisions 2. creating a working alliance at distance, and 3. the personal enjoyment, motivation and energy in the client work. In the following section we present a more detailed analysis of these themes.

Assessing needs and making decisions

Assessing clients’ mental and physical health, drug problems, current life situation and support needs was challenging in telephone and digital meetings. Many respondents wrote that not meeting physically could result in difficulties in ‘making correct and fair assessments’ and thus making the right decision about interventions or the possible rejection of interventions in terms of legal certainty. This aspect was also brought up in one of the focus groups. One interviewee said that an assessment of treatment needs or an Addiction Severity Index interview might be conducted more swiftly by telephone, but that ”there is a risk that certain information may be lost“. Another interviewee pointed to the risk that in some digital meetings you do not get an overall picture of the client: ‘I have a client who does not like technology at all or to be filmed … I don’t know. It is certainly great in some cases and effective in some cases and in others I think you miss a holistic view’ (social worker at out-patient treatment). A third participant who conducted assessments of treatment needs also believed that it can be more difficult to justify the granting of an intervention to a manager if it is not possible to describe the client’s current condition based on a physical meeting:

And exactly this holistic view, I mean, in a meeting with the client it’s very clear that you assess the client a lot based on, well, clothing and looks but also body language and so on. Do they sit and yawn, how do they sit in their chair, what do they say, facial expressions and so on. All those aspects are lost. When we make our decisions we present them to a boss who won’t see these things anyhow, but we sometimes try to illustrate ‘why should this guy get treatment?’. ‘Well, because if you had seen him you would have understood’ (social worker at the social services).

As exemplified by the quotation above, the tacit knowledge possessed by social workers was seen as an important part of assessing client needs and formed the basis of further interventions and treatment together with the working alliance. The potential negative impact that physical distance can have on how decisions are made and communicated was also raised. According to some social workers, an increased physical distance could entail a risk that it will be easier to make and communicate government decisions that are negative for the client.

Creating a working alliance at distance

A central theme in the survey responses and in the focus group interviews was centred around problems of creating a close relationship and a working alliance with clients without physical meetings, especially in the initial phase of a contact. Several participants argued that this problem negatively affected the quality of social work and the possibility to offer adequate support. One respondent summarized some of the problematic aspects of not meeting physically, mentioning a lack of tools and ethical stress:

In some cases, it is more difficult to identify and arrive at treatment goals, especially with new clients. I lack the tools and methods for treatment in digital form. Ethical stress - wanting to do a good quality job - fear of losing clients, being unable to interpret body language by phone in the same way, all create a distance in certain conversations (respondent 50).

Several respondents stated that the type of contact that suits different clients varies greatly. Some clients do not like to talk on the phone, while others, such as older clients, may have difficulty with digital technology. A social worker who worked with treatment described how conversations over the phone meant that you miss a lot of the silent communication in the form of body language and facial expressions that can be important parts of treatment conversations. These are aspects that are important in the development of a working alliance. One respondent described some of the challenges and possible ways of handling them:

We have switched from meeting in conversation rooms to having contact either by phone or outdoors on a walk or sitting on a bench. On the phone, you miss things that happen in the room (things that are not said, silence, wet eyes, body language, etc.) and which can be important to pay attention to in a treatment session. It is a little easier outdoors when we meet physically. However, there are other challenges outdoors, for example, external stimuli that can make it more difficult to stay focused and/or make it more difficult to discuss topics that are perceived as sensitive (respondent 60).

As the quotation above illustrates, the social workers developed strategies to handle problems relating to physical distancing requirements. One such strategy was to meet outdoors in the form of ‘walk and talks’, but this solution also involved challenges.

The personal enjoyment, motivation and energy in client work

It is not only the quality and accessibility of social work that might be affected by the shift to digital meeting programmes. Some respondents reported that you ‘lose a little bit of the enjoyment in the job’ when it was not possible to meet the clients physically. Meetings became more impersonal and there was not the same energy and motivation in meetings:

I feel that some people find it a little more boring to work without [physical] client contact, because I guess that people become social workers because they like working with people and there is less client contact in that way. But the times are as they are, and you have to adapt (social worker at the social services).

Respondents stated that the lack of physical contact and touch affected both themselves and the clients negatively and that it can have a negative impact on motivation, which can be interpreted as a negative impact on emotional energy and enjoyment in social work (Collins 2004).

An additional dimension of physical proximity and touch is the ability to reassure or comfort clients who are in crisis or in a particularly vulnerable situation. This was perceived as more difficult via telephone or digital meetings because the physical contact was seen as crucial in this context. Even in cases where social workers and clients met physically in the same room requirement for physical distance meant that safety distances had to be maintained, physical contact avoided, and sometimes gloves and a visor worn. Such a situation may become mentally stressing for both the social worker and the client. A counsellor at a low-threshold service described the problems that the requirements for distancing entailed in her work:

If you meet a patient in crisis who is very sad, it is also difficult to just sit on the other side of the desk in another chair. Even if you should not have too much physical contact now, to be able to hug someone who is sad, to be able to be close to someone in that way … I feel that I miss that in some of the meetings, both here and with newly diagnosed HIV patients for example, or patients who are hospitalized and are sad and sick … it still does something when you can hug or give a pat on the shoulder. I think that is definitely a big difference now. (counselor at the needle exchange program).

As seen in this quotation, the physical distancing impacted negatively on the social and emotional dimensions of the work. In working at distance, the social workers described challenges in creating emotional energy, as seen in their descriptions of losing enjoyment and motivation in their work.

Discussion

Based on the results of an online survey and focus groups with social workers, we found a range of challenges in social work organization and practice due to the Covid-19 pandemic. The results show that the pandemic entailed extensive changes in terms of the range and organization of social work interventions as well as the everyday social work practice, which has been reported also in other studies (Banks et al. 2020). According to the social workers, these changes had a negative effect on their overall work situation and the quality of work, and meant poorer opportunities for support for PWUD.

The Covid-19 pandemic affected different types of social work in different ways. Frontline social workers described an increased workload while experiencing the least opportunity to switch from physical to digital meetings. Limited access to services and meeting places, as well as limited digital capital among certain vulnerable groups (e.g. homeless persons, persons with mental health problems and older people) increased the pressure on frontline social workers. They became the ‘last outpost’ when other services shut down or became less available. In other cases, frontline social workers became ‘digital bridges’ between clients and other social workers or services. They used their computers or telephones to help older people or homeless PWUD in their communication with various government officials. Becoming digital bridges can be seen as one way that social workers used their higher levels of digital competence and access to technology compared to their clients, to counteract the digital divide and thus increase access to services for marginalized PWUD. A difficult situation occurred for frontline social workers in the trade-off between protecting themselves and clients from the risk of infection and providing help and support to a vulnerable group. Our finding that frontline social workers acted as last outposts and digital bridges show the importance of social work in crises. The additional risks and burden that this involves calls for the allocation of more resources to this kind of frontline social work, as well as measures ensuring that the work can be carried out under safe conditions.

Social workers who worked with assessments, screening and treatment had to a great extent switched from physical meetings to digital or telephone-based meetings and to working from home. This meant better opportunities for protection from infection by means of physical distancing, but at the same time entailed challenges in meeting the needs of all clients and in providing high quality and rewarding social work. Important principles in social work such as social closeness, trust, flexibility and accessibility (Coulshed and Orme 2012) were challenged by the demand for physical distancing. To interact with clients at an increased distance through digital technologies risks creating weak or failed social rituals and may lower the confidence and initiative of social workers and clients, affecting emotional energy in the work (Collins 2004). It seems that some aspects of social work with PWUD, such as assessments and follow-up, may be replaced or complemented by digital tools, but other tasks that to a higher degree involve emotional and relational aspects of practice may be extensively reliant on physical closeness. Another concern that some social workers expressed was that physical distancing might affect decision-making. For example, there may be less resistance among social workers towards making decisions that affect clients negatively when not meeting physically. This is one example of difficult ethical issues concerning digitalization in social work that needs to be explored in more detail (Nordesjö, Scaramuzzino, and Ulmestig 2021).

Digital tools for communication and data management in social welfare settings can be both enabling and constraining for social workers and clients. The notions of the digital divide and digital inequality have been used in previous research to point out that access to digital technology as well as digital knowledge is unevenly developed in society (Hansen, Lundberg, and Syltevik 2018). This became especially pressing during the Covid-19 pandemic within social gerontology in situations where older persons in care had to isolate and where social contact with relatives and friends occurred via digital technology (Gibson, Bardach, and Pope 2020). Although there have been calls for the development of telehealth/medicine and tele-psychiatry during the pandemic (Wahezi et al. 2021; Kim and Tesmer 2021), our results show that social workers in the addiction field saw several problems with telephone and digital solutions in client work, especially regarding assessment of clients’ needs, the development of a working alliance with clients, as well as loss of enjoyment and motivation in the work. However, we could also see that social workers developed their knowledge and practices regarding how and when to best make use of digital tools for communication. As such, it is possible to view the pandemic as having had an influence on increasing digital capital and competencies among social workers.

Our mixed methods approach allowed us to investigate changes in professional practices from May 2020 up to January 2021. As street-level bureaucrats the social workers seem to have a relatively large degree of discretion on how to interpret and enforce new rules, guidelines and policies relating to the Covid-19 pandemic. They have flexibility in their work which is important in meeting client needs in situations of rapid change, but this also involves uncertainty and responsibility for making difficult decisions and trade-offs. Especially at the start of the pandemic there was criticism of the slow communication and ambiguity of guidelines, and a lack of protective gear. These problems created worry and confusion for both social workers and clients. Furthermore, at the beginning of the pandemic there was a greater uncertainty, lack of knowledge and scepticism about the use of digital technology by social workers. However, social workers adapted to new technology and found both pros and cons in digitalized ways of working (Steiner 2020) and alternative ways of meeting with clients during the Covid-19 pandemic, such as walk-and-talks. These developments in practices and knowledge might also be of use in social work practice following the Covid-19 pandemic, considering that the pandemic has been described as a ‘great accelerator’ in speeding up the global trend of digitalization (Amankwah-Amoah et al. 2021).

Conclusions

The demand for physical distancing challenges important principles of social work such as social closeness, trust and accessibility, and led to a difficult work environment and fewer opportunities to conduct high quality social work, as well as a reduced likelihood of vulnerable clients receiving adequate assistance. Our study shows that social workers were aware of several risks that resulted in negative consequences for social work quality, and equality in access to support, due to the Covid-19 pandemic. The risks highlight a dilemma between offering high quality services and protecting staff and clients from disease transmission. The difficulty regarding protection from SARS-CoV-2 was especially present among frontline social workers since they had the least possibility to change their ways of working towards digitalization, being the ‘last outpost’ for vulnerable PWUD.

We believe it is important to continually assess and review social work organization and practice in the context of physical distancing requirements and lockdowns that may be recurring issues in the future. Such assessments should keep track on and document changes to social work practice and organization during and after the pandemic, which might provide important knowledge needed during future crises. More research is needed about the effects of increased use of digital meetings in different social work settings and to what extent and how these will continue to be used after the pandemic. Such research might focus on how digitalization may affect working alliances, decision-making processes, and emotional energy in day-to-day social work.

Acknowledgement

We would like to thank the survey respondents and the focus group participants for sharing their experiences and knowledge. We also thank the two anonymous reviewers for valuable comments on the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by the Riksbankens jubileumsfond [P18-0892:1].