Talking about change – Positioning and interpretative repertoires in stories about substance abuse and change

New institutional structures for social work

Over the past two decades, a number of policy and governance reforms throughout western Europe have established new institutional structures for social work. Many of these changes have been prompted by criticisms made of poorly coordinated social services. In response, integrated service models, often called one-stop shops, have been established in many countries (Askim et al., 2011; Minas, 2014). Activation, which refers to ‘social policies and programmes aimed at promoting the (more or less obligatory) participation of people dependent on unemployment benefits or social assistance in work’ (Van Berkel and Borghi, 2008: 332), has become a key target for social policy. This activation discourse implies important challenges for the organisational provision of individualised counselling services (Caswell et al., 2013; Heidenreich and Graziano, 2014; Lodemel, 2014). Both activation and integrated service models are consistent with broader trends to introduce regulatory policies and procedures in the public sector, often referred to as New Public Management (Bradley et al., 2010; Healy, 2014).

Activation has been a driving force in Norwegian social policy for decades. After the largest and most extensive activation and coordination-oriented reform in Norwegian history (2006–2011), a new front line service, called local NAV offices, was established (Christensen et al., 2010). Each NAV office is designed as a one-stop local welfare office combining social welfare services, unemployment services and financial social assistance. The overall objectives of the NAV office are to help clients gain employment as well as to provide clients with person-oriented, holistic and efficient welfare services. Central in achieving these goals are professionals having generalist caseworker competence. Since the NAV offices were established, a number of evaluations have shown that these goals of the NAV-reform have been difficult to coordinate and that the workfare orientation has been one-sidedly emphasised (Lægreid and Rykkja, 2014; Lodemel, 2014; Nilssen and Kildal, 2009).

We explore constructions of change within this new organisational management by looking at how a group of counsellors working in NAV talk about working with people with substance abuse problems. The drug and alcohol policy in Norway is integrated in and implemented through general health and welfare schemes (SIRUS/EMCDDA, 2015). The municipalities have the overall responsibility for monitoring individuals with substance abuse problems and NAV is an essential part of this system (Håland et al., 2014). In addition, people with substance abuse problems can get other municipal health and care services and be referred to multidisciplinary specialised services that give ambulatory or residential treatment. Clients with substance problems are often multiple service users representing a major target group for the NAV-reform (Lægreid and Rykkja, 2014). At the same time, substance abuse represents a major challenge to political objectives of getting more social service beneficiaries into the labour market (Ekspertgruppen, 2015).

‘Change’ and ‘substance abuse’ as objects of exploration

Previous research on substance abuse demonstrates two themes relevant to our concern. First, research demonstrates that substance abuse and change are understood and conceptualised in a myriad of ways (Laudet, 2007; McLellan, 2010; Neale et al., 2014; Sinnott-Armstrong et al., 2013). For instance, some researchers describe substance abuse problems as forms of a chronic, relapsing disease requiring long-term or lifelong treatment (Laudet, 2011; McKay and Hiller-Sturmhöfel, 2011; McLellan et al., 2014; O’Connor, 2013). Other researchers contend that addicts can choose to recover (Satel and Lilienfeld, 2013) and that many addicts quit using drugs, often without treatment (Heyman, 2013). Some studies show that social workers often experience ambivalence and feel unsure when engaging with substance abuse issues (Galvani et al., 2013; Hutchinson et al., 2013). Järvinen (2002) calls attention to an institutional resignation, where there is a large group of abusers in whom the alcohol and drug treatment system has lost all hope. Researchers studying the change process as seen from drug users’ own perspective demonstrate how recovering persons often make use of narratives that enable constructions of non-addict identities (Kelemen et al., 2007; McIntosh and McKeganey, 2000; Neale et al., 2014; Nettleton et al., 2013; Seltzer and Gabor, 2009). Andersen (2015) further explored the influence of drug treatment professionals on the development of such stories of moment-to-moment change among addicts in recovery programmes.

The second major theme highlighted by research focused on substance abuse involves professional discourses and roles in social work. Traditionally, professional roles have been seen as fixed sets of expectations and responsibilities associated with particular social positions (Hall et al., 1999). This version of the professional role has been criticised and several researchers study professional roles as more fluid and negotiated and as culturally and institutionally embedded (e.g. Gubrium and Järvinen, 2013; Hall et al., 2013; Järvinen and Mik-Meyer, 2012). Similarly are the identities of the clients examined as negotiated and culturally formed. For instance have Gubrium and Järvinen (2013) described what they term the clientization process: a process where the client’s troubles are turned into problems. In so doing, a problem designation leads to a chain of professional responses, while troubles are commonly kept out of sight. To decide what constitutes or does not constitute a serviceable problem is a process requiring the deployment of discourses. Several researchers point to the recent development of neoliberal discourses within the professionals emphasising the client’s responsibility for the change process (Berger and Eskelinen, 2016; Järvinen and Mik-Meyer, 2012; Liebenberg et al., 2015). Other studies have focused on the ways activation discourses create certain expectations about clients for counsellors (Møller and Stone, 2013; Solberg, 2011) while also generating dilemmas impacting on interactions between clients and professional helpers (Caswell et al., 2013). Järvinen and Mik-Meyer (2012) point out that traditional forms of professionalism are today intertwined with neo-liberal governance strategies making a contemporary terrain of conflicting professional rationalities. This article aims to contribute to this growing body of research by exploring how change is understood within the institutional setting of integrated social care at NAV agencies.

A discursive perspective on change; methodology and data

Twenty-three counsellors from three NAV offices located in rural municipalities (4000–14,000 inhabitants) in Norway were interviewed. The offices were selected from municipalities reporting sizable abuse problems. In addition, these three agencies had incorporated all or major parts of the municipal substance abuse services into the local NAV office. ³ The offices were organised differently and the criteria used to choose those to be interviewed were that each of them had counselled substance abusing clients. The caseloads for the interviewees ranged from 30 to 130 clients. Three of the counsellors worked mainly with substance abuse, two were local leaders, while the other 18 were generalist caseworkers dealing with all manner of clients having different social care needs. The interviewees performed a diversity of tasks like counselling, administrating economic allowances, referring clients to activation measures, conducting meetings with other relevant welfare actors, etc. Of the interviewees, 19 were women; 4 were men. Twelve were social work graduates, four had completed social or health educations, four had studied economics and three did not hold degrees but had qualifying work experience. Some interviewees viewed themselves as experienced workers related to substance abuse problems while others saw themselves as quite inexperienced. ⁴

The despair position; ‘you put an incredible amount of effort into it, but you see little effect’

Johan’s account introducing this article illustrates the subject position we call the despair position. This position is represented in many of the narratives told by the counsellors. The despair position is characterised by the practitioners’ despair about the outcome of their work. There is a mismatch between the defined goal and the means available to achieve it. In this position, work experiences are expressed as illustrated by Johan's words as ‘depressing’, ‘very discouraging’ and ‘like coming up against a brick wall’. Another example is from the interview with Anna. She has until recently had the responsibility of helping 16 clients she describes as ‘heavy drug users’:

I was completely worn out. They’re extremely demanding, and I always lagged behind on others. (…) It’s been hard, it really has. You say things you don’t really mean. Once I said: “We should have shipped them off to Africa and thrown them to the lions,” “I wish I had a gun now, you know.” I may have said that. But I never meant it. It has been a way when everything is hopeless. You spend a lot of time and energy to organise, and in a way there seems to be no possibility for failure, but then things go wrong anyway, because they’re back on drugs. They desire to drug themselves. That’s when you can become…

Substance abusers in Anna’s account are perceived as differing from other clients mainly owing to difficulties in helping them. Their problems make ‘things go wrong anyway’. The reasons why things go wrong are ‘because they’re back on drugs’. The responsibility of this failure to change is linked both to the characteristics of the substance abuse and to the character of the substance abuser. In this account, Anna’s own understandings and actions are not seen as relevant for the lack of change. She positions herself without influence, as not being able to make possible the necessary change. In telling this, Anna draws on an interpretative repertoire we call change as ungovernable. Within this repertoire the goal is sobriety, which is simultaneously perceived as very difficult to achieve. The substance abuse problem is constructed as irreversibly progressing and ‘incurable’. The understanding of the problem as ‘incurable’ positions both the substance abuser and the helper without control and deprived of agency. Other researchers have shown that this idea has a dominant position. Heyman (2013: 31) notes that ‘the idea that addiction is a chronic, relapsing disease has become increasingly influential’. Järvinen (2002) and Järvinen and Andersen (2009) point that there exists a relatively large group of substance abusers about whom the treatment system has lost all confidence.

However, at another point in the interview, Anna presents another version of herself:

It’s extremely difficult to feel like a good helper if the objective only is to make them quit their substance abuse. But I feel I’ve been a good helper because I’ve been looking after them all the time. And arranged for them and that’s proper help. That help doesn’t work has to do with the intoxication and the receiver that he hasn’t made it. It doesn’t mean that we have done a bad job. You have to think like that about it or else you may feel like a failure all the time.

Our analysis shows that when the counsellors make use of the change as ungovernable repertoire, this creates certain expectations about the future and plays a crucial role in their prioritisations. One excerpt from Julie’s account can illustrate this. She has a workload of 60 clients and talks about the difficult work of dealing with the problems of substance abuse.

Julie: It’s not easy to work with drug use. You are swamped by work, right. I feel it’s easier to work with the ones you can claim suffer from illness. It’s an entirely different matter when drugs are part of the picture. It saps you in a totally different manner.

Interviewer: How? Tell me about it.

Julie: When you read, – there isn’t very good statistical evidence for this, right? You have that up your sleeve, right, or in the back of your mind. (…) You put an incredible amount of effort into it, but you see little effect (…).

Interviewer: (…) How does this influence your work?

Julie: (…) It’s very sad when things collapse, right? When things were going well and you have done a lot, right? But somehow, someone chose to go in that trap again. So you get angry and so. And you think you shall be professional enough, right? You must not give up. But I think I unconsciously do it a bit anyway. I think I unconsciously invest less in them.

Analyses of our material make clear that goals central to the activation discourse create as well as reinforce the despairing position. Hanna gives a representative account:

NAV’s job is to make the user as capable as possible to cope and to be able to face the labour market. And if you then in addition have drug-related difficulties and other psychological challenges, you know. Then we become small.

The position of limited professional responsibility; ‘he has to be ready first’

The next position we call the position of limited professional responsibility. This position is characterised by the practitioners restricting their professional responsibility and actions to a limited part of the client’s change process. The counsellors’ contributions are only relevant when the clients are ‘ready’ and ‘able’. Strategies for change are regarded as having no purpose before this readiness is realised, and practitioners have no means to produce or contribute to this readiness. This position additionally implies that the counsellors have no means to continue an occurring change. This position can be exemplified by Line’s story about working with Lars, one of her 70 clients. She tells that Lars has substance abuse problems and she helped him first by referring him to treatment for three months, and then arranged a work training position for him. But Line then tells that soon afterwards, he began again to use drugs. Asked about what she thought next, she says:

I thought that I just had to start over. There is nothing else I can do. And he as well thought he just has to try again and get himself off drugs. (…) How it’s turned out, I don’t know. It’s been about one month now, and we’re having another meeting this month. (…) It’s to find out how things have developed, and what he intends to do next. Because at that time he was not at all able to envisage measures or work again. He felt he was not well enough, too ill. Had to recover before he could manage to try again. He has got a psychologist, though, and he does see him.

Like the despair position, the position of limited professional responsibility involves little agency on behalf of the counsellor. But unlike the former, it allows for less personal distress. The interpretative repertoires Line draws from make available a position of limited duties and responsibilities and hence protect her from the despair position. Line’s duty is to help her client gain employment when he is ready. Before this readiness is achieved, her duty is limited to ‘find out how things have developed’ and to refer to other professional services if needed. For this limited position, boundary work is central (Edwards, 2009). This requires counsellors to carry out a professionally defined sorting out of the various agencies and professions having responsibility for clients. In this position, relational approaches to change are absent. Ole provides another example describing his work with 130 clients:

When they need assistance, I refer them to others who may help in some way. I determine whether they need help or not. That’s what I can do. And then I must refer them to others around me who provides the aid. […] There is too little time to go into each and everyone.

Some accounts, however, demonstrate ambivalence about positioning themselves with limited professional responsibility and positioning the client as responsible and self-governing. A part of the second interview with Julie may illustrate this. During the first interview, she told about how they tried to help Jan become employed, but now she tells that they have applied for disability pension.

No, that’s, in fact nothing much has happened in this case at all. (…) It’s a difficult situation. He doesn’t want to. He isn’t able to understand the system here and in what way we could have helped him. (…) We have our mission, right? It’s to discover whether people are able to enter into employment, right? But here we don’t get into that position. (…) The client should decide and so on, but the problem is still there, right? Perhaps we give up too soon, and then use that as justification.

The position of resistance; ‘I fight for my clients’

In a number of the interviews, we found evidence of what we label the position of resistance. This position is one characterised by the counsellor’s criticism of the focus on employment and the emphasis on acute care found in current NAV policies. For counsellors in this position, it was important that change was conceived of as a long-term and relational process in contrast to established institutional practices at NAV offices. The ways in which counsellors positioned themselves varied. Some were explicitly oppositional towards institutional practices, while others did not explicitly contrast their practices with those of the institution, even though they maintained long-term and relational approaches to change. Others conduct a form of silent resistance. For instance, some tell of how they avoid reporting their decisions to allow clients to remain enrolled in programmes longer than permitted because of the benefits the programmes give to their clients.

Thea, with responsibility for about 30 clients, claims that ‘clients are at the mercy of who they encounter. They don’t receive the same service from all’. She describes as the ‘long terms’ with whom she works and presents the core of her work as ‘to communicate with clients frequently. To be accessible’ and ‘to call partners for meetings. (…) If we don’t, nothing will happen. Because it’s NAV who initiates all our meetings’. She points that ‘you have to keep it up, and not just sit back and receive applications and that sort of thing. But make a difference’. By employing a relational approach, Thea positions herself as a professional helper having not only many rights but also many duties in the client’s change process. The positions made available within the repertoires she draws from enables her to ‘make differences’, while the client is positioned as ‘at the mercy of who they encounter’. While boundary work was central in the limited position, Thea constructs counsellors working in NAV as having a particular important position in the client’s process of change (‘If we don’t, nothing will happen’). Good work in this account involves to ‘communicate frequently’, ‘call partners’ and to ‘keep it up’. Thea situates good work in opposition to a working style to ‘sit back and receive applications’, which is comparable with how counsellors from the limited position characterised their work.

Sara describes the work as:

It’s very much work of patience in a way. It’s a bit about keeping in touch whether it’s going well or not. And most of the time things are going badly until it may become a little bit better, and then back again. (…) I really think it’s an exciting field of work. But there’s a risk many will tire, and that they don’t see it themselves. I’ve asked myself that question from time to time. And I have thought about the clients I’ve had for a long time, is it good for them? And you are not always in the best position yourself to say anything about it. So we should have had more supervision than we’re actually getting. It’s about being confident and able to assess the quality of what we are doing. What’s frightening in this profession, I believe, is that so much is one to one. Clients are in the power of their counsellor.

From the position of resistance, change is perceived as a long-term process. Sara constructs working with substance abuse as a ‘work of patience’ and describes, in contrast to the accounts from the despair position, ‘little bit better and back again’ as ‘exiting’. Sara points that ‘keeping in touch whether it’s going well or not’ as essential to her way of working. Sara’s constructions of change draws on an interpretative repertoire we call change as a long-term process. This repertoire constructs changing substance abuse as a process unfolding over time. This is a repertoire described using somewhat different terminology by a number of researchers (Hser et al., 2009; Laudet, 2011; McKay and Hiller-Sturmhöfel, 2011; McLellan et al., 2014).

Another significant element of the resistant position is that of goal definition. While stable employment and abstinence were important objectives for counsellors acting in accordance with the two other positions, much more comprehensive definitions are introduced from the resistance position. Evy is the counsellor who most clearly creates goals along these lines. She challenges the idea of ‘work’ as the key element in client change:

In every NAV plan there are objectives written down: work, work, work. And they say these are clients’ own objectives. Don’t tell me that all those people say employment is my great ambition in life. But they are so into their own professional field that they don’t see it. For a substance user it may be to stabilise their life, to keep their flat in order, to keep in touch with their family once a week. No substance user has ever told me that his great ambition in life is to be able to work.

Many of the counsellors from the position of resistance talk about themselves as different from their colleagues. For example, this is evident in Evy's descriptions of other counsellors as ‘they’ and ‘their professional field’. This indicates an experience of divergence between her and the others. Similarly, Thea describes the existence of ‘significant cultural divergence among staff’. When the interviewer asked if they discuss these differences at meetings, Thea says:

We’re almost fed up with the discussion. That we no longer go into those kinds of discussions; we don’t feel that we are getting anywhere. Consequently, we stick to our allies. (…) I dream of working somewhere where I only have my own people, so to speak. That I’ll be in an environment where, yes, not that everyone needs to be the same, but somewhere I could feel at home. While here, I often feel I fight the system a lot. Fight for my clients, to make them noticeable. Because most of the time it’s just a question of establishing initiatives, work, and to get them out as quickly as possible. We work differently. But it’s hard, though. (…) It’s kind of a basic battle this, really. In fact, you need to connect with clients frequently and talk to them. While some may say yes, chit-chatting. They don’t understand the thing about change and developing relations. It’s a waste of time then.