James G Barber
James Barber's seminal study on social work with addictions is now available in Sweden. It is hard to think of a more appropriate region for the study of practical social work in this area. Sweden having mastered the basics of social democracy in the 1930s at a theoretical level, spent the rest of the 20th century and will probably spend all of the 21st, wrestling with how to make a just and equitable community function according to the consciences of enlightened administration.
One of the consequences of a comprehensive welfare state, where everything is forbidden or compulsory, is the alienation of the individual who feels his or her worth diminished by the emphasis on cohesion and corporate values. Alienation, a loss of a sense of identity, turns the mind quickly to ways of anti-social and destructive non-conformism, which, even if they lead to death, at least have the virtue of identifying the primary importance of the individual over the State. What is the use of hi-tech mobile phones, trains that run on time, cars that never rust, hospitals which prolong human life beyond its use-by date, if one doesn't know if one is Bjorn or Lasse? In Sweden, and the other Nordic countries, the answer has been traditionally found in alcohol, but more lately in heroin and cocaine.
As Barber points out, drug addiction is implicated in some of the world's most intractable social problems. And of all of the professions devoted to ameliorating their problems, social workers were in the front line of the world's drug prevention efforts. Barber's work provides a clear account of the theory relating to addictions, and a description of proven strategies to practice.
In a work which provides 24 pages of references, social workers in a variety of areas will find any number of leads to direct their thoughts and actions. If only the prisoners and the drug-injecting and alcoholic groups described could be persuaded to spend some time investigating the history of temperance and prohibition, unemployment and helplessness, social support for partners of heavy drinkers, and how to deal with dreams and nicotine.
Perhaps the most interesting part of the book deals with action strategies, and the advice given to social workers dealing with alcohol abuse should be approved by the obsessively non-judgemental Swedish social engineers. As Barber puts it:
The first step in our model consists in deciding whether to aim for moderation or abstinence. Naturally, this decision should be made by the client after taking account of all the considerations (including legal and financial) that are involved. For example, there is considerable consensus in the literature that a moderation goal is not for everyone. Of particular importance is the repeated warning that individuals with high levels of alcohol dependence should be encouraged towards abstinence because their ability to sustain controlled drinking has never been reliably established (see Pendery et al., 1982; Heather and Robertson, 1983; Foy et al., 1984; Miller and Hester, 1986, 1988; Heather and Tebbutt, 1990). Apart from high levels of dependence, abstinence should always be recommended to clients with alcohol-related organic damage of any kind, including brain damage. Pregnancy and the concurrent use of certain kinds of medication may also necessitate abstinence, irrespective of level of dependence. Nevertheless, it is not for the worker to browbeat clients at this first stage of the intervention, if only because there is firm evidence that clients who are allowed to participate in the choice of crucial elements of their treatment programme do better than those whose treatment is forced upon them (Miller and Hester, 1988). If a client insists on continuing to drink despite advice to the contrary, he or she should not be dismissed as 'unmotivated' as is so often the practice. For one thing, it may be possible to attenuate the damage of extreme drinking through controlled drinking therapy, and for another, clients can be helped to come to the realisation through treatment that abstinence is the only viable option.
Of course, social workers dealing with alcoholics often have the reward of seeing their efforts help their clents. In the case of heroin, the case is otherwise. Barber explains in an example typical of the thoroughness of the book, just what opiate narcotics are:
Common type and names
As used here, the term 'opiate narcotic' refers to natural or synthetic drugs which behave in the body like morphine - the major active agent derived from the opium poppy. Examples include: heroin (street names include 'junk', 'skag', 'H', 'Smack'), morphine, methadone, pethidine, dextromoramide (Palfium), codeine, paracetamol, and aspirin. Opiates are prescribed mainly for pain relief; also for diarrhoea and as a cough suppressant.
(b) Method of ingestion
Oral, inhalation or injection.
(c) Short-term effects
Opiates briefly stimulate the brain but then quickly depress the activity of the central nervous system. Immediately after injecting an opiate (especially heroin) the user feels a surge or 'rush' of pleasure often compared to orgasm. This state gives way to a euphoric state of feeling replete and satisfied. Initial side-effects may include restlessness, nausea and vomiting. At moderate doses the user drifts between wakefulness and drowsiness. At still higher doses, breathing is depressed and profound respiratory failure resulting in death can follow overdose.
(d) Longer-term effects
With regular use, tolerance develops to many of the desired effects. Nevertheless, withdrawal symptoms are reasonably mild and may include: uneasiness, yawning, tears, diarrhoea, abdominal cramps, goosebumps and running nose. Withdrawal has been compared to a dose of the flu. Besides respiratory failure, the most serious risk to health involves infection (especially HIV) from needle-sharing.
To sum up: this is a timely work, now placed in a market where it can do much good. Certainly it is not up to social workers to question why addicts are addicted and to provide global panaceas to western societies. Barber's use of the combat metaphor is apt and his work transcends national boundaries to such an extent, for example, that glue-sniffing aboriginals alienated by the failure of Australian political willpower in the area of reconciliation, have their counterpart in Swedish crack users disconcerted by the dehumanizing characteristics of - to use Roland Huntford's expression - the few totalitarians of the Swedish welfare state.