Teachable moments: Good practice for social workers delivering brief alcohol interventions

Social workers need to tackle parents’ risky drinking in ‘teachable moments’ and appreciate that approaches used in health settings are not likely to work, research has shown.

At a recent conference, ‘Building Fairer Futures for Children and Young People’, social worker Ruth McGovern presented her research, a discrete choice experiment looking into preferences for delivering brief alcohol interventions to risky drinking parents in social care.

Dr McGovern, who is senior lecturer in public health research at Newcastle University, said that alcohol misuse is identified as a risk factor for children in around 20 per cent of child-in-need assessments. She believed the real figure to be much higher than that given by public health; many parents are drinking below the threshold for alcohol treatment and don’t recognise the need to address the risk they create for their families.

‘There is a robust evidence base for brief alcohol interventions, in fact the largest evidence base for any alcohol interventions is for brief interventions and they are very varied,’ she said. These are usually delivered in primary healthcare in a ‘Teachable Moment’ – when the patient is seeking advice relating to their health.

‘As a social worker I can see lots of opportunity for replicating that teachable moment in a social care setting where you are asking the parent about how life is, how life might be tricky in the family. That might bring about behaviour change. But what we don’t know is how to do that in social care. There might be lots of reasons why it might be hard.

‘Social workers have responsibility for protecting -- sometimes we are actually moving children from places of harm and we can see that it might be really difficult for a parent to disclose something that might raise people’s concerns. So it is really important that we understand how this would work in this particular setting.’

She said that the children and families who come into contact with social care are among the most disadvantaged in our society. Drinking that creates risk can be seen as a public health issue, [but] it is still within the social care remit: ‘adversity and poverty track together to produce far worse outcomes for children and families. If we can do something to interrupt that adversity, that is going to bring about some positive outcomes for children in health and social care settings.’

The research involved 205 social workers, in Newcastle and London. They were asked to assess their preferences and the acceptability of a brief alcohol intervention with parents. ‘Some used methodology which looked at the different attributes and characteristics of interventions and then worked out the different values and levels of those interventions. We looked at sessions of ten minutes to sixty minutes, and we took the different attributes from research in the health sector. We came up with 99 attributes.’ Dr McGovern said that however the important thing was not the number so much as finding the combination of attributes which would work best.

A key point was not to screen everyone – the social workers said that the intervention worked with parents already identified as risky drinkers, and where the social care professional already knew that there was an impact on the family.

The social workers wanted the intervention to be with the ongoing case worker, rather than fill in an assessment... and the preference was for six sessions, each of 40 mins duration.

‘They wanted less structure…leaflets and structured advice really didn’t fit here. What didn’t matter at all to them was the supervision they received, or the “clout” the organisation had – the idea that you will have to do this, you will be monitored, you will be measured on this, or the training either; it was all about the risk and how best to work with the family.

‘A key thing we found was that what we do in health can’t be transferred simply into social care. There will need to be a lot of modification and adaptation...It is a move towards the central functions of social care…That presents a challenge for the universal screening processes used in health.’

The social workers ‘wanted more flexibility to intervene -- where it felt right, where the relationships were already in place and there was trust within that relationship. That was because of that threat to the environment, but also to introduce it at a time when it was more about structuring the conversation, rather than identifying the problem in the first place. So here screening is not about identification, it is about helping the practitioner to have a tricky conversation.

There was a clear preference from the practitioners that the child would be involved. ‘But we need to be cautious about that because many children won’t know about the parents’ alcohol abuse, or about the extent of it. They might feel stigmatised, embarrassed, ashamed, or more worried by that conversation.

‘I also led a Cochrane review which examined the effectiveness of interventions for parents at reducing substance misuse and that showed that when a child is involved in the intervention, while that is considered highly motivational for a parent to consider the impact on the child, if the child is in the room, it doesn’t seem to work. That is probably because there is lots of guilt and shame for the parent as well...So we want to be careful about that.

‘We also need to move away from that very short sharp intervention to one that is more intensive and less structured, more conversational in style. That disparity with what we know in health is probably brought about by health interventions being done in a short consultation with a clinician who you might not have a relationship with, in comparison to a social care situation where the social worker might be with that family for three months upwards and perhaps where the family’s having some very complex challenges.’