The Use of Intervention and Case Management Models in Maximizing Recovery and Reducing Relapse Risks for Substance Abusers
Kate Caravella, CAC, NCAC 1, BRI 1
Abstract
Substance abuse disorders tend to be difficult to treat, which has impelled treating professions to investigate alternate avenues of treatment delivery, such as intervention and case management. The utilization of both methods will be reviewed in depth. The rationale for the use of these models will be explored throughout. The continuum of substance abuse treatment will be identified as paramount in effectively decreasing the risk of relapse. Deficits in continuing care planning during the course of residential treatment and subsequent transition to an outpatient level of care will be reviewed. For reasons outlined within this paper, acceptance of both intervention and case management models can be challenging.
This paper will explore the use of intervention and case management models in working with individuals who have been diagnosed with substance use disorders. Substance use disorders, or addictions, are defined as a disease; a concept supported by the medical and psychiatric communities. As such, it is considered chronic and progressive, and without a cure. Individuals diagnosed with substance use disorders are especially prone to relapse. High incidences of relapse will be discussed and relapse prevention measures as used during the course of treatment will be reviewed.Keywords: Case management, relapse prevention, intervention, continuum of care, substance abuse.
Substance use disorders affect millions of individuals nationwide. The problems associated with these disorders are pervasive and destructive. Today, in the United States there are an abundance of treatment programs available to treat substance use disorders and the number of individuals actively seeking treatment and recovery has increased. A review of relapse statistics, however, yields disappointing results. It has been estimated that approximately 40% of all patients admitted for chemical dependency treatment in the United States are relapsers who have been previously treated for chemical dependency (1). Additionally, 47% of patients treated in private treatment programs will return to chemical use within the first year following treatment. (1) Most relapses occur within the first 18 months of recovery, and most of these occur within just the first six months of recovery (2).
Heightened relapse rates persist in frustrating professionals committed to treating the chemically dependent person and have prompted the need to explore and utilize additional methods and models of treatment intervention in an attempt to decrease the likelihood of relapse once treatment is initiated.
The substance abusing population tends to present with complicated clinical pictures. They may have deeply ingrained defense mechanisms that hinder their motivation for treatment or recovery and make treating these disorders more difficult. Chemically dependent individuals frequently experience co-existent issues secondary to their addiction such as comorbid psychiatric disorders, complicated medical issues, and legal problems. Substance abusers are defined as having complex needs and require continual rather than episodic drug abuse treatment (3).
The terms ‘substance abuse,’ ‘chemical dependency,’ and ‘addiction’ will be used interchangeably throughout this paper. The terms ‘slip’ and ‘relapse’ will also be used on a regular basis. The term ‘slip’ is defined as a brief or one time use of a substance following a period of abstinence whereas the term ‘relapse’ will refer to a full return of active substance use following a period of abstinence.
As noted, high relapse rates have prompted treatment professionals to identify alternate models of treatment to assist their client in maintaining longer periods of abstinence and recovery. Intervention and case management models are two such alternate approaches that will be explored in detail throughout the course of this document.
Both models, and especially the case management model, incorporate the tenets of relapse prevention programming. From a public health perspective, relapse prevention can be considered a form of tertiary prevention, the goal to prevent relapse (and promote progress) in individuals who have already developed an addiction problem and have made a commitment to abstinence (4).
Addiction is widely accepted as a chronic and progressive disease that is said to be incurable, only managed. The disease concept of addiction is such that it suggests that once an individual has been diagnosed with an addiction, the only real effective management of the addiction, or disease, is abstinence. An individual can have the disease of addiction, but can be in recovery. As such, the intervention and case management models are palliative in nature and aim to effectively manage the disease while promoting ongoing recovery. As with other chronic disorders, the only realistic expectation for the treatment of addiction is patient improvement rather than a cure.(5)Intervention and Case Management: Approaches and Similarities
Intervention can be viewed as both a method for initiating treatment and recovery as well as a tool for promoting stabilization during crisis events. Case management is described as a model of service delivery that seeks to ensure and maintain continuity of care. The roles of the intervention specialist and case manager are similar in terms of their primary functions. Both the intervention specialist and case manager assumes the responsibility of engaging an individual in the treatment and recovery process, overseeing the coordination of care, serving as advocates for the client, providing education and continual support, and attempting to either initiate or re-initiate treatment.
Intervention
The use of professional intervention in initiating treatment and engaging a chemically dependent individual into treatment has been gaining popularity. Agencies offering intervention services are now more widely available.
It is not unusual for substance abusers active in their addictions to have difficulty appreciating the extent of their substance abuse or their need for treatment. He or she may be fundamentally unwilling to take the steps necessary to initiate the process of abstinence and recovery despite the negative consequences that may result from continued usage. Deeply ingrained defense mechanisms such as denial, minimization, and rationalization can hinder the substance abusing individual’s personal ability to view the destructive path that results from ongoing substance abuse.
Intervention is a technique used to interrupt patterns of ongoing substance abuse. Its focus is on persuading treatment resistant and active substance abusers to make use of available professional help.
The process of intervention begins when family members or other concerned persons engage the services of an intervention specialist. It is likely that these support systems have previously made personal pleas to their loved one to receive professional help, often to no avail.
Until fairly recently, the benefits of utilizing intervention techniques had been questioned. Substance abuse professionals employed within the fields of addiction and mental health, as well as advocates of 12-step programs, expressed concern around the dynamics of the use of this motivational technique. Apprehension had been voiced by others “forcing” the addict/alcoholic into recovery, as opposed to allowing them to “hit bottom.” Advocates for the use of formalized intervention techniques countered that intervention is a realistic, established, and effective means of helping substance abusers initiate recovery and that further risks associated with ongoing substance abuse such as death, could and should be avoided. Once the individual is a client within the treatment environment, the opportunity for insight usually develops. This fosters active motivation towards ongoing abstinence.
Interventionists are typically trained professionals who have varied responsibilities in addition to the actual facilitation of the intervention meeting. They provide education and support to both the substance abuser and their families, identify barriers to initiating and completing treatment, perform detailed needs assessments, attempt to ascertain appropriate levels of care, and identify suitable treatment options for clients. Additional core functions of intervention specialists relate to the coordination of treatment efforts, the facilitation of referrals to programs, and arranging for admission into a chosen treatment program. Intervention specialists serve as the primary point of contact for families, clients, and colleagues during this initial phase of treatment. The role of the intervention specialist in planning and facilitating an intervention is particularly analogous to that of a case manager as had been noted earlier.
Trained intervention specialists are experienced in identifying which program would be most suitable for their client’s individual needs. This is achieved via the consideration of several factors including the client’s gender, age, financial means for treatment, clinical needs, and any secondary diagnoses that may exist. Appropriate treatment matching can increase the probability of treatment retention and completion. An additional benefit of treatment matching is the likelihood of the client having a positive treatment experience.
The role of the intervention specialist does not normally conclude at the time of the client’s admission into a treatment program. He or she may be responsible for ensuring that his or her client’s needs are being met during the course of treatment. When possible, intervention specialists work in partnership with the residential treatment team in developing a comprehensive and individualized continuing care plan that will be utilized upon discharge.
Thus, the role of intervention specialist is varied and can be viewed to be critical in engaging resistant substance abusers to pursue recovery as well as by playing a key role in managing the initial part of the continuum of care.Case Management Model
Case management is an approach to service delivery that works to ensure that clients with complex, multiple problems, and disabilities receive all the services they need in a timely, effective, and appropriate fashion (6).
This service delivery model can trace its roots to the discipline of social work. However, no formal or universal definition is assigned to describe the term ‘case management.’ Case management models, like the definitions of case management, vary with the context (7).
The term ‘case management’ has appeared in social services literature more than 600 times in the past 30 years (7). Case management service is not in and of itself a new or innovative service approach. Despite its historical prevalence and popularity, it remains an underutilized adjunct to treating substance abusers.
The case management model of treatment has been historically linked with the delivery of services within a hospital-based setting and most commonly within the professional disciplines of psychiatry and medicine. Case management is generally best associated with past legislation relating to psychiatric deinstitutionalization which, decades ago, escalated its overall popularity. The case management model had rarely been applied to the treatment of substance using clients. Substance abusers historically were never institutionalized as often as were persons with chronic mental illness and so were not directly impacted by legislation. Substance abusers were not generally targeted for the development of categorical systems of service delivery and were not generally recipients of case management services. (7)
Similar to deinstitutionalization efforts of the past, many modern chemically dependent individuals find themselves having to rely more and more on programs outside of residential settings. Private treatment programs can be significantly pricey, community-based programs may have long waiting lists, and insurance coverage for substance use disorders can be dismal, all of which prompt the need to explore alternate options for care. Alternate options for care, however, may be insufficient.
Intervention and Case Management in the Residential Setting
Upon admission into a treatment program, it is customary for the client to be assigned to one principal staff member who assumes the task of treatment planning and coordination of care. This staff member may be referred to as the client’s primary therapist. Additional responsibilities of this staff member may include the referral of the client to in-house specialists such as spiritual counselors, nutritionists, psychiatrists, and others for consultation and treatment. Additionally, the primary therapist may also be charged with the development and construction of the client’s continuing care or discharge plan. In many respects, this staff member serves as the client’s case manager.
Clients who are the recipients of care on a residential basis can benefit from this level of care for several reasons. This setting provides clients with the ability to focus on their substance abuse issues within an environment where drugs and/or alcohol are inaccessible. Treatment schedules are typically very structured and promote consistency and regularity. Clients have the advantage of receiving ongoing clinical services provided by multi-disciplinary professionals. Additionally, the client housed within this clinical setting is afforded a temporary reprieve from having to deal with the day to day stressors of everyday life. The client is usually provided with the opportunity to participate in various treatment approaches such as individual psychotherapy sessions, therapeutic process groups, family therapy sessions, and educational didactic groups.
Many residential programs have adopted formal relapse prevention programming elements into their treatment regimen as a means of educating clients about the very real possibility of relapse post treatment. Clients are encouraged to identify their personal relapse triggers, to develop action plans designed to avoid these triggers, and to develop coping plans to effectively deal with these triggers if encountered post treatment that would otherwise jeopardize their recovery.
Relapse prevention planning generally focuses on the more obvious or overt triggers, such as people (drug dealers, using friends/family), places (bars), events (celebrations), and mood events (positive or negative). Less obvious triggers such as the very real pressures and concerns of day to day life may be disregarded as non-essential. Many individuals in early recovery are ill prepared to deal with the stressors that may simply not be avoidable, and many identify “stress” as a primary trigger without clearly identifying the specific sources of stress.
Although high risk situations can be conceptualized as the immediate determinants of relapse episodes, a number of less obvious factors also influence the relapse process. These covert antecedents include lifestyle factors such as overall stress level (8).
A continuing care or discharge plan generally includes relapse prevention measures previously identified by the client. It rests upon the optimistic assumption that the client intends to continue treatment in some form on an outpatient basis and is committed to ongoing recovery. However, many continuing care plans tend to be overly simplistic in design. A typical discharge plan generally provides a written set of guidelines for the newly recovering person to follow such as 12-step meeting attendance, obtaining a sponsor, and selecting a home group. More sophisticated plans may include the name and contact information for a recommended clinician or outpatient program for continued care. More often than not, the actual plan does not resemble or attempt to replicate the services offered at the residential level such as the varied treatment modalities (individual, group, family therapy, nutrition, etc). Additionally, most plans provide directives on “what to do” and fail to inform the client on “how to do it.”
For example, a client may have a discharge plan that suggests continued adherence to their prescribed medication regimen. However, it may not identify a practitioner to prescribe these medications or consider the possibility that the client may not be able to financially afford the medications on an ongoing basis.
Furthermore, continuing care plans may lack directions for dealing with typically non-clinical issues such as how to seek employment or construct a resume, manage time efficiently, or locate a treatment provider for ongoing care. The very real pressures of finances, employment, housing, and perhaps reunifying with and caring for children can be very stressful to the newly recovering and usually vulnerable individual (7).
Real life issues or stressors may include the need to handle financial responsibilities appropriately, obtain employment, make childcare arrangements, have means of transportation, and maintain household responsibilities. The authentic challenge of meshing recovery needs with the demands of daily life can contribute to amplified stress levels and situations that could result in slips or relapses. The case management model assumes that the client has very specific recovery and mental health needs as well as non clinical needs (financial, employment, life skills, etc) that need to be addressed as part of the overall continuing care plan (7). Because addiction affects so many facets of the addicted person’s life, a comprehensive continuum of services promotes recovery and enables the substance abuse client to fully integrate into society a healthy, substance free individual (7).Case Management and Intervention in the Outpatient Setting
Making the transition from inpatient/residential to the outpatient setting can be extremely challenging for a newly recovering individual. The utilization of case management services can be significantly advantageous to the client. Without a case manager to guide the client through the continuum of care, the newly discharged client assumes the responsibility of following a continuing care plan without the benefit of a treatment coordinator.
In general, outpatient programs and outpatient service providers (therapists, psychiatrists, and internists) practice within the scope of their profession and typically do not assume the role of “point of contact person.” As such, they may be required to rely solely on the independent reporting of their client. Such information may be misleading or inaccurate. Case management is needed because in most jurisdictions, services are fragmented and inadequate to meet the needs of the substance abusing population (7).
Because a variety of professionals with specialized skills are involved in a treatment program, it is helpful to have one person aware of all the forces acting on the person (9). Thus, the use of a primary case manager to assume this role can be extremely helpful in bridging communication gaps among providers, providing timely updates, and ensuring that all providers are privy to critical information about the progress of their patient or client.
During this phase of treatment, the case manager continually assesses for plan compliance and progress and makes revisions as needed. The case manager is aware that in addition to the client’s immediate recovery and mental health needs, the need to refer to ancillary services such as vocational counseling, social service agencies, and financial counseling is equally important to the overall functioning of the client. Therefore, a key function of case management at this level is to perform in depth needs assessment and to facilitate referrals. Case managers advocate for their clients, assist their clients in applying for ancillary services, and negotiate fees on behalf of the client. Whether through simple referral, advocacy, or skills training, it can be argued that by helping clients obtain resources they will be less likely to relapse (10).
Another critical, yet less utilized function of case management is the use of life skills training. Life skills training assists clients in developing or maintaining the skills necessary to support their recovery process and to reduce their overall stress level.
Improvement of basic life skills may be needed with issues relevant to time management, home organization, budget/money management, appointment coordination, transportation, and overall lifestyle balance. Inadequate coping or life skills issues can increase the risk of relapse. There is a higher likelihood of a relapse immediately following treatment, but incremental changes in coping skills lead to a decreased probability of relapse over time (11).
The objective of the case manager in working with clients to develop and maintain mastery of basic life skills is to decrease their stress level when the existing skills set is inadequate, to promote self sufficiency, and to encourage clients to act as proactive agents in their own lives. Educating clients on how to establish goals and providing them with skills training to successfully meet these goals empowers clients and can positively reinforce continued behavior.
As identified, the period of initial abstinence and recovery, particularly in the outpatient treatment setting, can be a very trying time for the client and thus may increase the potential for relapse. Because the disease of addiction is chronic in nature, it is also exceptionally prone to lapses and relapses. Clients that slip or relapse during this phase of treatment will require immediate, rapid, and efficient intervention in order to successfully minimize the negative effects associated with ongoing or sustained use. The case manager is frequently the first professional to be aware of a slip or relapse and quickly notifies all pertinent supports. Immediate and competent intervention can reduce the length of time between periods of lapse or relapse and can reduce the likelihood of the client needing to be re-admitted into a hospital or residential treatment program.
Who Benefits the Most from the Case Management Model
It can be argued that most chemically dependent individuals would benefit from case management services. However, specific sub-populations such as young adults, chronic relapsers, those diagnosed with multiple disorders in addition to substance abuse, and older adults may benefit the most.
Young adults, due to their chronological age and limited life experience, may require additional assistance in the area of life skills development. They also tend to benefit from the additional supervision a case manager can provide. Similarly, individuals with longstanding histories of treatment and recovery attempts will also profit from the supplemental assistance of a case manager. Many such clients, as a result of repeated treatment attempts, may present as “institutionalized” and are only able to function well within the confines of a residential setting. They may have particular difficulty meshing their recovery needs and non-clinical needs on an outpatient basis.
Clients who have been diagnosed with co-occurring diagnoses which is common with substance abusers (depression, anxiety, bipolar disorder, eating disorders, ADD/ADHD, etc.) have multiple areas which need ongoing consideration and management. Several chemically dependent individuals experience medical and legal difficulties associated with their previous abuse of substances which may also need specialized attention. These clients will likely need additional support in problem solving these areas.
Older adults benefit from having a case manager to effectively coordinate their overall medical and psychological care. The need for a primary point of contact when working with older adults is critical as many providers may be part of the treatment team and ongoing communication among them is necessary.Criticism of the Case Management Model/Identified Problems with Its Use
Despite the numerous ways that the intervention and case management models can aid in facilitating the process of ongoing recovery with chemically dependent individuals, these approaches remain largely underutilized.
Many professionals who treat substance use disorders, particularly on an outpatient basis, may not be aware of the advantage of referring their clients or patients to a case manager. The variability in social services configurations has led to many different implementations of case management, resulting in conceptual disagreements about case management and difficulty in assessing its value (7).
Inpatient or residential staff members may be unacquainted with firms that provide case management services to their client, or they may minimize the added value that this type of service can provide. As noted earlier, despite the fact that residential programs typically offer an array of services to their clients, continuing care plans frequently do not bear a resemblance to the outlined discharge plan.
Critics of the case management model have suggested that they view case management services as enabling. It has been opined that the client ought to be able to achieve recovery-related tasks without the guidance of a secondary person. Case managers do not enable their clients but teach and empower their clients to assume reasonable responsibilities and assist them in areas where they display limitations or encounter difficulty. It can be argued that withholding support in areas where clients possess limited skills may serve to handicap the client and may hinder his or her ability to successfully navigate through critical issues.
Additionally, some case managers have experienced conflict with their colleagues or other agencies serving the addicted population. They may demonstrate resistance to receiving clinical input from non-physicians or credentialed mental health providers. Service agencies often do not recognize the authority of a case manager (3).
Resistance to case management services has also been noted by staunch proponents of the 12-step program. Generally, their maintained stance is that in order to effectively engage in the process of recovery, the client needs to practice the philosophy of “keeping it simple.” While in theory this line of thinking can be viewed as reasonable, it is argued that very little about addiction or recovery is, in fact, simple. Promoting this message without supporting the client by providing them with the tools or services to assist them in maintaining this philosophy can be detrimental to the process and/or success of ongoing abstinence.
The recent emergence of professionals and agencies which offer services called “sober coaching or recovery coaching” may be confused for case management services. Simply defined, sober or recovery coaches tend to be individuals who themselves are recovering addicts or alcoholics. They aim to assist their clients in understanding the principles of the 12-step program; attend 12-step meetings with them, and help them identify potential sponsors. As illustrated throughout this paper, case managers provide more in-depth services and are not aligned with any one treatment philosophy.
Another problem inherent inthe use and implementation of the case management model is that firms providing case management services may be scarce and widely unavailable. Community agencies may offer case management services though they may have long waiting lists or strict eligibility requirements.
It has become popular for some transitional living or halfway house programs to include in-house case management services within their existing programs. They may offer a resident the opportunity to work with a case manager who is also a staff member of their program.
Initially, it might appear that though the inclusion of this service type within a halfway house program could be useful, yet problems can be identified with this combination of service programming. These types of programs (also called sober residences and three quarter-way houses) may offer limited services such as transportation to appointments and referrals to outside agencies under the guise of providing case management. As previously described, actual clinical case management services are much broader in scope and do not limit resources for one or two needs. Additionally, the potential for unhealthy and unethical dual relationships may exist. Most reputable halfway houses or transitional living programs maintain strict rules on the use of substances during a client’s residence. If the client’s landlord or halfway house staff member dually serves as the case manager, disclosure of a slip or relapse may jeopardize the client’s ability to maintain their residence.
In addition, the client may at some point have issues with roommates or resident managers and may want to seek alternate housing options. Dual relationships have the potential to hinder the client’s ability to be truthful with their case manager and could serve to prevent the case manager from truly meeting their client’s needs.
Along these lines, case managers should always avoid real or perceived alliances with any one program, agency, or professional. If the intervention specialist or the case manager is to serve as an advocate for their clients, follow them through the continuum of care, and maintain neutrality at all times, it is essential that allegiances and dual relationships are regularly avoided.Summary:
The use of intervention and case management models can make significant contributions to the addictions and mental health fields by providing non-traditional services to a population which can be extremely challenging to work with. The roles and responsibilities of both the intervention specialist and case manager are very similar as identified throughout this paper. The utilization of both these models enables one professional or agency to follow the client through primary, secondary, and tertiary care.
Moreover, both case management and intervention models can be considered cost effective treatment options as they emphasize relapse prevention programming. Case managers actively seek to provide their clients with quality services that are also affordable. They assist their clients in applying for available benefits such as medication patient assistance benefits, public health services, and charitable services.
In summary, the case management model is tremendously similar to a model termed The Care Management of Chronic Addictions Model. This model is defined as, ”(a) model that accepts chronicity, recognizes limits of treatment methods, is palliative (non curative) in nature, stresses long term management and treats addiction like other chronic diseases such as bipolar disorder or diabetes.” (12)
Biography
Kate Caravella, CAC, NCAC 1, BRI 1
Kate Caravella is the founder of ICM Associates, Inc. - a Florida based firm specializing in family interventions and intensive case management. Kate is a Certified Addictions Counselor in the State of Florida, a level one Board Registered Intervention Specialist, and has the designation of level one National Certified Addictions Counselor. Kate has worked in the fields of substance abuse and mental health for 16 years.
Conflict of Interest Statement:
I declare that I have no proprietary, financial, professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of, the manuscript entitled: The Use of Intervention and Case Management Models In Maximizing Recovery and Reducing Relapse Risks For Substance Abusers, except for the following:
President/CEO of ICM Associates, Inc.
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