Scholar Practitioner Project Assignment: Models of Addiction, Treatment, and Case Management

Dilemmaswhenworkingwithsubstanceabuserswithmultipleandcomplexproblemsthecasemanagersperspective.pdf

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I N T E R N AT I O N A L

J O U R N A L O F

SOCIAL WELFARE

ISSN 1369-6866

270

Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

DOI: 10.1111/j.1468-2397.2008.00608.x

Int J Soc Welfare 2009:

: 270–280

Kolind T, Vanderplasschen W, De Maeyer J. Dilemmas when working with substance abusers with multiple and complex problems: the case manager’s perspective Int J Soc Welfare 2009: 18: 270–280 © 2008 The Author(s), Journal compilation © 2009 Blackwell Publishing Ltd and the International Journal of Social Welfare.

Since the 1990s, case management has been implemented in the USA and Canada – and recently also in various European countries – to support substance abusers with multiple and complex needs. Although this intervention is often presented as a set of standardised functions, its application is often a subjective task involving various dilemmas, which may influence case management outcomes significantly. Based on a comparison of case managers’ experiences in Denmark and Belgium, we focus on several core dilemmas in case management for substance abusers with complex problems. Case management practices vary from one project to the next and even within the same project. Such differences are apparently related to the way in which case managers approach dilemmas such as those existing between control versus self-determination, or between systematic versus ad- hoc planning. The conclusion is that it is vital to discuss these dilemmas during training courses and supervision meetings in order to ensure that the intended form of intervention is actually delivered on the ground.

Torsten Kolind

, Wouter Vanderplasschen

, Jessica De Maeyer

Centre for Alcohol and Drug Research, University of Aarhus, Denmark

Department of Orthopedagogics, Ghent University, Belgium

Blackwell Publishing LtdOxford, UKIJSWInternational Journal of Social Welfare1369-68661468-2397© 2008 The Author(s), Journal compilation © Blackwell Publishing Ltd and the International Journal of Social WelfareXXX Original Articles

The case manager’s perspectiveKolind et al.

Dilemmas when working with substance abusers with multiple and complex problems: the case manager’s perspective

Key words: case management, substance abuse, substance abuse treatment, coordination, Denmark, Belgium, qualitative research

Torsten Kolind, Nobelparken bygn. 1543, Center for Rusmiddel- forskning, Jens Chr. Skous Vej 3, 8000 Aarhus C, Denmark E-mail: [email protected]

Accepted for publication June 17, 2008

Introduction

Since the 1970s, case management has been introduced in various countries to improve the accessibility, accountability, coordination and continuity of services provided to diverse at-risk populations with multi-faceted problems, such as persons with mental illness, the elderly, homeless persons and multi-problem families (Hall et al., 2002; Holloway & Carson, 2001; Moxley, 1989; Sargent et al., 2007). Since the 1990s, programmes in the USA and Canada have also employed case management when dealing with substance abusers with multiple needs (Graham & Birchmore-Timney, 1990; SAMHSA, 1998); recent programmes in The Netherlands, Germany, Belgium, Denmark and other European countries have also started to include case management for such situations (Roeg, Van de Goor & Garretsen, 2005; Vanderplasschen et al., 2004).

Despite its widespread application, case management has not been unanimously defined and its practice varies from place to place due to diverging objectives, distinct target populations, programme variables and other factors (Ridgely, 1996; Ridgely & Willenbring, 1992). Case management, therefore, is probably characterised most accurately by its core functions: assessment, planning, linking, monitoring and advocacy (SAMHSA, 1998). Case management is also community- based, client-driven, pragmatic, flexible, anticipatory, outreaching, and offers a single point of contact.

A great deal of academic literature has focused on the effectiveness of (different models of) case management as compared with other intervention forms – and its effectiveness with regard to improving linkage and retention has been documented in particular (Coviello et al., 2006; Hesse et al., 2007; Morgenstern et al., 2006; Morse et al., 2006; Rapp et al., 1998, 2008). It

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appears, however, that most evaluation studies do not discuss the actual intervention delivered, and focus very little on the experiences of the persons directly involved, i.e. clients and case managers (cf. Brun & Rapp, 2001).

Often, case management is presented as a set of standardised functions (e.g. coordination, monitoring, planning), which are supposed to be carried out in unbiased fashion by the case manager (Moxley, 1989; SAMHSA, 1998). However, the application of case management is a subjective task, including various dilemmas and decision-making moments – not challenged at all by drug users’ lifestyles, living situations and programme and system requirements – that may influence the outcomes of this form of intervention significantly. Even when case managers have received intensive training and supervision, substantial differences between case managers are sometimes apparent even within a single programme (Huber et al., 2003; Kuhn et al., 2006; Morgenstern et al., 2006; Sorensen et al., 2003).

As a result, in this article we focus on some of the core dilemmas in case management practice, based on a comparison of the experiences of case managers applying intensive case management among substance abusers with multiple and complex problems in two European countries (Denmark and Belgium). These dilemmas will be clustered according to the basic functions of case managers, in order to identify some prerequisites in improving the fidelity and comparability of case management interventions, as fidelity appears to be an important mediator of the effectiveness of case management (Jerrell & Ridgely, 1999; Noel, 2006; Vanderplasschen et al., 2007b).

Method

In Denmark, data was collected as part of an evaluation of the Danish methadone project (2002–2005) by the Centre for Alcohol and Drug Research, University of Aarhus. This project’s general aim was to examine if enhanced psychosocial methadone maintenance treatment could improve drug users’ overall living conditions when standard methadone maintenance treatment has only a limited effect. The treatment focused on more frequent and accessible counselling, outgoing help, coordination, advocacy, access to drop-in centres, user participation and alternative ways of methadone dispensing. Each client was assigned a case manager, with a case manager/client ratio of 1:9. The target populations at three of the project’s four sites were the most extremely affected drug users, selected on the basis of several criteria, such as being over 30 years old, having more than a 10-year history of heroin abuse, having tried various forms of treatment, etc. In the fourth sub-project, all clients were randomly assigned to the programme. At all four sites, a significant reduction of clients’ psychological and social problems was

noticed, as well as increased levels of client satisfaction (Asmussen & Kolind, 2005; Pedersen, 2005). As part of the evaluation, all 16 case managers were interviewed several times, both individually and in focus groups, and 8 weeks of participant observation at all four treatment centres were conducted.

In Belgium, Ghent was the first region where intensive case management was implemented linking substance abusers with multiple and complex problems to the services they needed, and where the project was thoroughly evaluated (cf. Vanderplasschen et al., 2007a). Inclusion criteria for this project were severe problems on at least three ASI-life domains (according to the Addiction Severity Index); more than 5 years of substance dependence and prior admission to at least three different treatment modalities. Case managers assisted clients intensively during a 12-month period, and the case manager/client ratio was 1:10–12. Case managers operated from the methadone clinic in Ghent, but most of their contacts were with clients in the community. All the case managers were trained and supervised by the Department of Orthopedagogics at Ghent University. The evaluation (2003–2006) consisted of regular, semi- structured interviews and focus groups with all five case managers. An independent researcher administered the interviews and focus groups and made 12 weeks of participant observations of case managers’ activities.

In both the Danish and Belgian projects, semi- structured interviews consisted of open-ended questions aimed at understanding case managers’ daily activities, challenges and difficulties. Focus groups had the same goal, but were set up to discuss the main dilemmas and bottlenecks in applying case management to substance abusers with multiple problems.

In both projects, interviews and focus-group discussions were audio-taped and transcribed. Themes were identified and then counted and compared. These analyses used the following software programs for qualitative data analysis: WinMAX 98 (Belgian project) and NVivio (Danish project). The methodological aim was to identify patterns in social regularities, and to understand these patterns in the sense of controlled understanding of ‘the Other’ (Broekaert et al., 2001). In the Danish project, two researchers coded the interviews together, while in the Belgian project two independent researchers coded the text fragments independently and compared their results afterwards. Both procedures helped to increase the level of inter- rater reliability. Field notes were used to understand and interpret the statements made in the interviews and focus groups more accurately.

Results

We have clustered the experiences and perspectives of Danish and Belgian case managers according to some

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of the central elements of the intervention, as agreed on in the literature (cf. Moxley, 1989; SAMHSA, 1998): (i) planning and monitoring; (ii) linking and co- ordination; (iii) advocacy and user participation. First, the basic functions of case managers are described according to the literature. Next, these are confronted with the real-world challenges case managers experience in their daily work with substance abusers. The challenges and dilemmas discussed are listed in Table 1, including associated risks and difficulties and possible supports and solutions.

Planning and monitoring

The making and monitoring of a treatment/service plan is recognised as a core component of effective case management (Rapp, 2006). Based on an assessment of clients’ needs, wishes and strengths, client and case manager together identify goals in all relevant life domains and design a plan that includes the services to be provided in order to address short and longer-term problems and needs efficiently (SAMHSA, 1998).

Table 1. Overview of challenges and dilemmas identified by Danish and Belgian case managers, including associated risks and possible alternatives.

Challenges/dilemmas Risks/difficulties Supports/solutions

1. Planning and monitoring Long-term, systematic and written planning versus clients’ chaotic lifestyle and living situation

Irregular ‘ad hoc’ planning Unstructured or no formal plans Clients uninformed about their own plans Sole focus on active and motivated clients

Client-driven realistic goals, based on continuous dialogue Plans readily available for case managers and clients As a minimum, verbal communication of planning

Legal demands versus practical feasibility

Top-down demands of documentation experienced as control system

Focus on short-term goals Encouraging, not forcing, written planning Unrealised goals as indicator for continuing and monitoring the process

Time-consuming at the cost of client support Low goal-attainment and unrewarding planning with severely affected persons

Planning activities versus flexibility of case manager

Plans and activities ruined by unforeseen and acute problems

Anticipating crisis situations Combining acute crisis intervention with more long-term thinking Flexible use of constantly readjusted plans Need for clear, client-centred agreements

Formal obligations hamper flexible planning

2. Linking and coordination of care Fragmentation and competition versus integration and cooperation

Clients sent to and fro between agencies/ systems

Good understanding of (in)formal mechanisms between agencies/systems

No information exchange within/between (systems of) services

Formal interagency agreements An integrated treatment approach

Difficult interdisciplinary communication

Methodical approaches and techniques versus alternative pathways and personal contacts

Service delivery dependent on subjective factors and circumstances

Build up personal contacts Assist clients in contacts with services Outreach activitiesPrejudices about and inadequate approach of

drug abusers

3. Advocacy and client participation Paternalism and ‘taking over the initiative’ versus empowerment and ‘doing it yourself’

Clients become inactive and leave everything to their case manager

Offering clients options to choose from Learning by doing Leave as much initiative with clients, as long as they can do it themselves Set clear ‘upper’ and ‘lower’ limits

Dependent relation between case manager and client Needed services not provided

Normalisation and control versus client-centred trustful approach

Distant, non-understanding and disrespectful approach

Show interest in clients’ activities and situations Building up a genuine, respectful client-centred relation, based on trust Outreach activities and presence Realise something ‘big’ for the client Inappropriate behaviour as learning moment

Inappropriate client behaviour grows Case manager regarded as a ‘bore’ or ‘wise guy’

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Generally, systematic and written planning is presented as a more or less unproblematic formality that case managers either carry out or not. However, the reality is more complicated and, despite good intentions, planning appears to be a time-consuming and – at first sight – unrewarding activity when used with heavily affected substance abusers. In Denmark, anyone utilising the social services under

Serviceloven

(the Danish Act on Social Service) is entitled by law to have a social activity plan drawn up, whereas in Belgium treatment planning is encouraged, although not compulsory, in the health and social services.

Interviews with both Belgian and Danish case managers revealed that planning activities were irregular and seldom structured or formal. This, however, reflects the more general lack of such plans in the healthcare and social work system in these countries (Mahs, 2002; Vanderplasschen, De Bourdeaudhuij & Van Oost, 2002). The case managers discussed three aspects of this dilemma in particular: the incompatibility of written plans and clients’ living situations, legal demands as opposed to practical feasibility, and planning activities and the assumed flexibility of the case manager.

Planning and clients’ living situation

Danish case managers unequivocally stated that an excessively structured, long-term and systematic use of written planning was not only unrealistic, but sometimes also counterproductive when working with heavily affected drug users. They found that the living situations of most of their clients were rather chaotic, depending on the state of mind of the client concerned. Consequently, case managers had a hard time making clients attend appointments either with themselves or with service agents. Furthermore, they reported that clients primarily relied on verbal communication instead of written plans. The case managers therefore felt the need to find a middle course between a schematic, future-oriented and written social activity plan on the one hand, and the everyday lives of drug users (characterised by chaos, acute problems and verbal communication) on the other (see also Asmussen, 2006; Kolind, 2007). Consequently, planning activities varied to a large extent from one case manager to the next. For instance, some case managers complained about the bureaucratic character of such written plans:

If we have a user who is about to die by drinking himself to death, and we have found it most expedient to send him to this kind of inpatient place, then the decision-making authority demands that there is a plan saying something about what the user is going to do when the stay is over. There has to be a plan, right? A person whose life hangs by a thread has to find out how he keeps away from this

[drinking]

, he has to be motivated for something positive, something enabling him to contribute to society . . . Well, I think that the decision-making authorities are far away from real life.

Some Danish case managers also questioned the feasibility and durability of such planning:

We have plans that look nice in our

[computer]

system, but I don’t think you can use them for anything. It’s more, you know, if you have pains in the liver, okay then you go to hospital. Then, that is the treatment plan right now. Or, a person who is moving to another flat, then that is the treatment plan. All these activity plans, they have mostly expressed the social workers’ ambitions on behalf of the users. Some unrealistic goal is set up and the user just says yes, in order to get his methadone, and well you just give the user another defeat, as he cannot live up to these goals . . . [. . .] . . . If you have a relationship of trust with the user, then I find that the activity plan exists in a continuous dialogue [with the user], that’s what helps.

Legal demands and practical feasibility

Several case managers stressed that they regard compulsory written planning as a ‘top-down’ demand intended as a control and documentation system. So perhaps it is not surprising that some case managers viewed planning as a task of secondary importance, stealing time from supporting clients in the community. These findings correspond with clients’ perspectives on planning activities in general. Very few clients in the Danish methadone project knew whether they had a plan, and hardly anyone could recall the content of any such plan, even if a plan had actually been drawn up and signed. Alternatively, some case managers preferred to focus their work on clients who they perceived as active and motivated, clients for whom changes were more likely to occur.

In the Belgian project, case managers did not regard planning as being disconnected from the real life of their clients to the same extent. One reason for this was that clients’ goals and objectives – although not always explicitly stated on paper – steered the case management process. Case managers stated that even in crisis situations planning made it clear what to do next, made things easier to monitor and revealed when it was appropriate to stop case management. Clients appreciated being involved in planning activities, but case managers often expressed disappointment with the failure of clients to fulfil long-term goals. Ultimately, service plans were used in a flexible way, delineating common goals determined by the client in consultation with the case manager.

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Belgian and Danish case managers also differed in the extent to which activities preceding planning (assessment) and following planning (monitoring) were structured and formalised. Most Danish case managers actually preferred spontaneous and continuous talks with clients at drop-in centres, since they felt that these contributed more to building a trustful relationship with the client (see below). Belgian case managers tended to have scheduled appointments with their clients, but most of these contacts were arranged in the community instead of in their office. Both strategies, however, may interfere with adequate monitoring of (written) service plans, as they are simply not readily available for case manager and client.

Planning activities and case managers’ flexibility

Besides clients’ complex problems, the assumed flexibility of case managers may also hamper working with service and treatment plans. Danish case managers in particular regarded planning their working day as a rather difficult task. Plans can be made, activities prepared and appointments scheduled (both with clients and external service agents), but unforeseen and acute episodes and problems often ruined such planned interventions: a client acting violently, another who needs to be referred to detoxification, a long-awaited meeting with a landlord at which the client shows up intoxicated, etc. Some Danish case managers compared their job with working at a fire station: fires break out suddenly somewhere, and you have to be ready:

You never know what you will meet when you go to work in the morning. You may have planned a lot in advance, but when I get to work new and unforeseen things have to be dealt with. So a day at this place involves arriving without really knowing what the day will bring.

On the other hand, case managers agree that it is possible to draw up service plans if these plans are closely monitored and readjusted. However, the formal scheduled obligations imposed by Danish law may debilitate flexible planning. Case managers also need to find a good balance between solving acute problems and long-term thinking in order to avoid becoming crisis interventionists and nothing else. Belgian case managers stated that this could be done by making clear, client-centred agreements and anticipating crisis situations. Clear, long-term goals opened new perspectives after acute crisis intervention. Although case managers agree that such an approach is no guarantee of success, they say it at least reveals what clients want to realise in the long run.

Linking and coordination of care

It is acknowledged that many drug users have difficulties not only in linking with available services effectively on their own, but also in mobilising the determination needed to maintain contact with and receive the services needed (Brindis & Theidon, 1997; Rapp et al., 2008; Scott et al., 2002). Linking clients with various relevant services is therefore a core aspect of case management, as well as coordinating the services provided (Moxley, 1989; SAMHSA, 1998). However, several decisive factors may affect the coordination of services.

Fragmented or integrated delivery of services

Many case managers reported that the various service systems (e.g. the mental healthcare, judicial and social welfare systems) functioned as isolated sectors with little or no intra-institutional information exchange. A ‘classical’ example of such a lack of cooperation is expressed in the following statement about a client who was shuttled to and fro between the mental healthcare and substance abuse treatment systems in Denmark:

There is an everlasting fight between the treatment centre and the psychiatry. If we go to the psychiatry with them

[clients]

the psychiatry will say: ‘They have to solve their addiction before we can deal with them’. And then the client comes to us and we tell them they have to get their psychological problems solved before we can do anything. So they are thrown back and forth. Well, this guy he is actually free of drugs now, so that’s not our pigeon, it’s psychiatry’s pigeon.

This phenomenon was also observed in Belgium, where people with substance abuse problems are sometimes turned away by psychiatric hospitals and excluded from specific services such as relational or family therapy. In addition, case managers mentioned similar problems in the field of substance abuse treatment, as residential treatment centres tend to refer to their own services, regardless of clients’ actual needs and the case management plan that has been agreed on. Outpatient agencies appear to be more willing to cooperate with other agencies in order to meet clients’ needs. Given these diverging views and the competition between agencies, it is perhaps not surprising that some case managers stated that they sometimes felt that other services regarded them as rivals.

Objective and subjective factors in successful linkage

As a consequence of laborious contacts with some agencies, many case managers have learnt to rely on personal contacts instead. If they repeatedly contact the same people at a certain agency, or people they already

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know (e.g. former colleagues), case managers find that coordination is more successful. The dilemma then relates to the fact that case managers feel that in order to coordinate services in an acceptable way they have to find alternative pathways, make use of personal contacts and cultivate a good understanding of the informal working mechanisms of the various local agencies. Since this cannot be learnt methodically, some case managers feel uncomfortable with the situation because the quality of individual service delivery seems to depend on subjective factors and circumstances. This is illustrated by the following contact between a case manager and a nurse in a local Danish hospital:

I remember when Michael was hospitalised and I called to find out how he was doing. And then she – the nurse – was like, well snappish at first, as you sometimes find when talking to public health personnel about drug addicts. But then suddenly I could recognise the voice, and knew it was someone I had studied with, and I asked if it was her. And we had a good talk about Michael, and after that, he received really good treatment, and she called us when he left the hospital. You know, such things, they do play a part.

An experienced Belgian case manager described the informal pathway as follows:

Because people know me and I am respected in the field, they won’t say no that quickly to me. I think that’s more difficult for other people

[e.g. case managers]

they don’t know. I also enjoy great trust when I criticise treatment aspects; if people are open to criticism, of course.

The educational background of the case managers involved (psychologists, social workers, educationists and recovered drug users) also plays a role in this dilemma. Both Belgian and Danish case managers experienced a better and smoother level of com- munication with colleagues possessing a similar educational background. This may further interfere with case managers’ linking activities, as they sometimes feel insecure about aspects about which they have very little professional knowledge, but which may be of primary importance for the client.

Coordination and linking activities may also be challenged by the fact that some agencies are not equipped to deal with drug users and their problems. Case managers gave examples of doctors who had refused appointments with drug users because they failed to attend previous appointments, and of home- care professionals who refused to accept drug users as clients because they were afraid of being infected by dirty needles. As has been demonstrated by other authors (Hunt & Rosenbaum, 1998; Neale, 1998), Belgian and Danish case managers report that drug

users are often confronted with a lot of prejudices by professionals in health and social services. They say this is not necessarily without reason, as many drug users have problems attending appointments, or do not have appropriate communication skills to deal with institutional staff. Consequently, case managers find it important to assist clients in their contacts with agencies, such as hospitals, welfare offices, probation officers or dentists, as clients’ meetings with public servants are often more constructive when they are accompanied by their case manager. In the Belgian project, outreach activities had a central role in the case management project, and were regarded as very useful:

Outreaching is a must. Many clients would miss their appointment if you don’t look out for them and bring them. It sounds mothering, but it isn’t. If you drive a client three times to a service, and by doing so you cross the threshold, and after doing so the client will keep on going and doesn’t need you any more, . . . If you accompany them, you have a bigger chance to succeed. If you don’t join them, they

[other agencies]

will send your client from pillar to post and they will end up in the street. Because they can tell them

[clients]

where to go, but I fear the majority won’t go there.

Advocacy and client participation

The third set of dilemmas relates to the case manager’s role as an advocate, and clients’ involvement in the case management process. Advocacy can be defined as speaking out on behalf of clients, particularly when agreements, obligations or rights are denied or violated (SAMHSA, 1998; Schu et al., 2002). Client involvement relates to their participation and has to do with the difficult task of empowering clients, and strategies of normalisation versus building of trust.

Paternalism and empowerment

There is increasing focus on the importance of client participation in substance abuse treatment, as such involvement may have a positive effect on treatment outcome (Bacchus et al., 1999; Lilly et al., 2000). However, advocating on behalf of clients and explicitly focusing on client participation often involve the dilemma between how much initiative should be taken by the case manager and how much should be left to the client. If case managers leave too much to the clients’ initiative, in order to empower them, it may turn out that necessary services are not provided and that the case manager thus contributes to the failure of clients to link with services. On the other hand, pragmatically bringing clients into contact with a range of relevant services may make clients inactive and too dependent

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on their case manager, or it may even make them act on the basis of a ‘bad conscience’ for fear of letting the case manager down. As one case manager put it:

Often I have made the arrangements, because it is much easier if I do it. It is also faster, and probably I also say the right things; but the idea is that they should be able to do it themselves.

Belgian case managers stated that this dilemma can be reinforced by an excessively close relationship between case manager and client, as this may make it hard to draw clear lines and uphold sanctions (e.g. concerning drug use). On the other hand, the case manager may be placed in a dependent position if a client leaves everything to him/her.

You must pay attention to the dependent position of the client with regard to the case manager. You have to watch your limits very carefully, because sometimes they would eat you completely.

In order to avoid such situations, case managers stated explicitly at the outset of one of the Danish sub-projects that as professionals they should not become involved too deeply with their clients. However, at the end of the project two of the case managers had experienced this dilemma at first hand:

Case manager 1:

And now they

[the clients]

have started to ask, are you also leaving

[the project]

Interviewer:

Do you feel that the clients’ uncertainty has to do with you as individuals, more than with how the project will be continued?

Case manager 1:

Yes, that’s my feeling.

Case manager 2:

And that’s problematic, right? Because that was not the intention of the project, that they should be dependent on us.

The various Danish sites dealt with this dilemma quite differently. One site explicitly compared the treatment centre with a travel agency offering services which customers could choose to take or not. Other centres provided more outreach activities, and case managers acknowledged that they initiated and ultimately determined the kinds of services that were provided. During the course of the project, some centres changed their minds concerning this issue. For instance, after being closely involved with clients for a long time, one centre felt that they were going too far, so they tried to change their pedagogical approach to leave as much initiative with the clients as possible:

Basically, they

[clients]

are resistant when we make demands. Because, at the beginning

[of the project]

we kind of showed them that, well we fix this and we fix that, no problem. And suddenly, they maybe feel that we have made a U-turn. You know, if a call is

going to be made to a doctor, then: ‘You still have fingers, so call yourself’. Maybe they now feel that we are easing off and don’t really care any more. On the other hand, if they have to make a call to a doctor, we keep reminding them to make the call.

Belgian case managers mainly described their role as assistants and supporters, and stated that advocacy is only necessary when a client cannot do something himself. They tried not to take the initiative away from a client if he was capable of doing something himself.

‘Normalisation’ and trust

In continuation of the above-mentioned dilemma, two pedagogical strategies for approaching clients can be distinguished: education, ‘teaching manners’, steering and control, on the one hand, and a client-centred trustful approach, on the other (cf. Saleebey, 2006). In practice, these strategies were often mingled.

The interviews revealed that all the case managers involved regard the establishment of trustful relations with clients as one of the most fundamental aspects of their work, something that has also been stated by other authors (e.g. Brun & Rapp, 2001; Lilly et al., 2000). They are convinced that good case management can be achieved only if clients trust them as individuals with genuine intentions, individuals who are also helpful professionals (see also Boehm & Staples, 2002). Danish case managers made use of various strategies in order to win clients’ confidence: presence at drop- in centres to facilitate informal contacts, less control of clients’ behaviour, non-paternalistic attitudes etc. In addition, Belgian case managers stressed the importance of outreach activities, as clients seem to regard such activities as a sign of recognition and respect.

However, while focusing on building trustful relations, case managers also expressed the need to educate clients or, more precisely, to teach or model appropriate behaviour. Danish case managers referred to this as ‘normalisation’; it includes working on things such as: personal hygiene, social competences, conflict solution strategies, verbal skills, activities of daily life etc.

We try to give them some education or whatever you will call it. You know, like when you go to your social worker you don’t have to smash it all. You can say hello in a polite manner and say what’s on your mind.

At some Danish sites, such normalising endeavours were rare, while at others they were very much in focus and non-compliance with so-called normal behaviour was dealt with in different ways. Sometimes there were no consequences, sometimes clients were banned for a while. In the Belgian project, normalisation was a minor

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issue because the case managers’ client-centred approach primarily related to the stabilisation of the situation of substance abusers. However, by being clients’ advocates and maintaining a long-lasting and intensive relationship based on mutual trust, case managers received a great deal of confidential client information, which was not always easy to handle. According to case managers, they need to provide ‘responsible support and advocacy’, for example if a client’s own interests are in opposition to the interests of their children, thereby introducing an element of control which could run counter to the establishment of trust.

Discussion

This comparison of the experiences of case managers from similar projects for substance abusers with multiple and complex problems in two different countries has revealed a number of critical dilemmas concerning the practice of case management. Case management is often presented as a set of standardised functions that can be performed in unbiased and objective fashion, but actual case management practices appear to vary from one project to another, and even within the same project (Huber et al., 2003; Kuhn et al., 2006; Sorensen et al., 2003; Vanderplasschen et al., 2004). Moreover, case managers intervene in a variety of ways depending on, among other things, the person and the situation in question and the programme and system requirements they have to fulfil. We have demonstrated that these ‘inter-’ and ‘intra-’case manager differences may have a lot to do with the attitudes of case managers to the dilemmas that accompany their job. Ultimately, such decision-making moments (e.g. paternalistic versus empowering approach) may affect case management outcomes, since the case manager–client relationship and client involvement in planning and other activities play a central role in the effectiveness of case management (Rapp, 2006).

At a time when case management is increasingly being implemented in European healthcare and social welfare systems (Vanderplasschen et al., 2004), there appears to be far less certainty about the actual practice of this form of intervention than is generally assumed (Kuhn et al., 2006; Roeg, Van de Goor & Garretsen, 2007). It has been demonstrated that the use of manuals for implementing case management and the degree of fidelity with which the intervention is delivered affect outcomes (Hesse et al., 2007; Jerrell & Ridgely, 1999; Morgenstern et al., 2006). However, both aspects are closely related to the form of intervention (e.g. what services should be provided, how often, by whom?), and less to the content (e.g. how should these services be provided?). So despite (evidence-based) guidelines and protocols (Ontwikkelcentrum, 2003; SAMHSA, 1998), case management is confronted with a number of

inherent dilemmas. In training courses, supervision meetings and manuals, the dilemmas highlighted in this article usually remain undiscussed, leaving much space for interpretation by case managers. When evaluating case management and designing programmes for its implementation, we believe that it is important not only to consider these dilemmas but also to recognise that they, and other dilemmas, are part and parcel of performing case management.

In other words, it is not enough to state that this or that programme used individual plans, employed coordinated treatment or involved clients. It is also necessary to consider and report on: what kinds of plans have been laid; who will carry them out and when (and where); what kind of formal agreements and personal relations can case managers rely on; how has case management been integrated in the system of services; to what degree are clients involved in decision-making and in contact with services themselves; etc. Too often, evaluations of case management do not measure the actual behaviour of case managers. Consequently, even when its effectiveness is demonstrated, the reasons for effectiveness remain unclear (cf. Jerrell & Ridgely, 1999; Noel, 2006; Vanderplasschen & De Maeyer, 2007). Ultimately, one of the hazards is that a new, diffuse function is installed that does not differ substantially from standard treatment.

Planning and monitoring tailored to substance abusers’ pace and needs

Although planning is a core case management function (Graham & Birchmore-Timney, 1990), written and systematic planning appears to be difficult to realise with heavily affected drug users, as illustrated in the Danish project. Belgian case managers were more successful, but even so some clients had very poor written plans – or no written plans at all. The feasibility of planning seems to be associated with the degree of client involvement and the legal need for registration and documentation. Belgian case managers had no formal obligations to register service plans, and were trained to involve clients in this planning process; while Danish case managers were obliged to register social activity plans, often at the expense of client involvement in planning activities and the realisation of the stipulated objectives.

Client involvement and the identification of goals in collaboration with clients is advisable (Rapp, 2006). The use of specific tools (e.g. service plans on coloured paper, handing clients a copy of their objectives) can help to remind even severely affected drug users of the goal-setting process and the postulated objectives. Continuous monitoring of these plans should be an automatic activity by case managers in informal contacts, but it should also alternate with more formal

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monitoring (Godley et al., 1994; SAMHSA, 1998). This is because the nature of the problems of the target population calls for flexibility in developing and adjusting plans. Though at first sight this may seem unrealistic, the setting of mid- and long-term goals that can guide the course of the case management process, even in crisis situations, is recommended. In addition, attainable short-term goals should be formulated in order to provide clients with the satisfaction of demonstrating their abilities and to inspire confidence between clients and case managers (SAMHSA, 1998). The failure to realise goals should be regarded as an opportunity to re-evaluate one’s efforts and to look for an alternative approach (Van Ooijen-Houben, 1998). The quantitative evaluation of both the Belgian and Danish projects has shown that it is possible to achieve progress with heavily affected drug users (Hesse & Pedersen, 2008; Vanderplasschen et al., 2007a).

Facilitating linking and coordination of care

Case managers’ stories reveal a great deal of institution- based thinking in the agencies they collaborate with, which sometimes makes it difficult to achieve the objective of linking clients to the right services and coordinating the provision of services (cf. Moxley, 1989). This may be further reinforced by the negative attitude of some care providers towards substance abusers (Neale, 1998). Our findings, and the literature, show that it is important to make formal agreements with agencies and treatment providers in order to ascertain their availability (McLellan et al., 1999), but also that informal contacts and relations with these agencies seem to be of equal importance (Vanderplasschen et al., 2002). As shown in the Belgian project, it is therefore indispensable for case managers to meet regularly with care providers from other agencies, not only to make the path of linking and coordination activities smoother, but also to bridge the gap between agencies within and across sectors (Vanderplasschen & De Maeyer, 2007). Experienced case managers may have some additional advantages in this respect. In addition, informal talks and outreach activities should be stimulated to enhance relationships with other agencies.

Enhancing advocacy and client participation

The final case management dilemma relates to the degree of empowerment and self-determination of clients. Case managers certainly have an empowering role (Siegal et al., 1995), but most case managers have experienced that it can be unwise and ineffective to let clients with multiple and complex problems link with services themselves. In fact, the ideology of empowerment in modern welfare systems can sometimes prove counterproductive, as some people with multiple

and complex problems appear not to be capable of taking responsibility for their own treatment (Cruikshank, 1999; Leonardsen, 2007). So empowerment does sometimes lead to the neglect of clients’ needs. Even so, a strengths-based approach for individuals with multiple problems has also led to promising results among substance abusers (Hesse et al., 2007; Rapp et al., 2008). Furthermore, an open and respectful attitude is necessary to strengthen the client–case manager relationship (Brun & Rapp, 2001; Kolind, 2007). It is likely that this client–case manager relationship accounts for more of the explained variance than the case management intervention itself (cf. Lambert, 2003; Rapp, 2006).

In addition to a strengths-based approach, employing a multidisciplinary case management team also makes it easier to address the issue of ‘paternalism versus emancipation’, since this and other dilemmas can be discussed from varying perspectives during team meetings (Roeg et al., 2005). Given the web of dependence that drug users are usually involved in, clients should not be allowed to become dependent on case managers, or vice versa. As a result, case management should start with some clear goals and agreements and be of only limited duration (SAMHSA, 1998). The ultimate objective is that clients can function independently, or that clients can identify and contact the required services themselves. After all, case management has been implemented to complement existing services and interventions in the field of substance abuse treatment – not to replace them or make them redundant.

Conclusion

When implementing case management, it is important to realise that this form of intervention does not include a clear set of tasks and functions that can be performed objectively, but rather consists of a global framework and some general directives, which apply to any case management process. Case management projects are often characterised by more diversity than unity. Part of this diversity is due to some of the dilemmas inherent in case management, like systematic and written planning versus informal and ‘ad hoc’ planning and monitoring, and normalisation and control versus emancipation and self-determination. In order to monitor what the intervention entails, it is important to discuss these dilemmas during training courses and supervision meetings, and to choose the position that has been adopted and record it. If this is not done, the intervention may drift further away from its original concept, becoming just another redundant part of substance abuse treatment. Furthermore, unless these dilemmas are properly addressed and discussed, it will be impossible to account for any degree of success that has been achieved by the case management process.

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