For this Assignment, review the Learning Resources for this week. You submit your selected models of addiction, treatment, and case management for your Scholar Practitioner Project (SPP). In addition, you provide a rationale for selecting these models and explain their strengths and limitations. Refer to the “Instructions for Scholar Practitioner Project (SPP) Case Study” document in Week 1.

In a 4­–5 page APA-formatted paper:

Submit the models of addiction, treatment, and case management you selected for your Scholar Practitioner Project (SPP) Case Study. Include the following information:

• Your chosen model of addiction and the rationale for your selection
• Potential strengths and limitations of this model of addiction
• Your chosen model of treatment and the rationale for your selection
• Potential strengths and limitations of this model of treatment
• Your chosen model of case management and the rationale for your selection
• Potential strengths and limitations of this model of case management 

I have attached the required reading documents. 

These are also required readings below 

 
Doweiko, H. E. (2019). Concepts of chemical dependency (10th ed.). Stamford, CT: Cengage.
Chapter 28, “The Assessment of Suspected Substance Use Disorders” (pp. 389-404)
Chapter 31, “The Treatment of Substance Use Disorders” (pp. 424-436)
Jung, J. (2010). Alcohol, other drugs, and behavior: Psychological research perspectives (2nd ed.). Thousand Oaks, CA: Sage Publications, Inc.
Chapter 3, “Alcohol and Other Drugs: Use, Abuse, and Dependence” (pp. 57–79)
Chapter 14, “Treatment of Alcohol and Other Drug Dependencies” (pp. 377–394, stop before Evaluation of Treatment Programs)

Instructions for Scholar Practitioner Project (SPP) Case Study

1. For your SPP, you will prepare a case study of Marge, the client presented in the media throughout the course.

2. Your case study will consist of two sections: A narrative case study section and a treatment plan section.

3. The narrative case study section will be written using the required APA style. You will use this document as a guide for the narrative section of your case study and include at a minimum the 18 elements presented below. The final narrative case study section should be approximately 15–20 pages in length.

4. Your treatment plan section will follow the Treatment Plan Template introduced in your Assignment for Week 5.

5. The timeline for your case study will extend from the client’s admission into residential treatment (Counseling Session 1), proceed through her course of treatment there (Counseling Sessions 2 and 3), and conclude with a discharge plan of her projected long-term treatment extending through the next 12 months.

Case Study Format

Treatment Plan Section

· Treatment plan developed using Treatment Plan Template and attached at end of case study.

Narrative Case Study Section

IDENTIFYING INFORMATION

· Name, age, race/ethnicity, gender, marital status, and any other appropriate information

PRESENTING PROBLEM

· Brief summary of the problem(s) and concerns that brought the client to treatment

· Description of current condition including physical and mental status and attitude on admission

· Who accompanies client and provides collateral information

· Other relevant information

ASSESSMENT

· Description of how initial screening was conducted to validate the existence of a problem and make initial treatment recommendations. Include how information was gathered (e.g., verbal clinical interview, paper-and-pencil assessment instrument) and sources of information (e.g., client, family members).

· Overview of ongoing assessment process to evaluate severity of the addiction, rule out the co-existence of other relevant problems, assist in treatment planning, and monitor progress (e.g., continued more detailed interviews with client and family members, observation, standardized assessment instruments).

ADDICTION HISTORY

· Substance(s) used and/or any addictive behaviors identified

· Age of first use

· Family history of addiction (chemical and/or behavioral)

· Progression of use to current stage

· Average frequency and amount over last six months

· Other signs and symptoms of addictive use (e.g., blackouts, increased tolerance over time, physical withdrawals if use stopped)

· Negative consequences experienced due to use

· Previous attempts to stop on own and/or treatment history

· Level of denial of problem (e.g., none, mild, moderate, severe)

· Level of motivation to change on admission (low, moderate, high)

CO-OCCURRING DISORDERS

· Any other current or past mental disorder or mental health problem

· Signs, symptoms, course of disorder, and other pertinent information necessary to plan treatment

· Past history of treatment or counseling

MEDICAL HISTORY

· Pertinent current or past medical history related to or affected by addiction

· Current medications (in particular psychotropic and/or prescribed addictive medications)

EDUCATIONAL/VOCATIONAL HISTORY

· Education

· Work/career history including problems related to addiction

· Current financial status

LEGAL HISTORY

· Current or past legal problems

· Current status of any existing legal problems

SOCIAL/CULTURAL STATUS

· Socioeconomic status

· Any cultural/ethnic factors influencing addiction and recovery

· Social/leisure activities

FAMILY/RELATIONSHIP STATUS

· Composition of immediate family

· Description of roles identified for each family member

· A explanation of the potential impacts of these roles on family members

· Include family in client’s treatment plan and a minimum of two resources that would be useful to them

MODEL(S) OF ADDICTION

· Model(s) of addiction used to plan treatment approach. Rationale for use and strengths and weaknesses of chosen model(s)

MODEL(S) OF TREATMENT

· Model(s) of treatment used. Rationale for use and strengths and weaknesses of chosen model(s)

MODEL(S) OF CASE MANAGEMENT

· Model(s) of case management used. Rationale for use and strengths and weaknesses of chosen model(s)

THE ROLE OF SPIRITUALITY

· Describe how spirituality could be an important factor in client’s recovery

· Ways in which client’s spiritual needs might be addressed through case management referrals to community 12-step support groups or other spiritual resources

COURSE OF TREATMENT

· Current level of treatment (as defined in Week 4 by the American Society of Addiction Medicine’s Patient Placement Criteria [PPC])

· Projected PPC level(s) of treatment after discharge from residential treatment over the next 12 months and an explanation of why this level(s) would be effective

· Projected levels of treatment over next 12 months

· Response to treatment

· Prognosis for response to treatment over next 12 months

DISCHARGE PLAN

· Summary of treatment recommendations over next 12 months (as reflected in treatment plan)

REFLECTION ON PERSONAL MISSION STATEMENT

· Conclude the case study with a statement of how personal traits, skills, motivations, and experiences you possess might be helpful in pursuing a career as an addiction counselor. How will these factors contribute to your ability to maintain self-awareness and a healthy work/life balance?

©2012 Laureate Education, Inc. 2

2

Treatnet: International Network of Drug Dependence
Treatment and Rehabilitation Resource Centres.

Good practice document

Sustained Recovery Management

Good Practice

www.unodc.org/treatnet

Vienna, September 2008

3

Disclaimer

The views expressed in this good practice document are those of the authors
and do not necessarily reflect the policies or views of UNODC. A reference to
a document or a website does not imply endorsement by UNODC of the
accuracy of the information contained therein. This document has not been
formally edited yet.

This good practice document has been prepared by a professionally and
geographically diverse working group with participants from five drug
dependence treatment centres as part of UNODC project GLO/H43 “Treatnet
– International Network of Drug Dependence Treatment and Rehabilitation
Resource Centres”. It was peer reviewed to assure comprehensiveness and
its relevance to different sociocultural environments as well as a balanced
representation of different perspectives on the issue.

4

Acknowledgements

The present publication is one of a series of four documents developed under UNODC
project GLOH43: Treatnet-International network of drug dependence treatment and
rehabilitation resource centres. It responds to UNODC’s mandate, to develop and
disseminate good practice in the field of drug dependence treatment.

During Phase I an international network of drug dependence treatment and
rehabilitation resource centres in all regions was initiated, with a view to facilitating
dissemination of knowledge and good practices. This document has been produced by
members of one of four working group consisting of representatives from Treatnet
members and the topics of the documents include:

• Community Based Treatment
• Interventions for Drug Users in Prisons
• The Role of Drug Dependence Treatment on the Prevention and Care of HIV and

AIDS
• Sustained Recovery Management.

The United Nations Office on Drugs and Crime expresses its gratitude to the
following:

• The donors of project GLO/H43: The Governments of Canada,
Germany, The Netherlands, Spain, Sweden, The United States of
America and the Robert Wood Johnson Foundation for their generous
contribution.

• All Treatnet Resource Centres (in alphabetical order by country)

participating in the working group on Sustained Recovery Management
and the respective Treatnet Focal Points for their professionalism,
commitment, enthusiasm and the mutual support given to each other
as well as the financial and time resources dedicated to the network:

• Mario Alberto Zapata on behalf of CARISMA- Centre for
Attention and Integral Rehabilitation of Mental Health, Medellin
(Colombia)

• Max Hopperdietzel on behalf of Mudra, Nürnberg (Germany)
• Shanti Ranganathan on behalf of TT Ranganathan Clinical

Research Foundation, Chennai (India)
• Akinwande Akinhanmi on behalf of Neuropsychiatric Hospital

Aro, Abeokuta (Nigeria)
• Mike Boyle on behalf of Fayette Companies, Peoria, Illinois

(USA)

5

UNODC and the working group on Sustained Recovery Management would
like to express their special thanks to the international experts, who have
commented on an earlier draft of this document, for their generous support,
insights constructive feedback and contributions to improve and finalize the
Treatnet publications (in alphabetical order):

• Natalie Bartelt, Gesellschaft für Technische Zusammenarbeit (GTZ)
• Anna de Boer, Independent Consultant, Capacity Development and

Coaching
• Nicholas Clark, World Health Organization
• James Egan, Scottish Drugs Forum
• David MacDonald, International drugs and development advisor
• Patricia Kramerz, Gesellschaft für Technische Zusammenarbeit (GTZ)
• Ingo Ilja Michels, Office of the Federal Drug Commissioner, Federal

Ministry of Health, Germany
• Jacek Moskalewicz, Department of Studies on Alcoholism and Drug

Dependence, Institute of Psychiatry and Neurology Warsaw, Poland
• Vladimir Poznyak, World Health Organization
• Nicola Singleton, UK Drug Policy Commission, Recovery Consensus

Group
• Robert van Lavieren, United Nations Industrial Development

Organization
• Inez Wijngaarde, United Nations Industrial Development Organization
• UNODC colleagues: Cristina Albertin (UNODC Bolivia), Kham Noan

Hsam (UNODC Laos), Estella Maris-Deon (UNODC Vienna), Anja
Korenblik (UNODC Viena), Isabel Palacios (UNODC Peru), Jorge Rios
(UNODC Viena)

Furthermore UNODC and the Treatnet working group on Sustained Recovery
Managament would like to thank the following persons for their substantive
contributions to this document:

• Consuelo Cassarotto, alternative development and livelihoods expert
• Marguerite Sheila Martindale, WildMind Communications
• David Moore, Fayette Companies
• Arun Pinto, MD, Vice President of Medical Services, Fayette Companies
• William White, Chestnut Health Systems/Lighthouse Institute
• Maria J. Zarza, University of California Los Angeles – Integrated

Substance Abuse Program (UCLA/ISAP)
• and all those who have provided the information for the case studies

(Chapter IV)

6

Table of contents

Page

Introduction and Overview

A Brief Background
Definitions of Good, Evidence-based, and Promising Practice
Who Can Use This Manual
Overview of Chapters

Chapter I: A Sustained Recovery Management Approach

Sustainable Livelihoods
A Recovery Framework
Recovery Capital
A Sustained Recovery Management Approach
Benefits of a Sustained Recovery Management Approach

Chapter II: Components of Sustained Recovery Management

The Components of Sustained Recovery Management

Domain 1: Physical and mental health
Domain 2: Family, Social Supports, and Leisure Activities
Domain 3: Safe Housing and Environments Conducive to Health

and Recovery
Domain 4: Peer-based Support
Domain 5: Employment and Resolution of Legal Issues
Domain 6: Vocational Skills and Educational Development
Domain 7: Community Integration and Cultural Renewal
Domain 8: Pathways to (Re)discovering Meaning and Purpose in
Life

Chapter III: Laying the Groundwork for Building Recovery Capital

Laying the Groundwork for Building Recovery Capital
Steps towards Building Recovery Capital

Domain 1: Physical and Mental Health Supports
Domain 2: Family, Social supports, and Leisure Activities
Domain 3: Safe Housing and Environments Conducive to Health

and Recovery
Domain 4: Peer-based Support
Domain 5: Employment and Resolution of Legal Issues
Domain 6: Vocational Skills and educational development
Domain 7: Community integration and cultural renewal
Domain 8: Meaning and Purpose in Life

7

Chapter IV: Case Studies

Promising Practices in Action

Promoting Micro Enterprises and Vocational Training in the
Cochabamba Tropics: Bolivia
Education: Cambodia
Cultural Support: Canada
Vocational Skills Training and Employment: Germany
Special Employment Programme for At-Risk Youth: Honduras
Family Support: India
Vocational Skills Training and Employment: Nigeria
Legal Support: Spain
Peer Support: United States of America

Chapter V: Advocacy

Target Groups at the Personal and Community Levels
Target Groups at the Institutional and National Levels

Advocacy Methods
Information Sources

Chapter VI: Sustained Recovery Management: Documentation and
Evaluation

A Step-by-Step Approach to Documentation and Evaluation
Step 1: Set up an evaluation group
Step 2: Describe the programme in detail
Step 3: Assess the resources available for conducting an
evaluation
Step 4: Identify and prioritize areas of evaluation
Step 5: Generate evaluation questions
Step 6: Programme design
Step 7: Selecting measures or instruments
Step 8: Managing data
Step 9: Analysing and interpreting data
Step 10: Using the results and lessons learned

Appendix I: Figures for Chapters I and III

Appendix II: Screening and Assessment Instruments

Appendix III: Chapter References and Further Reading

8

Introduction and Overview

A Brief Background

This manual is a product of Treatnet, the International Network of Drug
Dependence Treatment and Rehabilitation Resource Centres, initiated by the
United Nations Office on Drugs and Crime (UNODC). The goal of the network
is to improve the accessibility, affordability, and the quality of drug
dependence treatment and rehabilitation. Twenty drug treatment and
rehabilitation organisations from all regions of the world have joined Treatnet
as Resource Centres, and 15 providers are associate members.

Four good practice documents, developed by the Treatnet workgroups, are
products of this initiative and are available to assist drug dependence
treatment providers around the globe. Their focus is on:

• Community-Based Treatment Services;
• Drug Dependence Treatment in Prison Settings;
• The Role of Drug Dependence Treatment in HIV/AIDS Prevention and

Care; and
• Sustained Recovery Management

Furthermore the Treatnet Capacity Building Package, (developed by the
University of California Los Angeles Integrated Substance Abuse
Programme), provides in-depth training manuals on the following topics:

• Screening, Assessment, and Treatment Planning;
• Elements of Psychosocial Treatment;
• Addiction Medications and Special Populations; and an
• Administrative Toolkit.

Definitions of Good, Evidence-based, and Promising Practices

Treatnet defines good practice as an umbrella term that encompasses
evidence-based and promising practices. Good practices display the following
features:

• Relevance to local needs;
• Ethical soundness;
• Sustainability likelihood (low cost, cost efficient, integrated,

supported), and
• Replicability, that is, practices that have been sufficiently documented.

Evidence-based practices are supported by scientific studies and were
ideally replicated in multiple geographic or practice settings. These practices

9

produce specific, consistent, outcomes and have been documented in
scientific journals; sometimes they are available as manuals.

The strength of the evidence available can, in general, be ranked into specific
gradations (British Hypertension Society, 2001) as follows:

Promising practices have been demonstrated to be effective, using
objective measures, in one or more organisations. These practices may be at
an early stage of development, but show promise of replication, and long-
term sustainability with the possibility of becoming evidence-based practices.

Who Can Use This Manual

This document is intended as a practical guide for persons or organisations
who want to develop or improve recovery supports for persons with drug use
problems integrated in or in collaboration and coordination with treatment
services available in the community. (See the Community Based Treatment
Services manual, one of four training manuals designed to assist drug
dependence treatment providers around the globe.)

The primary audience for this manual is:

• Practitioners in drug dependence treatment and rehabilitation services,
especially in low-income countries; and

• Front-line health care personnel (e.g., social workers, medical and
psychiatric support staff).

Additional audiences include, but are not limited to:

• Government policy makers;
• Non-Governmental Organizations (NGOs);
• Academic institutions;
• Advocacy and community groups;
• Educators and Employers
• The judicial system; and
• The general public.

Strength of Evidence Gradations:

Ia: Evidence from meta-analysis of randomized controlled trials;
Ib: Evidence from at least one randomized controlled trial;
IIa: Evidence from at least one controlled study without randomization;
IIb: Evidence from at least one other type of quasi-experimental study;
III: Evidence from descriptive studies, such as comparative studies,
correlation studies, and case controlled studies; and
IV: Evidence from expert committee reports or opinions or clinical
experience of respected authorities, or both.

10

Overview of Chapters

Chapter I introduces the emerging practice of sustained recovery
management from a rather theoretical perspective by giving a brief overview
of some of its underlying concepts drawn from a variety of fields, (e.g.,
Sustainable Livelihoods, Recovery Framework, and recovery capital). Some
of these concepts, though not yet rigorously tested, are implicit in emerging
good practice already in use in the area of drug dependence treatment and
rehabilitation. The chapter furthermore introduces the key principles of
Behavioural Health Recovery Management as an example of an alternative to
the traditional “admit, treat, and discharge” model.

Chapter II presents the results of a literature review on various types of
recovery supports to sustain recovery from drug dependence. This chapter
also explores how drug dependence treatment and rehabilitation services can
be effectively integrated within a sustained recovery management framework
that helps address the needs of the client in a holistic way.

Chapter III is intended for those who are interested in the more practical
“what” and the “how” of the implementation of a sustained recovery
management approach. It responds to these questions by setting out guiding
ideas, and giving a list of practical steps as a means of laying the
groundwork for (re)building recovery supports (also referred to as recovery
capital) in eight domains.

Chapter IV provides good practice approaches of projects that have
developed rehabilitation and social reintegration approaches with a focus on
recovery supports. The case studies, while presenting a regional and
thematic balance, reflect the cultural and resource settings of specific
regions.

Chapter V focuses on ways to advocate for recovery supports for drug
dependent persons by targeting groups at every level of society: the inter-
individual and community levels, as well as at the more arms-length
institutional and national levels. It demonstrates how, through advocacy and
wide outreach, it is possible to raise awareness at every level of society
about the emerging promising practice of sustained recovery management.

Chapter VI deals with the components needed to document and evaluate
programmes from a sustained recovery management perspective. It
promotes a step-by-step approach to documentation, and lists nine steps
needed to carry out a successful evaluation. A vocational programme is given
as an example of what is required. (See also Appendix II for more
information on service evaluation.)

11

Chapter I: A Sustained Recovery Management
Approach

Health is a state of complete physical, mental and social wellbeing
and not merely the absence of disease or infirmity.

(World Health Organization, 1986)

This document presents an integrated continuum of care framework and
recommendations, developed through a review of literature and good
practice, for effective long-term rehabilitation and social reintegration of drug
dependent persons. In a “sustained recovery management” approach, drug
dependence is seen as a multifactorial disease that often follows the course
of a relapsing and remitting chronic disorder (A.T. McLellan, D.C. Lewis,
O’Brien, et al., 2000; A.T. McLellan and C. Wisner, 1996). This chapter
introduces the emerging practice of a sustained recovery management
approach to drug dependence treatment, rehabilitation, and social
reintegration.

The approach, as it is described here, brings together the Sustainable
Livelihoods framework, derived from the area of development cooperation,
and the drug dependence-specific recovery capital/recovery framework
approach as an organizing concept and assessment tool for practitioners of
drug dependence treatment and rehabilitation services. Its elements, coming
from different areas, have only partly been applied and evaluated in this
combination. Therefore, this promising practice remains in need of careful
evaluation to verify its effectiveness. The case studies included in Chapter IV,
from existing drug dependence treatment programmes that have successfully
incorporated some of its key components, stand as examples of promising
practice.

This chapter introduces and links the Sustainable Livelihoods framework and
the Recovery Framework from a more theoretical perspective. It concludes
with an introduction to the more practical approach of sustained recovery
management that will be the major topic of the following chapters.

Sustainable Livelihoods

The concept of Sustainable Livelihoods derives from the field of development
cooperation. Its intent is to help practitioners to:

a) Better understand the livelihoods of marginalized groups and their
contexts, as seen through their own eyes, and

b) Improve poverty reduction efforts.

12

According to FAO, the United Nations Food and Agricultural Organization,
Sustainable Livelihoods is defined as:

The capabilities, assets—both material and social
resources—and activities required for a means of living. A
livelihood is sustainable when it can cope with and
recover from stresses and shocks, maintain or enhance
its capabilities and assets, and provide net benefits to
other livelihoods locally and more widely, both now and in
the future, while not undermining the natural resource
base.

Though the Sustainable Livelihoods concept has not been applied within the
continuum of drug dependence treatment, rehabilitation1, and social
reintegration, it is suggested here (see also Figure I, Appendix I) as a guiding
reference for those developing or working in sustained recovery management
services.

Creating the necessary supports to maintain a sustainable livelihood gives
persons in the process of rehabilitation and social reintegration more financial
security and the opportunity to shift towards social environments and
relationships conducive to stabilization and positive changes.

In this document, Sustainable Livelihoods is also understood as a
comprehensive way to understand, assess and support the human, social,
and vocational resources needed to support people to build stability and well-
being in their lives and to reduce the negative health and social
consequences of drug use.

The following characteristics make the Sustainable Livelihoods framework
(Figure I, Appendix I), as adapted from DFID (UK Department for
International Development), a broad and useful assessment tool in that it:

• Identifies appropriate entry points for livelihoods development;
• Provides a checklist of availability of livelihoods/resources;
• Draws attention to multiple interactions between key factors

affecting livelihoods;
• Is people centred, that is, it is helpful in gathering multiple data and

analysis on people’s livelihoods; tracks how these are changing over
time; and focuses on the impact of policy and institutional processes
on people and households;

1 It is well to note that, for some persons (especially vulnerable populations), it may be a case of social
integration and ‘habilitation.’ [In some countries where drug dependence is long standing and worsened
by adverse socio-economic environments, the question is asked, “How can someone be rehabilitated or
reintegrated when they were never ‘habilitated’ or integrated in the first place?” Therefore, the
rehabilitation process is going to take them to a completely new space and not a return to the extremely
impoverished and socially dislocated context they were in before they started to use drugs.] (Paraphrased
from an e-mail dated Jan 18, 2008, from David Macdonald, Demand Reduction Advisor, Afghanistan.)

13

• Is holistic, for example, organizes the factors that reduce or increase
opportunities for improved livelihoods outcomes;

• Is dynamic in that it acknowledges the vulnerability context, which
are the effects on livelihoods of shocks such as job loss, divorce,
illness, death of loved ones, loss of assets due to natural disasters,
and conflict;

• Is strengths based because it focuses on people’s strengths and
inherent potential gained through social networks, access to physical
resources and infrastructure, including the ability to influence policy
making and the institutional environment;

• Is sustainability focused in that it seeks sustainable solutions (e.g.,
those that can facilitate long-term recovery); and

• Links the personal with the political as seen in the multilayered
Sustainable Livelihoods approach that is central to identifying
supportive strategies in the immediate environment (e.g., personal
efforts and assets, community-level initiatives and strengths), and
linking with a wider public policy agenda for positive outcomes.

The Sustainable Livelihoods Framework and, specifically, its Asset Pentagon
(Figure II, Appendix I) can be used as assessment tools to:

• Analyze the livelihoods of drug dependent persons in relation to the
livelihoods of their communities by identifying and increasing their
strengths, opportunities, and assets in key areas such as human
capital, natural capital, financial capital, physical capital and social
capital.

Human Capital represents a basic requirement to
gaining access to other livelihoods’ building blocks.
It includes good health, knowledge, skills (e.g.,
college education and vocational skills), all of which
can ease the way to entering the labour market. It
is the sum of all personal resources that can be
utilized to combat poverty in the context of
recovery and substance dependence.

Financial and Physical Capital comprise
economic and financial assets (e.g., income,
property, and investments), basic infrastructure,
and producer goods such as tools and equipment)
needed to support livelihoods: transport, secure
shelter, water supply and sanitation, clean and
affordable energy.

Social Capital includes all the resources that can
be drawn from social networks, memberships and
relationships of trust and reciprocity that can
support the creation of “safety nets.” High levels of
Social Capital add significantly to Human Capital.

Natural Capital consists of natural resources from
which livelihoods are derived (e.g., land, trees, key
environmental services, and food).

14

In the view that in an impoverished environment, people with drug problems
are especially vulnerable and in need of access to scarce resources available
in the community, other components of the Sustainable Livelihoods
Framework (Vulnerability Context, Transforming Structures and Processes:
Figure I, Appendix I) help place the sustained recovery management process
within a broader socio-economic and political foundation to:

• Identify and address external factors (social, economic, and
institutional) that can influence, ease, or inhibit the likelihood of
sustained recovery and social reintegration;

• Explore means of transforming the underlying politico-economic and
social factors that have an impact on overall poverty levels,
marginalization, social exclusion, stigma and drug dependence; and

• Assess the effectiveness of prevention, treatment and rehabilitation
programmes of drug dependence given specific contextual
circumstances.

Recovery and the recovery framework

Drug dependence treatment—within an acute care, symptoms-focused
paradigm—has fallen short of properly addressing the complex, multi-
factorial nature of drug dependence that often follows the course of a
relapsing and remitting chronic disease. There is disillusionment with the
“admit, treat, and discharge”, revolving door cycles of high dropout rates,
post-treatment relapse, and readmission rates. As a response to this
situation there is a shift towards a more long-term perspective of sustained
recovery management (White 2007; White and Davidson, 2006) that is much
broader and holistic in scope (Bradstreet, 2004) than linear recovery models.

While there is no overall accepted definition of recovery yet (Betty Ford
Institute Consensus Panel, 2007, the (adapted) definitions below illustrate a
strengths-based view of recovery, in line with long-term and holistic
interventions, such as sustained recovery management:

Recovery is a continuum process and experience
through which individuals, families, and communities
utilize internal and external resources to address
drug dependence and substance abuse problems,
actively manage their continued vulnerability to such
problems, and develop a healthy, productive and
meaningful life.

(Adapted from W. White, 2007)

and

Recovery is the summary term for positive function
in most of the outcome domains typically measured
among individuals who have attempted to overcome
substance use problem

(Adpated from A.T. McLellan, M.

15

Chalk, and J. Bartlett, 2007)

and

Recovery may be the best word to summarize all the
positive benefits to physical, mental, and social
health that can happen when alcohol- and other
drug-dependent individuals get the help they need.

(Betty Ford Institute Consensus
Panel, 2007)

The recovery framework is aligned with the World Health Organization’s
definition of health (“Health is a state of complete physical, mental and social
wellbeing”, WHO, 1986) and links drug dependence treatment and
rehabilitation with recovery-oriented systems of care that encompass all
domains of a person’s quality of life (e.g., physical, vocational, social,
cultural, and spiritual.2

The key elements of the recovery framework listed below, as defined in the
literature, bring to mind those of the Sustainable Livelihoods model and
highlight the compatibility of the two approaches. Namely, it:

1) Has a strengths-based, client-centred focus. The model
empowers the individual to move towards a healthy, productive, and
meaningful life. Thus the ultimate owner of successful rehabilitation
and social reintegration is the client (Cloud and Granfield, 2001; W.
White, 2007).

2) Is recovery outcomes driven. Recovery is intended as a continuum

process. With access to good practices and evidencebased services the
client can be assisted through the stages of rehabilitation and social
reintegration to build the necessary resources for a meaningful life in
the community. There are many pathways to long-lasting change and
stability, regaining a sense of self-identity and self-esteem,
(re)discovering one’s meaning and purpose in life; and developing
stronger interpersonal and community relationships. Recovery
supports can help explore the ways that are best suited to a client’s
needs.

3) Realizes that context influences the recovery process and the

likelihood of recovery outcomes. A person’s background, culture,
gender, past experiences, external factors (e.g., punitive policies
promoting social exclusion, stigma and discrimination, and adverse
agro-ecological factors; institutional barriers), employment and
training opportunities, housing and social exclusion, all greatly

2 See also The National Institute on Drug Abuse “Principles of Effective Drug Addiction Treatment: A
Research Based Guide” http://www.nida.nih.gov/PODAT/PODAT1.html, supporting the importance of
access to longterm recovery supports

16

influence recovery outcomes (White and Kurtz, 2006). Further, very
much in line with the Sustainable Livelihoods Framework, it can be
stated that

[t]he extent to which someone enjoys good
health and well-being is influenced by a very
wide range of social, environmental and
individual factors and is about much more
than the management of symptoms
(Bradstreet 2004).

4) Promotes cultural relevance and gender sensitivity. It is open to

the integration of cultural practices and community support into
treatment and social reintegration. Also, it facilitates gender
mainstreaming by taking into account, while planning projects, the
barriers that make access to treatment difficult for women (e.g.,
stigma, inflexible schedules, distance from home, and lacking daycare
for children).

5) Aims at promoting assertive approaches to integrated and

continuing care. These approaches emphasize building long-term
supportive relationships with clients, and providing continuity of
service to increase their recovery capital. Duration and intensity of
check-ups and monitoring also vary during periods of increased
vulnerability for relapse (W. White and E. Kurtz, 2006).

6) Integrates clients’ respective families and/or significant others

as both participants and partners in the recovery process. This
is demonstrated by actively involving them in client engagement,
development of clients’ recovery plans and processes. Social support
can play an important role in the process of rehabilitation and
reintegration.

7) Sees the community as a reservoir of resources, opportunities,

and support. Recognizing that no single organization and/or
institution can provide all the essential resources necessary to provide
a continuum of care, it favours and promotes developing recovery
supports through community networking and collaboration with
multiple entities and resources (See White, in press). The focus is on
educating the public, through advocacy, on the benefits of recovery,
and collaborating with existing recovery support resources to develop
integrated recovery strategies and services. Creating meaningful
participation in the community is a key component of the recovery
framework.

8) Recognizes that combating and overcoming the stigma of

drug dependence is essential to gain and maintain the
community’s support in the individual’s recovery process.
Therefore, advocacy to influence and convince decision makers,
educate service providers, and society at all levels about the issue

17

of drug dependence and the benefits of drug dependence
treatment and rehabilitation for the individual and the community
is encouraged. (See Chapter V.)

Recovery Capital

In this context, “recovery capital“ is the sum of personal and social
resources at one’s disposal for addressing drug dependence and, chiefly,
bolstering one’s capacity and opportunities for recovery” (Cloud and
Granfield, 2001).

Recovery capital can be used as a tool for drug dependence treatment
professionals practitioners, to identify the strengths of their clients, support
them in building up and maintaining a sustainable livelihood, while looking
holistically at all domains of life. This approach meets individuals “where they
are” and supports them along the continuum of treatment, rehabilitation and
social reintegration.

Building recovery capital is a strengths-based approach. It involves
identifying and building upon the client’s major personal and social assets,
which may have been developed earlier in life or are newly acquired. These
assets can support treatment engagement and enhance motivation for
treatment, the treatment process and ongoing recovery from drug
dependence problems.

The eight domains of recovery capital identified by the Treatnet working
group (shown in Figure III) are:

1) Physical and mental health;
2) Family, social supports, and leisure activities;
3) Safe housing and healthy environments;
4) Peer-based support;
5) Employment and resolution of legal issues;
6) Vocational skills and educational development;
7) Community integration and cultural support; and
8) (Re)discovering meaning and purpose in life.

A lack of such assets could hamper the recovery process and desired
outcomes. As such, the concept of recovery capital complements the Asset
Pentagon of the Sustainable Livelihoods Framework (Figures I and II,
Appendix I).

18

A Sustained Recovery Management Approach

The recognition of drug dependence as a multi-factorial health disorder,
which often follows the course of a relapsing and remitting chronic disease,
has spurred calls to shift the focus of drug dependence treatment from acute
care to an approach of sustained recovery management in the community.
Sustained recovery management applies many of the central components of
recovery capital and the Sustainable Livelihoods framework. Service wise, a
sustained recovery management approach offers the following:

• Uses a strengths-based approach, considering the resources available
in the clients life;

• Takes into account the main areas of life/the eight domains of
recovery capital (and their potentially compounding interrelationships)
that can support rehabilitation and social reintegration for drug
dependent persons;

Figure III: The 8 Domains of Recovery Capital

Essential Supports for achieving rehabilitation and social reintegration

Source: Treatnet Working Group on Sustained Recovery Management

19

• Integrates a broader range of drug dependence rehabilitation and
social reintegration support services, to strengthen human, vocational,
and social capital necessary for a healthy, stable and meaningful life.

• Uses broad, family- and community-focused, strengths-based,
continual assessment processes;

• Implements early and assertive engagement by service professionals;
• Develops client- and family-generated recovery plans;
• Includes assertive management of co-occurring disorders and

challenges to recovery;
• Uses peer-based models of recovery support and community resource

development and mobilization;
• Shifts the centre of service activity from the institutional environment

to the client/family’s natural environment in the community;
• Puts emphasis on sustained monitoring, recovery coaching, assertive

development and linkages to the community services for recovery
support and, as needed, early re-intervention;

• Focuses on long-term evaluation of the effects of service combinations
and sequences.

• Establishes a sustainable health care partnership between service
providers and clients;

• Aims at easy access to services by shifting their location from remote
institutions to the client/family’s natural environment in the
community;

• Emphasizes the importance of policy change and advocacy to reduce
social stigma attached to drug dependence, and to promote recovery
supportive policies and programmes (White, Boyle, and Loveland,
2002);

Building social capital is a visible, central element of sustained recovery
management. It encompasses four of the eight domains of recovery capital in
Figure III above, namely, family and social supports; peer-based support;
community integration and cultural renewal; and healthy environments. It is
also a central component of the Sustainable Livelihoods Asset Pentagon
(Figure II, Appendix I). Cloud and Granfield (2001) define social capital as:

The resources that are developed through the
structure and reciprocal functions of social
relationships … [and] the accumulation of social capital
can lead to normative systems as well as assorted
resources that serve as pathways to change.

Granfield and Cloud (2001) and Cloud and Granfield (2001) highlight the
possibility of achieving “natural recovery” from drug and alcohol dependence,
without formal treatment or mutual aid interventions. Their findings show
that, for some, recovery is sometimes facilitated within the context of very
supportive social relationships of family, friends, and the community. On the
other hand, without personal and social resources and supports, it might be
harder for drug dependent persons to manage their own recovery processes

20

without additional support by accessible, available and affordable quality
drug dependence treatment and rehabilitation services.

Benefits of a Sustained Recovery Management Approach

Most evaluations of existing sustained recovery management services have
sought to determine the effects of post-treatment monitoring and support on
long-term recovery outcomes (see McKay, 2005, for a review). Preliminary
studies of these more assertive approaches to continuing care with adults
(Dennis, Scott, and Funk, 2003) and adolescents (Godley, Godley, Dennis, et
al., 2002) suggest that these approaches can:

• Lower relapse rates;
• Get those who need additional treatment back into treatment earlier;
• Generate longer periods of service involvement following re-admission;

and
• Lower the percentage of clients remaining in need of treatment at

follow-up.

The eleven principles of behavioural health recovery management. A
practical example of a sustained recovery management approach is the
Behavioural Health Recovery Management project, which has developed a
disease management approach to drug dependence and serious mental
illness that follows certain principles (Boyle, White, Corrigan, Loveland).

The principles share elements contained in disease management approaches
for other chronic diseases such as diabetes, hypertension, and chronic
asthma. They include the use of evidence-based medicine, clinical guidelines,
patient education and empowerment, and ongoing monitoring and support.
Further, the sustained recovery management approach goes beyond these
common factors of disease management by including the community in
recovery support, and putting greater emphasis on individual empowerment
and peer supports.

21

The principles are:

1) Focus on recovery. The BHRM model
emphasizes recovery processes over disease
processes by working towards full and partial
recoveries and by emphasizing client strengths and
resiliencies rather than client deficits. Recovery re-
introduces the notion that any and all life goals are
possible for people with severe behavioural health
disorders.

6) Application of technology. The rapid
advances in technology must be applied to recovery
from serious mental illness and addictions.
Technology being utilized in other fields may be
adopted or adapted to addressing behavioural
health issues.

2) Client empowerment. The client, rather than
the professional, is at the centre of the BHRM
model. The goal is the assumption of responsibility
by each client for the management of his or her
long-term recovery process and the achievement of
a self-determined and self-fulfilling life.

7) Service integration. Based on the recognition
that severe disorders heighten vulnerability for
other disorders and problems, the BHRM model
seeks to coordinate categorically segregated
services into an integrated response focused on the
person rather than on territorial ownership of the
person’s problems.

3) Fighting stigma. The BHRM model seeks to
“normalize” or otherwise respect a person’s
experiences with behavioural health disorders and,
subsequently, provides ongoing support services.
The public begins to endorse positive images of
behavioural health that undermine the prejudice
and discrimination that frequently accompany
service delivery.

8) Formation of recovery partnerships. In the
BHRM model, the traditional professional role of
“expert” and “treatment provider” progressively
shifts to a recovery management partnership with
the client. Within this partnership, the professional
serves primarily as a “recovery consultant.”

4) Use of evidence-based practices. The BHRM
model emphasizes the application of “evidence-
based” interventions at all stages of the disease
stabilization and recovery process, but the ultimate
proof is the fit between the intervention and the
client at a particular point in time as judged by the
experience and response of the client.

9) Ecology of recovery in the community.The
family (as defined by the client) and community
constitute a reservoir of support for long-term
recovery from behavioural health disorders. The
BHRM model seeks to enhance the availability and
the support capacities of family, intimate social
networks and indigenous institutions (e.g., mutual
aid groups, churches) to persons recovering from
behavioural health disorders. The BHRM model also
extends the locus of service delivery from the
professional environment to the natural
environment of the client.

5) Use of clinical algorithms: As knowledge
and application of evidence-based practices
advance, the challenge becomes knowing what
treatment approaches to use with specific
individuals as they progress through the stages of
change and treatment. Medication algorithms have
been developed that specify preferred first line
prescriptions for specific diagnoses, dosing and
time frames for evaluating the effects. Similar
practice support algorithms are needed for
clinicians utilizing psychosocial treatments.

10) Provision of monitoring and support.
The BHRM model emphasizes the need for on-going
monitoring, feedback and encouragement, linkage
to indigenous supports and, when necessary, re-
engagement and early re-intervention. This model
of sustained monitoring and recovery support
services contrasts with models that provide
repeated episodes characterized by “assess, admit,
treat, and discharge,” as is traditional in the
treatment of substance use disorders. It also
contrasts with mental health programmes that
focus on stabilization and maintenance of symptom
suppression rather than on recovery and personal
growth.

11) Continual evaluation. Service and support interventions must be matched to the unique and
stage-specific needs of each client as they evolve through the stages of recovery. In the BHRM model,
both assessment and evaluation become continual activities rather than activities that mark the beginning
and conclusion of a service episode.

22

Chapter Two: Components of Sustained Recovery
Management3

As noted in Chapter I, the principles of sustained recovery management can
be applied to the management of many other chronic disease states.
Similarly, the recovery capital framework, which focuses on the sum of
personal and social assets (e.g., family/social relationships, health, work, and
a feeling of interconnectedness with the community), by extension, can be
applied to promote a healthy lifestyle whether or not one is actively
experiencing a state of disease.

That this is true is clearly seen when individuals without drug use problems
experience serious life crises such as job loss, the death of loved ones,
divorce, and/or ill health. The shock of such crises affects not only the
individuals but often also their families, their relations to the community and,
overall, their personal and communal sense of well-being. Failure to draw on
family, medical, legal, and other needed support systems may prolong and
entrench the state of crisis. This is no less true for persons challenged by
drug dependence and their families.

Drug dependent persons frequently experience crises in the areas of medical,
psychological, social, vocational, and legal well-being, partly due to their
particular vulnerability related to negative health and social consequences of
drug use and often co-occurring disorders. In addition, they face the social
stigmatization and punitive barriers that often hamper sustained recovery
and social reintegration (Braithwaite, 1999, 2001). Therefore, a continuum of
care approach, addressing a range of areas, is especially necessary for
sustainable drug rehabilitation and social reintegration efforts.

The management of substance dependence as multifactorial health disorder
that often follows the course of a chronic disease requires time, empathy,
and the integration of individual, family, and community resources.
Programmes offering a continuum of care, case management, and a broader
range of recovery support services are the most effective in addressing
obstacles to entering the process of recovery, and enhancing long-term
recovery maintenance (Siegal, Rapp, Li, et al., 1997; McLellan, Grisson,
Zanis, et al., 1997; McLellan, Hagan, Levine, et al., 1998). Without such

3 This section includes an extensive literature review that was carried out using mostly electronic
databases such as PubMed, ScienceDirect, PsycINFO, ETOH, NCJRS; the Virtual Clearinghouse on Alcohol,
Tobacco and Other Drugs; as well as relevant websites. In addition, previous UNODC publications were
checked for references. The search was conducted using the following key words: addiction recovery and
community reintegration. It then branched into the following: addiction treatment; natural recovery;
recovery capital; addiction as a chronic disorder; recovery prevalence; recovery pathways and styles;
addiction-social rehabilitation; co-occurring disorders; recovery and family/social support; recovery-
housing; recovery-employment; recovery-economic self-sufficiency; recovery-religiosity/spirituality/life
meaning; recovery management; and addiction-chronic disease management.

23

broad-spectrum support, stabilization, treatment, and recovery outcomes are
frequently undermined. A lack of these supports increases the probability of
repeated relapse. Emerging good practices are moving away from traditional
drug dependence treatment delivered within an acute care framework, as
those models often suffer from limited attraction and access; high dropout
rates; weak systems of continuing care; and high post-treatment relapse and
readmission rates.

The Components of Sustained Recovery Management

The following sections provide emerging evidence for each of the eight
domains of recovery capital within a sustained recovery management
framework. These domains are intended to promote key actions, highlight
assets and experiences that may help facilitate the progression from
treatment to long-term recovery and social reintegration support. Some
persons have lost access to and knowledge about the resources available in
the different domains of their life. In such instances, they might need
professional support to regain access to:

1. Physical and mental health;
2. Family, social supports, and leisure activities;
3. Safe housing and healthy environments;
4. Peer-based support;
5. Employment and resolution of legal issues;
6. Vocation skills and educational development;
7. Community integration and cultural support; and
8. (Re)discovering meaning and purpose in life.

Domain 1: Physical and mental health

Physical health. Drug dependence treatment alters the client’s relationship
with psychoactive drugs and, to the extent possible, a reversal of co-
occurring health problems. Thus, a sustained recovery management
approach proposes that service providers take into account concurrent health
problems at intake, so that clients can receive the necessary supports
throughout and beyond the treatment period.

The following findings are worth noting:

• Studies to date have found that clients who receive long-term medical
care integrated into substance dependence treatment and continued
monitoring have better recovery outcomes than those who receive
standard treatment (Weisner, Mertens, Pathasarathy, et al., 2002;
Samet, Friedmann, and Saitz, 2001). Further, drug dependence needs
to be insured, treated, and evaluated like other chronic illnesses
(McLellan, Lewis, O’Brien, et al., 2000).

• An estimated 3% of the world’s population is infected with Hepatitis C,
which calls for greater public health efforts in the areas of prevention
and medical treatment of this disease, but also for substance

24

dependence treatment to play an active role in the prevention and
care of blood-borne diseases related to drug use.

• A study of alcohol-, heroin-, and cocaine-dependent individuals
admitted to an urban hospital for detoxification found that 47% had at
least one chronic illness (20% of which had two or more such
conditions) and that 80% had prior hospitalizations for such conditions
(DeAlba, Samet and Saitz, 2004).

• Morbidity and mortality rates revealed in follow-up studies of persons
admitted for substance dependence treatment are quite high (2 1/2
times that of age-matched controls in a 10-year follow-up study)
(Edwards, 1989), and mortality rates are dramatically increased for
tobacco smokers (Vaillant, 1996).

• In spite of the general neglect of health and the severe medical
problems that often accompany prolonged substance dependence
problems, a significant portion of individuals entering treatment does
not have an ongoing relationship with a primary care physician
(DeAlba, Samet, and Saitz, 2004).

• When available, the medical care delivered within substance
dependence treatment is generally limited to an intake assessment,
supervision of detoxification, and referral for treatment of medical
problems that would interfere with participation in substance
dependence treatment.

• The maximum restoration of physical health is an important dimension
of long-term substance dependence recovery. The risk of premature
death for persons dependent on alcohol who have achieved stable
remission is no greater than that for non-alcoholic control groups
(Bullock, Reed and Grant, 1992).

• Maintenance medication with proven efficacy and effectiveness in
preventing relapse and stabilizing drug dependent patients are
available for opioid dependence. These medications belong to two
main groups: long-acting agonists and antagonists. Opioid agonist
therapy is one of the most effective treatment options for opioid
dependence when methadone or buprenorphine are administered in an
individualized dosage for a period of several months to years.
Alternatively, a defined group of opioid dependent patients who are
detoxified and highly motivated can be prescribed an antagonist
medication (naltrexone) as part of continuing relapse prevention
treatment (UNODC discussion paper on Principles of Drug Dependence
Treatment, 2008).

• Studies show that methadone maintenance treatment is more effective
when integrated with standard care, basic counselling, and on-site
professional services. Significant reductions in opiate use within four
weeks, and major increases in positive outcomes (McLellan, Arndt,
Metzger, et al., 1993) could be seen.

Improvements in the quality of substance dependence treatment include:

a) Attempting to link each client to a primary care physician at admission
(Samet, Larson, Horton, et al., 2003); and

25

b) Integrating primary medical care as a dimension of substance
dependence treatment.

Fleming, Barry, Manwell, et al. (1997) reveal that such integration of primary
care physicians has potential merit in terms of the influence they can exert
on their patients’ substance dependence patterns. These efforts, however,
need to be tested for their effects on the long-term recovery process, and on
the potential reduction in health care costs.

Mental health. Until now, research studies on the relationships between co-
occurring psychiatric illnesses and substance use disorders, and their
influence on treatment and long-term recovery outcomes, have revealed
significant findings:

• The co-occurrence rate of psychiatric and substance dependence

disorders is quite high (Regier, Farmer, Rae, et. al., 1990; Kessler,
Nelson, McGonagle, et al., 1996). Half of all persons experiencing serious
mental illness go on to develop a co-occurring substance dependence
disorder (Rache-Beisel, Scott, and Dixon, 1999. See, also, Krausz, M., et
al. 1998).

• As with co-occurring health problems, it is important for service
providers dealing with drug dependent clients to take into account
concurrent psychiatric problems at intake, so that clients may also
receive the necessary supports throughout the treatment period.

• Psychiatric symptoms are more prevalent and closely linked to poly drug
use. Gender, physical health, drug dependence and personal

Sustained Recovery Management with a Perspective on Gender

Studies show that women entering substance abuse treatment are a highly

vulnerable group and are most likely to present co-occurring, chronic medical
problems (Claus, Orwin, Kissin, et al., 2007; Rosen, Ouimette, Sheikh, et al., 2002).

Compared to men, women treated for substance abuse are more prone to be also

victims of interpersonal violence (child abuse, rape, and battering). They, therefore,
have a much broader range of physical and mental needs (Morrissey, Ellis, Gatz et
al. 2005).

Failure to address and understand the complexity of these issues, during and after

treatment, or merely offering fragmented services, usually increases their
vulnerability in the areas of: health, food and housing, parenting stress, child
exposure to violence, lower social functioning and integration, and an overall
decreased quality of life (Lincoln, Liebschutz, Chernoff, et al., 2006).

Programmes that integrate specialized services for women (including pre-natal and

child care) are associated with better treatment retention, length of stay, and
positive treatment outcomes (Claus, Orwin, Kissin, et al., 2007).

26

relationships were more powerful predictors of psychiatric symptoms
than substance dependence (Marsden, Gossop, Stewart, et al., 2000).

• Of the total pool of those with substance dependence-related problems,
the best predictors of treatment seeking are global distress and
psychiatric co-morbidity. A Korean study of the influence of psychiatric
co-morbidity on alcohol and drug dependence found that psychiatric co-
morbidity was associated with more severe substance dependence
disorders, later onset of those disorders, and a greater likelihood of help-
seeking (Cho, Hahm, Suh, et al., 2002).

Co-occurring psychiatric and substance use disorders have generally been
treated using:

a) Parallel models in which each condition is treated by a separate
service team over the same time span;

b) Sequential models in which treatment for one disorder is completed
and followed by referral and admission to treatment for the second
condition;

c) Collaborative models that attempt to coordinate care of both
conditions across mental health and substance dependence
treatment service teams; and

d) Integrated models in which both disorders are treated at the same
time and by the same staff using a clinical design reflecting
knowledge of treatment and recovery from both conditions (CSAT,
1994).

While collaborative care is an improvement, and integrated care is
recommended, (Minkoff, 1989; Muser, Noordsy, Drake, et al., 2003), parallel
and sequential models of acute intervention continue to be standard practice
in most countries. However, this lack of integration may contribute to the link

Notes on Mental Health Recovery

The prevalence of co-occurring mental illness, substance abuse, and trauma (with even
higher rates for women) present several challenges:

Substance abuse treatment programmes need to screen for other conditions in
order to:

a) Identify the comprehensive needs of clients entering drug treatment
and rehabilitation; and
b) Facilitate referrals for further assessments and treatment services.

The lack of adequate assessment tools that are easy and quick to administer by

staff members and counsellors, with varied levels of clinical training, remains a
key barrier to screening. (See Appendix II for suggested screening and
assessment instruments.)

Addressing substance use along with multi-factorial diseases requires well-

coordinated and integrated care supports. (Claus, Orwin, Kissin, et al., 2007).

27

between psychiatric co-morbidity and poor post-treatment outcomes
(McLellan, Luborsky, Woody, et al., 1983; O’Brien and McLellan, 1996;
McLellan, Lewis, O’Brien, et al., 2000).

The good news is that providing psychiatric care as an addition to substance
dependence treatment (McLellan, Arndt, Metzger, et al., 1993) as well as
integrated models of care have been found to enhance rehabilitation and
social reintegration outcomes (Mangrum, Spence, and Lopez, 2006).
Nonetheless, these outcomes are often further challenged by issues such as:

• Educational/vocational impairment;
• Disruptive family relationships;
• Inadequate housing or homelessness;
• Violent perpetration or victimization;
• Enmeshment in criminal and drug cultures;
• Involvement in the criminal justice system; and
• A lack of basic resources (e.g., transportation, daycare) to allow easy

access to needed services.

Gender Notes on the Importance of Integrated Services

Women display substantially higher addiction severity (Lincoln, Liebschutz, Chernoff, et
al., 2006) and the most complex set of co-occurring psychiatric disorders and
psychological distress (i.e., depression, anxiety, and psychosis/suicidal thoughts,
stemming from sexual abuse and interpersonal trauma). For women, coupling drug
rehabilitation with provision of psychiatric care is often important, though not sufficient.
These provisions also need to be complemented with well coordinated recovery support
services that address concurrent needs, such as, medical and child care needs, lack of
vocational skills, fewer financial assets, and low income (Lincoln, Liebschutz, Chernoff,
et al., 2006).

The following quote from a study on predictors of relapse and facilitators of recovery
(VanDeMark, 2007), points at the overwhelming difficulties facing women, in particular,
when uncoordinated and fragmented assistance (in this case, welfare, housing, and
drug treatment services) obstruct their path to drug rehabilitation, social reintegration,
and recovery. The following excerpt speaks volumes:

Not having the resources I need hurts my recovery. I can’t get housing
because of my [criminal] record. Can’t get my kids unless I have housing.
Can’t get transitional assistance unless I have my kids. Even though I have
[a diagnosis of] bi-polar [disorder], I can’t get disability because of my
substance abuse. I can’t get to meetings because I have no transportation. I
exhausted my program options.

This example shows the urgency for integrated systems of continuum of care that
can respond to multiple problems complicated by high severity and long duration.

Studies consistently reveal that providing a greater number of collateral services
(e.g., medical, psychiatric, family, employment services) as part of substance
dependence treatment is associated with better substance dependence outcomes
and better social adjustment (McLellan, Alterman, Metzger, et al., 1994). Directly
providing such supplemental resources, or linking clients to them through assertive
case management can increase positive outcomes across many domains by as
much as 25–40%. (McLellan, Hagan, Levine, et al., 1998).

28

Domain 2: Family, Social Supports, and Leisure Activities

Supportive family relationships. Not only individuals, but also families
and communities with a need for rehabilitation are exposed to the acute care
models of drug dependence treatment. Failure to achieve a successful “cure”
may result in putting individuals and their families through endless cycles of
detoxification and stabilization that lack the interventions and duration to
create and support sustained recovery.

Supportive family relationships play a major role throughout the drug
dependence recovery continuum. Yet, there are disparate findings on the
extent to which they can influence or be affected by long-term recovery. On
the one hand, family members can play a significant role in prompting
substance dependent persons to seek treatment (Hingson, Mangione,
Meyers, et al., 1982). Also, family participation and support in both
treatment and recovery efforts exert a significant influence on long-term
recovery outcomes for adults (Isaacson, 1991) and adolescents (Risberg and
Funk, 2000).

On the other hand, sustained substance use in a client’s living environment
can hamper recovery efforts (Catalano, Hawkins, Wells, et al., 1991; Godley,
Kahn, Dennis, et al., 2005). Sometimes changes in family structure and
vitality on a societal level (e.g., the increasing shift to city living) influence
the family’s capacity to prevent alcohol and other substance use problems.
Not surprisingly, families often are less prepared to effectively address such
problems when they arise (Spielmann, 1994; Boyce-Reid, 1995).

While the long-term positive effects of recovery on family life would seem
obvious, researchers have discovered that such long-term effects may be
preceded by a period of intense confusion and dislocation (Brown and Lewis,
1999). Family structure, roles, and rules are dramatically altered through the
process of drug dependence, and must be reformed during the process of
rehabilitation and social reintegration. Brown and Lewis call this latter family
adjustment process the “trauma of recovery” (Brown and Lewis, 1999, p.
181). They found that the chaotic family environment of the drug
dependence years continues into the early years of recovery and that,
without support, this adjustment may threaten both the marital relationship
and the stability of the entire family.

The effects of drug dependence and recovery are even more profound where
intimate partners are both drug dependent. Post-treatment recovery or
relapse of one partner is predictive of whether the other partner returns to
substance dependence or continues along the path to rehabilitation and
social reintegration (McAweeney, Zucker, Fitzgerald, et al., 2005).

29

Social supports and leisure activities. Studies on adolescent treatment
outcome reveal ways in which family and social relationships interact with
leisure and alternative activities. Brown (1993) identified the main factors
associated with long-term, post-treatment recovery outcomes. They are:

• Supportive family relationships aimed at recovery;
• Relationships with non-using peers;
• Recovery support group participation; school involvement; and
• Recovery-conducive employment.

Specific Factors Affecting Women’s Addiction, Treatment, and Recovery

Women’ social context and personal relationships (friends, intimate partners, children but also drug
dealers) play an important role in both drug dependence and recovery outcomes, more so than men’s
(Claus, Orwin, Kissin, et al., 2007; Stark, 1992). Where both partners are drug dependent, women are
more vulnerable to relapse. They usually feel more socially alienated, particularly if they have been
abused physically and sexually. Therefore, upon returning to their communities, after treatment ends,
and if lacking appropriate social and family supports, they are more likely to reconnect with their pre-
treatment supporters, some of whom (principally their partners) enable their drug use (Falkin and
Strauss, 2003). This reality poses a few challenges in providing drug treatment for women, specifically:

Acknowledging the likelihood that women will return to their partners, programmes need to integrate them

in the therapeutic process, and develop “couples-specific” programming (Simmons, 2006).
Encouraging treatment programmes and providers to help women differentiate between family and social

networks that provide constructive support during and post-treatment, and those who hamper their efforts
to remain drug-free (Falkin and Strauss, 2003).

Focusing on appropriate strategies for managing relationships with partners and social networks that may
hamper their recovery (Falkin and Strauss, 2003).

Most women in treatment are served through mixed-gender programmes. Thus, their needs and the complex patterns
and interdependence of drug dependence, as they pertain to women, are overlooked (Grella and Greenwell, 2004).
This reality confirms the need for family-oriented models of treatment, and family-focused, post-treatment monitoring,
support, and early re-intervention services.

The design and delivery of treatment for women need to take into account that gender is deeply embedded and
affected by personal, social, and treatment factors (Saunders, Baily, Phillips, et al., 1993). Thus, the importance of
promoting gender-specific treatment and recovery support services that address gender-related vulnerabilities for
substance use disorders, special needs in treatment, and obstacles to long-term recovery (Claus, Orwin, Kissin, et
al., 2007; Greenfield, Brooks, Gordon, et al., 2007; Carten, 1996; Morrissey, Ellis, Gatz, et al., 2005; Falkin and
Straus, 2003).

Programmes that integrate specialized services for women (i.e., pre-natal and child care) are associated with better
treatment completion, length of stay, and treatment outcomes. (Ashley, Marsden, & Brady, 2003). Women who are
allowed to bring along their children during treatment have demonstrated higher rates of retention (Chen et al., 2004;
Coletti et al., 1992; Hughes et al., 1995).

Studies show that women would favour programmes that provide:

A continuum of coordinated and family-focused services: a safe medium for their recovery and their
children, and opportunities to improve the quality of family life (Claus, Orwin, Kissin, et al., 2007; Stark,
1992).

“Gender-specific” treatment and substance abuse education tailored to their needs, such as case-
management and social services, mental health services, vocational and job training, in an environment
that supports them and their children and enhances the quality of family life.

Referral systems and linkages to facilitate transition to continuity of care (Marsh, D’Aunno, and Smith,
2000).

Less confrontational, less structured and rigid styles of treatment and interpersonal group dynamic
communication. In single sex-group sessions, women tend to be more expressive, whereas mixed-
gender settings can promote adverse psychological effects (Hodgins et al., 1997).

30

Domain 3: Safe Housing and Environments Conducive to Health and
Recovery

Safe housing and environments. Research reveals the fragile balance
between recovery and relapse that typifies the reality of many individuals
following primary treatment for substance dependence problems. Also noted
was the profound effect the post-treatment family and social environments
can exert on recovery outcomes. Further, abstinence-supportive living
environments can increase the rates of recovery outcomes (Humphreys,
Moos, and Finney, 1995; King and Tucker, 1998; Jason, Davis, Ferrari, et al.,
2001).

The above-mentioned effects have shaped a long tradition of residential
therapies, halfway, three-quarter-way houses, and structured environments,
and fuel the modern “recovery home” movement (White, 1998). Halfway-
houses in North America and in Europe, seen as a step-down level of care
following residential treatment, are springing up rapidly as examples of
supported housing (Nemes, Libretto, Skinstad, et al., 2005). Residents in
these facilities are expected to work, pay their rent, and provide each other
mutual support within an environment that may or may not include, or be
linked to, professional treatment services. Nevertheless, a continuum of care
approach, which provides access to a professional treatment provider and
integrates rehabilitation treatment with social reintegration services, is
recommended.

Collectively, these efforts show the importance of support in the physical and
social environment during the early stages of recovery and maintenance.
Early studies of communal living environments were primarily descriptive
(Jason, Davis, Ferrari, et al., 2001), but the first randomized trial of
placement in supported housing or a traditional aftercare environment
revealed that those in the communal housing situation experienced lower
substance use, higher monthly incomes, and significantly lower arrest and
imprisonment rates (Jason, Olson, Ferrari et al., 2006).

In “recovery villages” (e.g., as units within public housing projects or
specialty programmes within shelters), recovering individuals and their
families can sustain themselves in physical and social environments
conducive to rehabilitation and social reintegration (Graham, Graham, Sowell
et al., 1997; Leaf, Thompson, Lam, et al., 1993).

There is increased interest in integrating drug dependence treatment services
and shelter services for those who are homeless (Leaf, Thompson, Lam, et
al., 1993). However, most of these programmes admit only those who are
abstinent. “Wet hotels” provide housing services to homeless alcohol
dependent persons. Service providers and policy advocates trying to
introduce these programmes, have faced objections from those who see
them more as an encouragement to continuing alcohol dependence than to
promoting recovery (W.R. Miller, 1983; Wittman, 1993; J. Körkel, 2005). In
practice, there are two different philosophies of supportive housing services

31

for drug dependent persons. One provides housing as a reward for sobriety;
the other views stable housing as an important support to motivate and aid
recovery. Research and advocacy activities supporting the latter philosophy
appear to be growing (Tsemberis, Gulcur, and Nakae, 2004).

Domain 4: Peer-based Support

Peer-based support. The international proliferation of recovery support
groups (Humphreys, 2004) is currently being supplemented by new models
of peer-based recovery support services and new “paraprofessional” service
roles. Examples of these include recovery coaches and recovery support
specialists (White, 2004b). Peer-guided models of recovery management
effectively contribute to the process of long-term recovery (Durlak, 1979;
Hattie, Sharpley, and Rogers, 1984; Riessman, 1990). This approach is
particularly used within the area of drug dependence recovery (Connett,
1980; Blum and Roman, 1985). Moreover, peer-supported recovery
approaches assist the individual seeking recovery within the community.

Such supports exist on a continuum and include:

• Recovery mutual aid groups such as 12-step programmes;
• Peer-based (non-clinical) recovery support services that function as

both an add-on to professional treatment (for those with high problem
severity), and an alternative to professional treatment (for those with
lower problem severity and higher recovery capital); and

• Clinical services delivered by professionals who are in long-term
recovery support services.

Domain 5: Employment and Resolution of Legal Issues

Employment and economic self-sufficiency. Increased employment is a
desired outcome of drug dependence treatment and recovery, but the
relationship between these factors is a complex one. Recent studies include
the following findings:

Gender Notes on Peer-based Supports

Participation in meaningful and responsible social roles plays is important for
women’s recovery from substance abuse. The following are predictors of
relapse and facilitators of recovery (VanDeMark 2007):

Social support and participation in peer support groups encourage
lower alcohol consumption and increased abstinence among
substance abusers; and

Engagement in helping others promotes lower relapse rates.

32

• Individuals entering drug dependence treatment have high
unemployment rates, and employment counselling is an expressed
need for more than half of individuals admitted to drug dependence
treatment (Hser, Polinsky, Maglione et al., 1999; Henkel, Dornbusch,
Zemlin, 2005).

• Employment counselling, vocational training, and job-seeking skills
training are not components of most drug dependence treatment
programmes, nor are assertive linkages to such services a routine
component of drug dependence treatment (Room, 1998).

• Employment counselling increases post-treatment employment rates,
but employment counselling and post-treatment employment status
are not predictors of abstinence. This finding suggests that successful
recovery is possible without stable employment (Reif, Horgan, Ritter,
et al., 2004).

• Providing standard drug dependence treatment does not significantly
increase post-treatment employment rates (Magura, 2003).

• Programmes that place greater emphasis on combinations of
supportive and complementary services (e.g., housing, employment)
have better recovery outcomes than those that offer strictly clinical
interventions (Kaskutas, Ammon, and Wesiner, 2004).

Low wages, high unemployment rates and lack of job skills can have a
negative impact on rehabilitation and social reintegration outcomes.
Therefore, it is important for persons in recovery who have begun this
process to become economically self-sufficient (McLellan, Lewis, O’Brien, et
al., 2000).

To achieve this goal, new recovery support organizations (e.g., the Recovery
at Work project in Atlanta;White, in press) are also experimenting with
recovery work co-ops as a transition from treatment to mainstream
employment. These co-ops are small businesses within the community that
serve as places of safety within which people in recovery can return to
mainstream employment or obtain first-time employment. Such services
integrate achieving stable employment within the complementary and
supportive goals of stopping criminal activities, clearing up existing legal
problems, participating in community life, and performing acts of community
service.

Promising practices for specialized approaches to increase vocational
functioning in recovery include conditional rewards for employment, and the
integration of broad employment supports (counselling, skills training, rapid
job placement and continuing support) within drug dependence treatment
programmes (Magura, Staines, Blankertz, et al., 2004). A study of
successful recovery of substance dependent women found that completion of
treatment in a gender–specific programme followed by a drug-free
environment and achievement of economic self-sufficiency to be the key
predictors of successful recovery (Gregoire and Snively, 2001). Further,
projects such as the “Occupational Guidance Service for Recovering Drug
Addicts” in Spain also seek to develop a large network of companies

33

committed to helping those recovering from drug dependence successfully
enter or re-enter the mainstream workforce (http://eddra.emcdda.eu.int/).

Resolution of legal issues. It has been noted that, among persons
entering the criminal justice system, a high percentage have substance use
problems. This has led the system to explore creative alternatives to
imprisonment for substance dependent offenders. Some of the most
significant of these include:

• Diversion programmes;
• Pre-trial release programmes (conditional upon entry into treatment);
• Drug education programmes;
• Assessment and referral services;
• Mandated treatment through specialized drug courts;
• Specialized intensive probation services;
• In-prison treatment; and
• Pre-release and post-release counselling and referral programmes

(Lipton, 1995).

One trend is the development of specialized courts that integrate the
resources of the criminal justice system with community-based drug
dependence treatment agencies in the rehabilitation of drug dependent
criminal offenders.

What makes drug courts stand out from traditional courts is:

• The unique combination of judicial monitoring (regular status

hearings);
• Drug dependence treatment and case management services;

Gender Notes on Employment and Economic Self-sufficiency

The findings from VanDeMark’s (2007) study of predictors of relapse and facilitators
of recovery indicate the need to refrain from punitive and stigmatizing policies.
Instead, they encourage establishing treatment programmes that:

Provide access to women’s basic needs;
Link them to constructive social networks; and
Encourage them to assume roles of responsibility in work, family,

education, and parenting.

Perpetuating stigmatization actually increases the tendency towards substance
dependence and illegal behaviour. The following quote from a female respondent,
in the same study, also confirms the relevance of psychological factors to recovery:

[What is helpful to my recovery is that I care for me today. I
am somebody. I’m not a people pleaser. I am a go-getter. I
do have dreams; bottom line, I have goals to accomplish.]

34

• Drug testing;
• Probation supervision;
• A non-adversarial collaboration between prosecution and defence

counsel; and
• Multi-agency case conferences for service planning and progress

reviews (Office of Justice Programmes, 1997).
A critical review of research on the effectiveness of drug courts, (an approach
that is so far primarily implemented in the United States), indicates that drug
dependence and criminal activity are reduced while participants are in drug
court. Studies using comparison or matched samples show lower re-arrest
rates for drug court participants than for the comparison group. A majority of
the studies found lower relapse rates for drug court participants after they
had participated in the programme. Cost analysis estimates indicate that
drug courts are less expensive than traditional adjudication.
(www.ncsconline.org; Belenko, 2001)

Another area of growing interest is providing treatment in closed settings. A
recent follow-up study of prison-based treatment found that, while nearly
46% of those leaving prison are rearrested within a year of release, only
37.4% of inmates who received brief substance-focused treatment, and only

Some Objectives and Findings of a Clinical Justice Programme in Spain

A specific programme for police stations caters to all arrested persons who have a
substance use-related problem. The three chief objectives of the programme are:

To evaluate the degree of the subject’s intoxication and dependence at the
time of arrest;

To “enlist” arrested drug [dependent persons] who, for whatever reason,
have not accessed the treatment network, into such treatment and referring
them to the respective centres; and

To continue treatment for patients who have already initiated care.

When assistance is provided in the context of court trials, this service attempts to
enable the system to apply the most suitable security measures in each case where
judicial problems derive from addictive behaviour, to ensure that the perpetrator’s
circumstances play a relevant role in the legal proceedings. Findings indicate:

Global and individualized treatment according to different patient needs
significantly lowers addiction-related offences.

The number of persons visited in 2002 was 2860, including 829 for the first
time; 12.18% of these were referred to conventional treatment centres.

The above result would not be possible without the appropriate training for
and co-ordination among the various professionals taking part in the
process.

Excerpted from: “Evaluation and Support Units for Drug Addicts in Courts and Police
Stations in the Provinces of Alicante, Castellon, and Valencia” project. For more on this
approach, see the Spanish case study in Chapter IV.

35

23.5% of inmates who received intensive treatment were rearrested in the
year following their release. (Please see:
http://www.jointogether.org/news/research/summaries/2005/study-finds-
prison-based.html, 21 January 2005)

This study reflects two trends in research findings:

1) The rates for those who are re-arrested and returned to jail are lower
for those drug dependent offenders who receive treatment inside
prison.

2) The degree of that effect is affected by treatment dose and intensity.
The longer and more intense the treatment episodes, the lower the
relapse rates.

Efforts are underway to enhance these effects by preparing previously
dependent inmates for prison release (e.g., The Esbjerg Model in Denmark),
and linking inmates treated in prison to local treatment and recovery support
groups during their community re-entry (For good practice examples from
Europe see: http://eddra.emcdda.europa.eu/). Treatnet developed a good
practice document on Drug Dependence Treatment in Prison Settings, which
is available for additional information.

Domain 6: Vocational Skills and Educational Development

Vocational skills and educational development. Substance dependence
problems can prevent one’s successful (re-)entry into educational institutions
and the workplace. It can have a negative effect on one’s education and
vocational performance, and contribute to one’s disengagement from
educational activities and legal employment (Magura, 2003). These findings
underscore the need for: recovery support services that focus on educational
and vocational training and placement; and early intervention programmes in
schools and workplaces to resolve substance dependence related problems.
Examples of these are student assistance and employee assistance
programmes.

Substantial efforts are underway to enhance the educational and vocational
outcomes of persons recovering from severe substance dependence
problems. These include formal recovery programmes in high schools (and
the establishment of special recovery schools), as well as colleges and
universities (White and Finch, 2006). These programmes integrate enhanced
access (e.g., scholarship programmes for individuals in recovery),
educational guidance (special tutoring), and in-school recovery support
groups and counseling. Evaluations to date have noted low relapse rates
within such programmes, and high levels of academic achievement (White,
2001).

36

Domain 7: Community Integration and Cultural Support

Integration and cultural renewal. A broad extension of the zones of
recovery capital is reflected in efforts to address substance dependence in
the community through cultural support and community development. These
efforts integrate culture-specific approaches to personal transformation with
strategies that strengthen the community. Such strategies are exemplified
here in the “Wellbriety Movement” within Native communities of North
America, but many other examples might be found. The strategies of this
specific movement include:

• Engagement of tribal leadership;
• Recovery education (e.g., Well Nations Magazine and recovery-themed

books such as The Red Road to Wellbriety);
• Recovery awareness walks such as “Hoop Journeys”;
• Training indigenous leaders to organize recovery circles such as

“Firestarters”;
• Hosting recovery celebration events in local Native communities; and
• Advocating for culturally informed social policies and treatment

approaches (www.whitebison.org).

This example of recovery capital in action is taken from the case study in Chapter IV on
“Special Employment Programme for At-Risk Youth” in Teguchigalpa, Honduras, Central
America.

Denis, 18, is a husband and father of a four-month-old daughter. His wife was unemployed,
but Denis did not go to school or work; he did nothing. His sole access to financial capital was
his grandmother, until she died.

Then he heard about the project to reintegrate at-risk youth and former drug dependent
persons into special employment programmes from a friend. He enrolled in the hospitality
services course, earned a scholarship, was given a uniform and materials, and now works in a
hotel in the city. According to Denis, the course helped him a lot. Without it, he would have no
means of livelihood. His “days of unhappiness and agony are gone.”

This example of recovery capital is taken from the case study in Chapter IV on “Community
Integration and Cultural Support”, Alkali Lake is a Native Reserve in British Columbia,
Canada

Alcohol dependence was a major problem on the reserve and every man, woman, and child
was seriously affected by it. With alcoholism, came poverty, hunger, sickness, and physical
and sexual abuse. The Shuswap tribal community in Alkali Lake was plagued by alcohol
dependence until two local tribal members made a commitment in 1972 to stop alcohol use
and to address alcohol dependence that affected their community.

In order for people to be able to imagine themselves living a healthier, alcohol-free life there
had to be tangible opportunities and incentives that could support a new way of life.
Opportunities were needed for meaningful employment, recreation, and a social life that
was alcohol-free. Most immediately, there had to be accessible and fairly continuous
opportunities for healing, personal growth, and learning. What, in fact, was developed in
Alkali Lake was a series of interconnected interventions and opportunities as well as built-in
rewards and consequences that constituted a healing pathway.

37

Domain 8: Pathways to (Re)discovering Meaning and Purpose in Life

Meaning and purpose in life. In their studies on the relevance of recovery
capital, Granfield and Cloud, 2001 (and Cloud and Granfield, 2002) noted
that natural recovery from drug dependence is often preceded by personal,
transformative changes and a conversion to a new way of life that may be
induced in many different ways. For some persons, there is a faith-based
conviction threaded through their lives upon which they may draw in their
attempts to regain balance. Yet others may draw upon different grounding
and centring practices (e.g., yoga, meditation, Tai Chi Chuan, aerobics) as
part of their cultural traditions or personal assets—old and new.
Faith-based frameworks of recovery usually advocate the resolution of
substance use problems through the support of religious experience and
rituals, and by being rooted in a community of shared belief (White and
Whiters, 2005). They are primarily aimed at a reconstruction of personal
identity, values, and interpersonal relationships. Non-religious frameworks of
recovery, such as Women for Sobriety and Secular Organizations for
Sobriety, tend to promote and facilitate reintegration into the community,
through employment, education, and community life. They stress the
importance of strength of character, self-reliance, assertive problem solving,
and lifestyle balance.

All of them share the placement of one’s past, present, and future
relationship with alcohol and drugs within the larger context of one’s personal
identity, self-esteem, and destiny (White and Nicolaus, 2005). They help to
reintegrate the recovering person into the community through participation
in shared cultural practice. The criteria would be for any of these frameworks
(whether personal, cultural, or religious) to integrate and be open towards
evidence-based drug dependence treatment and rehabilitation practices,
while considering the client’s needs, recovery capital, and personal strengths.

The vision that emerges from this literature review is the transition
from traditional approaches to drug dependence and rehabilitation to a
sustained recovery management approach. This approach is aimed at helping
drug dependent persons achieve meaningful, productive, and sustainable
livelihoods in their communities. Favouring a long-term, continuum of care
approach, sustained recovery management integrates clinical interventions,
community development activities, and processes of personal, economic,
social, and cultural renewal. This integrated and holistic approach can
stimulate the many components of recovery capital within individuals,
families, and communities worldwide.

38

Chapter Three: Laying the Groundwork for Building
Recovery Capital

This chapter is intended for those who are interested in integrating a
sustained recovery management approach into their programme, and are
questioning the “what” and the “how” of its implementation.

As stated in Chapter I, this integrated approach emerges from good practices
applied at different treatment centres around the world. Studies identified
through the literature review in Chapter II support this shift from the
traditional, acute-care approach to an integrated continuum of care approach
for drug dependent persons through sustained recovery management.
Recognizing that sustained recovery management may be best implemented
in a framework of community based treatment and rehabilitation, Treatnet
also produced a good practice document on Community Based Treatment.

Sustained recovery management uses the Sustainable Livelihoods framework
(Figure I, Appendix I) and the recovery capital model with its eight domains
(Figure III, Chapter I) as comprehensive assessment tools to help
practitioners understand the contextual opportunities and obstacles easing or
hampering livelihoods and recovery capital development of their clients. They
also provide a solid foundation for developing a realistic treatment and
rehabilitation plan, as well as a means to assessing progress, effectiveness,
and outcomes. (See Figure IV, Appendix I for a graphic representation of the
sustained recovery management framework.)
It is important to first recognize that assessing recovery capital is just one
component of sustained recovery management, and cannot exist in isolation
from the broader socio-economic, political, and environmental context that
also plays a key role, but a more detailed description of the influences of the
wider environment is beyond the scope of this document.

Laying the Groundwork for Building Recovery Capital

The following sections compile a set of practical ideas and activities, to help
practitioners build upon each of the eight domains of recovery capital.
Suggested actions contribute to an integrated care approach that includes
systematic support for the rehabilitation, social reintegration, and sustained
recovery of persons affected by drug dependence.

This approach effectively shifts the emphasis from pathology measures to
strengths-based recovery indicators. Evaluation can then focus on the impact
of service combinations and sequences on a person’s overall life over time.

39

Activities for (Re)Building Recovery Capital

Supports that can open and ease the way for the development of recovery capital
for drug dependent persons as they move towards rehabilitation and social
reintegration are facilitated by:

Implementing a sustained recovery management plan that uses a

strengths-based approach beginning with a comprehensive assessment
(using the recovery capital model) of each client’s needs, strengths, assets,
and vulnerabilities. (See Figure III, Chapter I for relevant domains.);

Placing greater emphasis on the contextual (physical, economic, social,
cultural, political) opportunities and obstacles that could make drug
rehabilitation and social reintegration succeed or fail;

Shifting away from an exclusive focus on diagnosis and treatment of
substance dependence to sustained healthcare and recovery partnership
(The recovery plan is broader in scope: it includes all eight domains of
recovery capital, and focuses on a continuum of care approach before,
during, and after primary treatment.);

Improving access to services by identifying potential barriers and conditions
that prevent such access (See Figure I, Appendix I for the Vulnerability
Context that includes: social discrimination, institutional and funding
barriers, and access to resources.);

Making programme services and the process of delivery culturally relevant,
gender sensitive; providing supportive environments; and proactively
identifying and addressing potential barriers that could promote exclusion,
discrimination and/or continued relapse;

Being client-centred, which empowers the individual to move towards a
healthier, more productive and meaningful life (Client choice and consent
are encouraged because it supports clients—along with their families and
significant others—in developing and driving their own recovery plans. This
confers on them a greater sense of dignity and ownership of the process of
rehabilitation and recovery);

Giving special attention to gender-specific approaches that can address the
needs of women that differ, to some extent, from those of men;

Providing a cost-effective sustained recovery management programme that
provides long-term support; a continuum of care; regular check-ups; and
interdisciplinary service models that integrate contributions and support
from a variety of professionals (e.g., social workers, public health nurses,
psychologists, medical doctors), and well-trained paraprofessionals (e.g.,
coaches and spiritual leaders) as well as family, peer-based supports, and
the community);

Replacing fragmented services with strategic partnerships, networks and
coordination arrangements between governmental (public) and non-
governmental organizations to increase the network of resources,
supporting available drug treatment and rehabilitation services, and
providing a continuum of care; and

Ensuring that adequate follow-up is part of treatment and rehabilitation in
order to: assess and reduce potential risk factors with regard to drug
consumption; encourage protective factors for a healthy lifestyle; and
provide adequate support for sustained recovery and social reintegration.

40

Steps towards Building Recovery Capital

Domain 1: Physical and Mental Health Supports

Physical and mental health supports are important elements of drug
rehabilitation and social reintegration processes. Beneficiaries are not only
persons in the process of recovery, but also their families, their immediate
environments, and the community at large. They are:

• Integrating primary health care and substance dependence treatment;
• Addressing physical and mental health needs together with substance

dependence as part of a sustained health care model;
• Putting in place a system to facilitate referrals for further assessments

and treatment services;
• Ensuring that sustained recovery management of both substance

dependence treatment and primary/mental care services are carried
out by an interdisciplinary team of professionals, involving
paraprofessionals (peer-groups), as far as possible, to ensure cross-
disciplinary support, cost-effectiveness, and a continuum of care
throughout the process of treatment, recovery, and social integration;

• Making available follow-up services to treatment within the
community, through networking with primary health care institutions,
government agencies, NGOs and peer-group supports;

• Ensuring that adequate assessment and screening tools are easy and
quick to administer by staff members with varied levels of clinical
training, (see Appendix II for WHO’s Quality of Life Assessment tool,
and the Treatnet Addiction Severity Index) and are able to identify
both substance dependence and other co-occurring diseases;

• Offering psychosocially assisted pharmacological treatment of opioid
dependence and co-occurring psychiatric disorders; and

• Having in place specialized programmes for women who are most
vulnerable when drug dependence is coupled with interpersonal
violence such as child abuse, rape, and battering. (See Chapter II for
more details on gender-specific measures.)

The prevention of negative health (and social) consequences of drug use
through the following services—as part of a comprehensive package of drug
dependence treatment and rehabilitation—are also ways to help people with
drug related problems to stabilize their life (UNODC discussion paper:
“Reducing the adverse health and social consequences of drug abuse: A
comprehensive approach” (2008), available at:
http://www.unodc.org/unodc/en/frontpage/reducing-the-harm-of-
drugs.html):

• Offering non-discriminatory services to drug dependent persons aimed
at protecting them from the adverse health and social consequences of
drug dependence;

• Providing reliable information and counselling on the physical and
psycho-social risks of drug abuse (overdose, infectious diseases,

41

cardiovascular, metabolic and psychiatric disorders, and impaired
driving);

• Offering low-threshold pharmacological interventions (e.g., opioid-
agonists and antagonist drugs), for immediate health protection and
stabilization;

• Providing vaccination programmes against Hepatitis to drug dependent
persons;

• Offering medication and emergency kits for managing overdoses;
• Offering services for the prevention and management of sexually

transmitted diseases, particularly to those involved in the sex trade;
• Establishing voluntary HIV counselling and testing, and antiretroviral

treatment for HIV-infected drug users;
• Making available measures to prevent the acute consequences of

stimulants use so as to contribute to the prevention of related
emergencies;

• Equipping street-workers and peer outreach workers units so that they
are adequately trained to contact drug dependent persons in need of
assistance; and

• Setting up needle/syringe exchange programmes for injecting drug
users, where appropriate, under sound medical practice.

Domain 2: Family, Social supports, and Leisure Activities

Family involvement, social supports, and leisure activities have been
shown to contribute to better outcomes in the treatment and rehabilitation
process. The following actions show how families can play a key role in the
treatment and rehabilitation process for drug dependent persons:

• Include the family throughout the treatment, rehabilitation and social
reintegration process.

• Offer training and educational programmes to family members and
significant others that educate them about: the adverse effects of
substance dependence; early detection; the basic components and
process of the treatment plan; and the key steps of the client’s
recovery goals to help prevent relapse and improve treatment
outcomes.

• Provide family-based therapy that includes information on building
communication skills, parenting skills, couples support, recognizing
and preventing child abuse, and other supports to help restore family
structure, vitality, trust, and build an environment that is conducive to
recovery processes.

• Set up family-focused post-treatment monitoring and follow-up aimed
at identifying and addressing obstacles to long-term recovery and
preventing relapse.

• Make available gender-specific and relational models to help women
and men learn appropriate strategies for positive relationships with
partners and social networks that could encourage relapse and thus
hamper their recovery.

42

• Link clients to significant others or relevant support networks that
provide companionship, communication, and affection where lacking,
necessary, and appropriate. (E.g., significant others can be extended
family members, friends, neighbours, community members, or
housemates in communitarian lodgings such as halfway houses.)

Leisure activities can help develop skills and knowledge that lead to
healthy ways of living, a functional family, and positive social relations.
Participating in cultural and recreational activities such as sports, handicraft
workshops, and group excursions is an important aspect of the process of
treatment, rehabilitation and social reintegration of drug dependent persons.
These activities can contribute to a comprehensive education offer for
persons in recovery. Actions to promote this outcome include the following:

• Make an initial assessment and identification of clients’ preferences,
skills, and needs that can help develop a leisure time plan during
rehabilitation;

• Establish and develop group activities to support the development of
social skills that can ease the rehabilitation process;

• Have skilled personnel to lead recreational, cultural, and sport
activities that contribute to harmonious socialization;

• Incorporate rehabilitation programmes that offer practical activities to
deliver information and encourage motivation (e.g., games, group field
trips to ecological and cultural places, handicraft and artistic
workshops, sports events and the development of recreational
proposals by the patients themselves);

• Develop strategic alliances with public or private organizations that
offer recreation activities, sports, and cultural activities. (E.g., short-
term intensive training can be organized in coordination with
institutions specializing in occupational therapy, sports, education, and
cultural activities.); and

• Monitor leisure time activities, designed through mutual agreement
between the therapeutic team and the person in rehabilitation, since it
allows assessing treatment outcomes and reacting in a timely manner
should problems occur.

Domain 3: Safe Housing and Environments Conducive to Health and
Recovery

Loss of safe housing and environments conducive to health and
recovery is a common situation for drug dependent clients. It is a serious
risk factor for relapse and decreases the chances of social reintegration and a
healthy lifestyle. Providing safe housing is an important factor in the recovery
process. It allows continued contact with service providers but grants a
higher level of independence and reintegration into the community than is
the case with inpatient treatment. A range of benefits can be ensured. For
example:

43

• Supported housing (half-way houses) provide a drug-free ambience
that may help sustain abstinence and support the recovery process.

• Collective living promotes the development of positive peer
interactions and building up support groups and networks.

• Stable housing provides an adequate setting for family contacts and
visits and the re-establishment of trust among family members.

Different housing models and arrangements (e.g., state or publicly owned
social welfare houses, halfway homes, wet hotels) are available that provide
different kinds of supports along the continuum of rehabilitation and social
reintegration. These supports range from housing services for the homeless
and chronic drug dependent persons to housing possibilities that are more
integrated in the community, and fostering growing independence and
reintegration into the job market and productive work.

Examples to promote community housing:

• Families, public authorities, and society at large are informed about

the benefits of housing provision for drug dependent persons. This is
done through broader information-education-communication strategies
to community members, education services, and policy makers.

• Formal and informal leaders may choose to mobilize the community to
provide housing for recovering users.

• Housing strategies for drug dependent persons and recovering clients
are included in the local governments’ social welfare programmes.

• Participation of the private sector could contribute to the sustainability
of housing initiatives. Thus it is important to include them in
discussions about strategies, scope of the plan, and possible
outcomes, including alternative financing for sustainability.

• Housing provision services need to have close links with drug
dependence treatment services.

• Financial support can be obtained from various sources: Where
possible, through direct contributions from the families of drug
dependent persons; on a limited basis from marketing products or
services offered through the vocational component of a rehabilitation
programme; or from public or private assistance.

Domain 4: Peer-based Support

Peer-based support is necessary for persons in the process of rehabilitation
and social reintegration who may be going through a transition period in their
lives that requires changes in social behaviours and roles. During this period
clients may feel insecure, fearful, and anxious, and such feelings may
increase the risk of relapse. While facing uncertainty, it is important to have
positive life strategies that may include self-help, peer group, or tutoring
groups support. Support groups may act as positive mirrors, generate
confidence, and offer support in times of crises. Ways of providing this critical
support in a more structured way include:

44

• Sharing experiences through the individual recovery process and
implementing this action (of sharing) in every rehabilitation process in
a self-help group setting;

• Having clear rules and regulations, particularly those regarding
confidentiality, that are known to all members in the group;

• Moderating self-help groups using professional or especially trained
staff, if resources and group consensus or organizational setting allow;
(Their main function would be the modulation and monitoring of
individual and group achievements.);

• Developing a qualification model for self-help tutors who can update
their knowledge on drug dependence and group moderation with the
support of treatment institutions;

• Assigning a tutor or guide for orientation and counselling to each
group member, so that the tutor can establish a close and trusting
relationship with the person and act as a positive role model in the
rehabilitation process. (A tutor who is knowledgeable about drug
dependence treatment and rehabilitation could make the best use of
contact mechanisms with the therapeutic team to assess the
advances, achievements, and difficulties in the rehabilitation process.)

• Employing Recovery Coaches as peer support. (See US case study in
Chapter IV.)

Domain 5: (Self-)Employment and Resolution of Legal Issues

(Self-) Employment issues are frequently linked to drug dependence. Many
persons with long years of drug dependence have had difficulties in finding
jobs, and unemployment is usually one of the major reasons for relapses.
(See German case study in Chapter IV.) Invariably, they need support and
guidance in reintegrating themselves into the job market. The following
initiatives, when integrated into a drug dependence treatment and
rehabilitation programme, can positively contribute to recovery outcomes,
when current market needs are taken into account:

• Employment counselling, including job seeking training and rapid job
placement;

• Development of vocational skills;
• Recovery work co-operatives as “safe sanctuaries” for those in

transition from treatment to rehabilitation and social reintegration;
• Screening for potential barriers (personal, social, structural) to

achieving economic self-sufficiency, and providing assertive linkages
between services to help drug dependent persons obtain meaningful
and rewarding employment, while resolving challenges,.such as, legal
and criminal issues, lack of safe housing, and access to transportation;
(The easing of these barriers significantly improves the abilities of
persons in recovery to participate in meaningful activities and
reintegrate into their communities and society at large.)

• Establishing a close working relationship between treatment providers
and industry, private sector companies, and/or employment agencies

45

to make it easier for persons in the rehabilitation process to (re)enter
the job market;

• Making it possible for persons in recovery and/or their family members
to learn how to access and manage micro-credits so that they can get
small scale loans to set up small enterprises, which is an important
aspect of creating sustainable livelihoods; and

• Implementing programmes for the development of micro enterprises
with the support of governmental and nongovernmental institutions.

The resolution of legal issues is of great importance for drug dependent
persons in the process of rehabilitation and social reintegration and is linked
closely to the aspect of finding employment. Integrating legal support into
the rehabilitation process could help prevent the destabilizing effect of
unsolved legal issues, which could, because of the associated stress, be a
risk factor for relapse.

Ways of averting relapse because of the pressures of unresolved legal issues
could include:

• Making an initial assessment of the legal situation on a standardized
and confidential basis, with the client’s approval; and

• Taking advantage of legal advice through non-governmental or public
institutions (e.g., universities’ legal offices or non-profit organizations),
all the while strictly respecting the autonomy and privacy of users.

Rehabilitation service providers may wish to establish ongoing
communication with members of the judicial system. As always, clients’
privacy needs to be respected and the confidentiality requirements that are
part of the rehabilitation process need to be strictly observed.

Domain 6: Vocational Skills and educational development

Acquiring occupational and vocational skills builds self-worth and self-
esteem. This is also true for drug dependent persons. Work supports the
creation of individual and social participation and responsibility. Some of the
positive outcomes of acquiring marketable vocational skills and involvement
in productive activities are experiencing higher levels of satisfaction and
security, and reducing the risk of relapse. Steps to make this possible
include:

• Making vocational assessment and counselling services part of

rehabilitation and social reintegration programmes aimed at the creation
of sustainable livelihoods;

• Developing the vocational component of the programme and embedding
it into the treatment and rehabilitation plan, based on the client’s initial
assessment;

• Conduct a market analysis to identify current needs for skills and
products;

• Making vocational training responsive to market needs;

46

• Adapting and renewing vocational support and counselling services to
respond to technology and market changes, in order to enhance sales
options for the programmes’ products and services;

• Making simple and easy-to-manufacture products that are useful, have
low production costs, and a ready market.

Education is a necessary asset for a full life and the assurance of a
sustainable livelihood. Access to different educational schemes and models is
one way to address problems related to drug use and drug dependence.
Treatment providers often work with individuals who, due to the particular
circumstances in their lives, might not have sufficient schooling, or did not
take the necessary exams to obtain a certified degree or qualifications
required to enter the job market. Having an education improves one’s
chances in the job market and may be an additional factor in sustaining
recovery.

The following actions are aimed mainly at young people, since they are a
highly vulnerable group for substance use, but also because of the important
role of formal education in this stage of life. However, education aimed at
exploring vocational skills and work training is, at any stage of life, a key
factor for supportive interventions to be carried out. Some strategies are:

• Implementing school policies aimed at supporting strategies for
rehabilitating and reintegrating students with drug dependence
problems;

• Integrating measures to address the special needs of young people in
recovery through the development of appropriate curricula and
methodologies;

• Training teachers to address drug dependence as any other chronic
disease, since their attitudes can help to reduce stigmatization and
enhance support in the school environment to students in recovery;

• Implementing coordination mechanisms between the health and
educational sectors on strategies to address drug problems;

• Offering educational opportunities in appropriate settings, and
adapting to factors such as age, learning ability, and availability;

• Including treatment and rehabilitation services that allow
outpatient/community interventions that can increase options for
continuity in school;

• Encouraging joint family/teacher efforts to prevent drug use and
relapse while encouraging healthy and protective leisure time activities
at home; and

• Providing counselling sessions (in addition to supporting access to the
formal education system), that integrate an educational/informational
segment on ways to deal with peer and environmental pressures that
could lead to relapse.

47

Domain 7: Community integration and cultural renewal

Community integration and cultural support often have a startling effect
on alcohol and/or drug dependence. In some more traditional settings,
complementary cultural and indigenous activities, when embedded in or
closely linked to a treatment programme, may help to induce relaxation;
facilitate self-regulation of physiological processes; release emotional
trauma; alleviate isolation and alienation; encourage personal
transformation; promote spontaneous manifestations of leadership skills,
and, more importantly, create a sense of interconnectedness between the
self and the community (Winkelman, 2003).

These methods are most helpful when:

• Applied as complementary offered components to drug dependence
treatment and rehabilitation programmes to address relapse;

• Integrated into major rehabilitation programmes, community
centres, training programmes, weekend retreats, as well as prison
systems;

• Provided as additional counselling approaches that may help
address severe psychological and emotional trauma through
culturally accepted (traditional) methods;

• Used to facilitate cognitive-emotional integration, social bonding,
and community affiliation;

• Incorporated in promoting self-expression and conflict resolution;
• Used to promote a sense of purpose and grounding in life;
• Employed as a means to engaging tribal/traditional/community

leadership and encouraging training for indigenous/traditional
leaders and healers to organize recovery circles;

• Applied to hosting indigenous recovery celebration events; and
• Employed in advocating for culturally informed social policies and

treatment approaches.

Also in less traditional settings, activities that create a sense of community
and open opportunities for (re-) integration can be helpful and may serve
some of the above mentioned functions.

Domain 8: Meaning and Purpose in Life

Meaning and purpose in life is central to leading a full and healthy life.
Regardless of how this desire for meaning in life manifests, most persons
know when it is absent and seek it.

The following steps are suggested in assisting clients in the process of
rehabilitation and social reintegration to uncover what, for them, constitutes
meaning in life:

48

• Making an initial assessment, taking into account spiritual interests of
clients, is useful in defining the content of the therapeutic counselling
process;

• Suggesting different types and practices of spiritual practice,
depending on the cultural context, might have an added value (e.g.,
as a relaxation strategy to face fears, anxiety, anger, and create a
mental sense of recovery and well-being);

• Encouraging spiritual practice in groups, if applicable in the cultural
setting, might support the connection with others and a sense of
belonging; and

• Working with therapeutic staff to develop skills to approach and
explore the spiritual and religious interests of clients in the process of
rehabilitation and social reintegration.

Once the “what” and the “how” of implementing the various aspects of
recovery capital—an essential part of sustained recovery management—have
been realized, the next step is to increase recovery supports, through a
systems approach, additional funding or in-kind-contributions, for drug
dependent persons. Chapter V provides helpful strategies for accomplishing
this aim. It outlines: a) how to advocate for changes in policy, structure, and
processes by influencing decision makers, and b) how to raise awareness and
create buy-in by targeting groups at every level of society.

49

Chapter Four: Case Studies

The case studies and testimonials presented here relate to some of the eight
domains of recovery capital explained in the previous chapters. Case studies
were selected with regard to regional balance and to cover many of the
possible domains that can support the development of recovery capital. They
reflect the cultural, economic, and social context in which they were
implemented, and are in line with the definition of “good practice” Treatnet
has agreed upon. (See Introduction and Overview.) Key areas covered in the
case studies include background information, contact details, objectives,
processes, achievements, challenges, and lessons learned.

Case studies come from Bolivia, Cambodia, Canada, Germany, Honduras,
India, Nigeria, Spain, and the United States. Emphasis is placed on those
from developing countries. Those whose practices may not yet have been
scientifically evaluated are also included. Testimonials give voice to how drug
dependent persons and, in some cases, whole families and communities,
were able to draw upon their various assets, as outlined in the Sustainable
Livelihoods framework, to reduce drug dependence and begin the process of
rehabilitation and social reintegration.

As these case studies show, recovery capital can be applied to a whole range
of situations. Its principles can also be applied to life situations where there
has been a need for recovery and balance such as job loss, divorce, death of
a loved one, and recovery from codependence.

Promising Practices in Action

The following “good practices” are drawn from projects that have developed
or implemented rehabilitation and social reintegration approaches with a
focus on sustainable livelihoods, as well as building specific recovery capital
domains:

•
•
•
•
•
•
• Promoting Micro Enterprises and Vocational Training in the

Cochabamba Tropics: Bolivia
• Education: Cambodia
• Cultural Support: Canada
• Vocational Skills Training and Employment: Germany
• Special Employment Programme for At-Risk Youth: Honduras
• Family Support: India
• Vocational Skills Training and Employment: Nigeria

50

• Legal Support: Spain
• Peer Support: United States of America

51

DOMAIN: PROMOTING MICRO ENTERPRISES AND VOCATIONAL

TRAINING

CASE STUDY: COCHABAMBA TROPICS, BOLIVIA

Issue That Has Been Dealt with in the Case Study:

Vocational training, promotion of micro enterprises, and gender

mainstreaming

Project Background:

For more than 20 years, the United Nations Office on Drugs and Crime
(UNODC) has supported the Andean countries in their efforts to promote
viable options for employment and income generation for low-income
families in rural areas. Traditionally, strategies for alternative development
and the creation of a sustainable livelihood have focused on agricultural
production by supporting production systems, including the processing and
marketing of traditional products in coca production regions, such as coffee,
bananas, palm hearts, pineapples, and other tropical fruits.

BACKGROUND INFORMATION

Project Name: Vocational Training and Promotion of Micro-enterprises in the
Cochabamba Tropics

City/Country: Cochabamba Tropics, Bolivia

Contact Details Including Contact Person: Mr. Carlos Diaz, UNODC Country
Office, Bolivia, Casilla 9072 La Paz, Bolivia
Tel: (591-2) 279 5935, 279 5938, 277 3286; Fax: (591-2) 211 2746

Websites: http://www.unodc.org/bolivia/index.html; www.proyecto-bole07.org;
carlos.diaz@unodc.org

Project Status: Closed. (On 18 July 2007, after six years working in the
Cochabamba Tropics, the tripartite meeting decided to close project BOLE07. In
September 2007 the UNODC Country Office in Bolivia will initiate project I80
Vocational Training and Promotion of Micro-enterprises in the Yungas of La Paz.

Funding Source: UNODC; International Labour Organisation (ILO); Vice Ministry
of Coca and Alternative Development and UNODC

Years of Operation: Ongoing since December 2000 until July 2007

Target Group: Youth (male and female) who were engaged in coca cultivation, as
well as local development institutions that were strengthened by the project

52

This case study describes an experience in an interagency cooperation
project between UNODC and the International Labour Organization (ILO),
which has applied a strategy in support of integral development in coca
production areas. Recognizing urban tendencies and population dynamics in
the coca producing area of the Tropics of Cochabamba, a vocational training
and support plan for the micro-enterprise sector strategy was designed
specifically to promote labour skills for the non-agricultural market among
young people between 15 and 34 years of age.

Objectives:

• To eliminate growing and trafficking of coca in the region and, instead,
to establish an alternate sustainable economy;

• To teach vocational skills to youth so that they can enter the labour
market;

• To promote opportunities for men and women to obtain productive
jobs that allow for freedom, equality, security, and human dignity.

• To apply a gender-sensitive approach so that women can achieve
equitable participation in vocational training that will enable them to
be integrated into the labour market; and

• To promote self-employment through creation of micro enterprises.

Process/Activities:

• Specific courses were identified for women based on their interests
and competencies.

• Ninety-eight training modules were developed based on market
demand. The courses lasted from 1 to 6 months with an average
strength of 25 students and an average duration of 110 hours. Some
of the courses identified were: Food processing; dress
making/tailoring; harvesting and packing of agricultural crops;
carpentry; masonry; baking and cooking; hospitality services;
painting; electrical work; car mechanics; and artisan crafts.

• Micro enterprises were promoted by addressing issues such as
production process, business administration, cost calculation, and
access to credit.

• Ongoing coordination with government offices was encouraged and
implemented.

• Human resources development was undertaken to support various
projects.

Lessons Learned:

• Removing barriers that could prevent women from participating in the
project were taken into account (e.g., schedules, distance from home,
custody of small children, and teaching in the local language).

• The methodology of learning-by-doing was most effective.

53

• Given that vocational training is a continuous process, municipalities
might wish to consolidate project activities related to vocational
training and promote micro enterprises. In this context, municipalities
can promote the creation of vocational training centres to generate
micro-credit access for micro enterprises.

• Local development in the Cochabamba Tropics requires working on
market access, and introducing new technology for production in order
to increase productivity and competitiveness.

• It would be beneficial for municipalities to promote a new school
curriculum in educational institutions that incorporates vocational
training in trades.

• It is important to work collaboratively with beneficiaries/target groups
in order to know which areas of vocational training interest them.

• Vocational training modules need to be constantly updated.
• Since trades are in demand in the labour market, a focus on vocational

training would ensure ready placement of trained personnel while
satisfying this demand.

Outcome/Achievements:

• The project supported 212 micro enterprises and improved their
productivity and competitiveness. Of 2,028 people, 46% were women
working in these enterprises.

• The creation of an employment bureau, with the support of municipal
government, allowed for 744 young people to be integrated into the
labour market. Out of the total, 280 were female.

Challenges:

• To create a modern and sustainable economy, alternative agricultural
products were cultivated with the support of the Alternative
Development Project. Although private investors were creating a large

54

source of employment, one of the main problems was the lack of
trained human resources to support such a process.

• The social, economic, and political context posed a challenge for the
project. Project leaders had to continuously adapt their intervention
strategies in order to respond to beneficiaries’ interests, meet the
needs of qualified persons in the region, while maintaining close
coordination with both parties.

• Expanding project E07 activities to Yungas of La Paz will be
challenging.

Cultural or Situational Issues Related to This Project:

Traditionally, a large number of youth were involved in the production of
coca. Many had no education. Due to lack of business knowledge and
technical support, they were unable to initiate any micro-enterprises. These
issues have been systematically dealt with through this programme. Also, the
project has taken into account cultural issues such as teaching participants in
their own language, and respecting their traditions by encouraging music and
handicraft.

Evaluative Data Available Related to the Project:

An independent external evaluation was carried out in June 2007. The main
conclusions of this assessment are:

• Of the beneficiaries who have received vocational training from the
project, 26.4% are now productively employed.

• The incidence of non-qualified workers was reduced from 57% to 23%.
• The income of the target group has increased by 31%.
• The competence (knowledge and skills) of the target group generated

by the project is utilized by at least 50% of project beneficiaries.
• The majority of project beneficiaries agreed that vocational training

courses carried out by the project responded to their requirements.
• Employment at micro-enterprises supported by the project was

increased by 196%. Of the workers in micro-enterprises, 50% have
stable jobs.

• Eighty-one percent of micro-enterprises have permanent labour
activity.

• Fifty-seven percent of micro-enterprises supported by the project are
using accounting and management procedures.

A publication describing this project is available through the UNODC Country
Office in Bolivia at http://www.unodc.org/bolivia/es/index.html.

Key Findings:

• The importance of networking with various departments such as
government, NGOs and other UN agencies from the beginning of the
project was realized.

55

• Even though the new learning acquired was within the framework of
an alternative development project, it is believed that the strategies
implemented would be applicable to projects on the creation of
sustainable livelihoods for rehabilitation and reintegration.

• Although not directly addressing persons affected by drug abuse, this
project might also be of interest for services working in the area of
rehabilitation and reintegration.

The following testimonials have been taken from the publication on the
project in Bolivia.4 As noted earlier, the project was not focused on
rehabilitation from drug dependence. However, the outcomes demonstrate
clearly how drawing on some of the domains of recovery capital was able to
support the rehabilitation and reintegration of persons into mainstream
society in the tropics of Cochabamba. Some of the outcomes were:

• Developing meaning and purpose in life;
• Developing vocational and/or educational skills;
• Obtaining employment; and
• Assisting communities and their cultures to provide recovery supports

for individuals and families.

4 UNODC, Government of Bolivia and ILO (2007): Training young people, dignifying employment and
building an entrepreneurial culture in the tropics of Cochabamba.

56

Testimonials

La Moxenita: Indigenous art embodied in a micro-enterprise

The Fabricano family, composed of seven members, concentrates on making carved
handicrafts made from wood and other natural materials. Mr. Fabricano was a leader in
coca production from Isiboro Sécure Sub-central Federation. He decided to change and to
move to Villa Tunari where he could provide better education for his children.

He contacted the project because he was motivated to transmit his art to young people and
other craftsmen. So the project contracted him as a trainer to make handicrafts. Mr.
Fabricano says: “The project has trained us to improve product design and finishing, to
estimate our production costs and develop better business management practices.
Besides, it helped us to participate in handicraft fairs where we sold our products at better
prices.” When demand is high, Mr. Fabricano subcontracts to other craftsmen whom he
trained to make handicrafts with features similar to products offered by “la Moxenita,” the
name of his small business. Mr. Fabricano points out. “We have been working with the
project for a long time and, because of this, we have promoted handicrafts from the tropics
of Cochabamba at a departmental and national level. Now, our aim is to export our
products.”

Cat’s Claw Handicraft: Hand-made furniture for export
Mr. Luis Condiri makes furniture with cat’s claw wood and bark. Helped by his relatives and
a couple of workers, he was able to produce enough furniture for export to China and
Spain.

In the past, the craftsmen were engaged in coca production, but as he himself says, “That
belongs to the past.” Through the project’s support, he was able to improve and expand his
business. In his words, “First, they helped me with business management because I really
needed it. At the beginning we sold just to sell, without knowing if we had profits or not; so
they helped us to manage the business. After that, they took us to Expocruz fair in Santa
Cruz where we signed an important contract with the Rio Selva Resort hotel to make 30
sets of dining room furniture. We are sure that without the project’s support it would not be
possible for us to be where we are now.” The project also provided Mr. Condori with some
small machines to support and develop production.

Other Testimonials

Mr. Raúl Santos, together with his workmates, organized a carpentry workshop. He says,
“The project encouraged us to form an association, so we could sign big contracts to
produce furniture. They also trained us in the treatment of wood and furniture production,
and gave us some tools that make our work easier.”

Mrs. Cinda Postigo, 53, is now making handicrafts. She says, “I became interested in
producing handicrafts, and so I attended the project’s training courses. Gradually my son
also started to be interested and now we are so completely engaged in this job that we
have to hire workers to work our land.”

Mrs. Nora Rojas prepares food for a living. She says, “I received training to diversify and
improve my offerings. They gave me an oven and other utensils to make and preserve
products and raw material. I now have a job because of the project. My life has changed,
and now I can offer my children a future.”

57

DOMAIN: EDUCATION

CASE STUDY: CAMBODIA

Issue That Has Been Dealt with in the Case Study:

Education, vocational training, and employment for drug-dependent street
children

Project Background:

Friends International founded Mith Samlanh in 1994. The Cambodian
organization offers several services at its centre and in the community for
street children, such as, providing: cultural activities for children; innovative
education material; and vocational training.

Objectives:

The objective is to offer vocational skills training opportunities for drug-
dependent street youth. In order to promote sustainability, restaurants were
established to provide jobs for youth who have been trained in hospitality
services.

Process/Activities:

• The restaurant and hospitality services training were launched in
February 2001. A curriculum was designed, and a location was

BACKGROUND INFORMATION

Project Name: Mith Samlanh/Friends International: Restaurant and Hospitality Skills
Training towards Sustainable Reintegration of Former Street Youth

City/Country: Phnom Penh, Cambodia

Contact Details Including Contact Person: Sebastien Marot, 215, Street 13,
Sangkat Chey Chumneas Khan, Daun Penh, Phnom Penh, Cambodia
Postal Address: PO Box 588, Phnom Penh
Tel: 855 23 220596; Tel. & Fax: 855 23 426 748; E-mail: friends@everyday.com.kh

Website: www.streetfriends.org

Project Status: Ongoing since 1994

Funding Source: Friends International

Years of Operation: 14 years since 1994

Target Group: Drug-dependent children who are living and working on the street

58

identified to provide training. After that, students were identified to
attend the programme.

• The students received training in cooking and hospitality services.
• The agency established a few restaurants. First, the trainees learnt to

prepare lunch for all children admitted to studies. Second, a small
business canteen was established. Third, a restaurant was opened
called Friends. It offered Asian-Western fusion flavour. In 2003, a fast-
food restaurant named Popzone, which specializes in Cambodian
cuisine, replaced the canteen project. Romdeng, an upscale
Cambodian-cuisine restaurant, then replaced this project in 2005.

• The trainees are given opportunities to gain firsthand experience in the
hospitality business. They learn how to serve customers, take orders,
cook, and maintain good hygiene. Thirty-six students in the Tapas
restaurant, and 27 in the Khmer restaurant are trained on a regular
basis.

• Since 2003, a French restaurant called Cafe du Centre has been
established to generate income.

Lessons Learned:

• Since the trainees have been given opportunities to work in the
restaurants, the quality of training has improved tremendously. The
result is a dramatic reduction in dropouts, and increased employability
of graduates.

• Based on the needs of the children and also market research
conducted, a new laundry workshop was opened in June 2006.

Outcome/Achievements:

• Until 2006, more than 100 individuals have received hospitality
services training.

• Seventy-four youths have been employed, representing a 90% success
rate in student placement.

• Other youths have stabilized their lifestyle and are reintegrated into
society.

• The government has recognized the Mith Samlanh/Friends
International training programme and its approach. As a result, an
official from the Ministry of Social Affairs signs diplomas given to the
graduates.

• The curriculum is designed as a modular system that allows students
to advance at their own pace while being regularly monitored by
teachers.

• Profit from the restaurants contributes significantly to the other
activities of Mith Samlanh. Through regular revenues, the project has
become self-sustaining.

59

Challenges:

• An ongoing issue is the inability to find qualified teachers for the
students.

• The centre’s clients were having difficulty in handling personal issues.
Therefore, a team was created at the centre to provide client support.

• Fair pricing was a potential threat (i.e., having a price structure similar
to other restaurants). Placing some of the trainees in other restaurants
also helped in maintaining good relationship with other restaurant
owners.

• Mith Samlanh faced the possibility of having to move from its current
location, an ideal location to conduct programmes for street children.
The funds available from the business enterprises and a loan received
from the bank were used towards the purchase of land. Fund raising
activities were also conducted.

Cultural or Situational Issues Related to This Project:

Cambodia is one of the poorest countries in the world, and available
resources are very limited. The project provides children with cultural and
entertainment activities that allow their personal expression and growth. A
team of teachers organises workshops that include dance, singing, painting,
theatre, and sports. Children regularly organise shows and exhibitions for
their peers and a wider audience.

Evaluative Data Available Related to the Project:

In 2006, 468 students were trained in the vocational training centre. Two
hundred and five students graduated and received the diploma from Mith
Samlanh and the Ministry of Social Affairs, Veterans and Youth Rehabilitation.
One hundred and ninety-nine students have been placed in employment; of
these, 59 are girls.

Key Findings:

Learning from experience, the centre has successfully initiated 10 types of
vocational training programmes, and developed full-fledged businesses.
Other vocations providing training are: beautician; car mechanics; tailoring;
electronic equipment repair; welding; electrician, and farming. Roughly
around 350 trainees have enrolled.

60

Chai, supported by the human and social capital she had already
accumulated in her family circle before the death of her father, was able to
stop drug use. Initially, this gave her the strength to escape an abusive
situation. However, as a runaway she became part of the vulnerable
population of street youth. But, as a result of meeting a social worker on the
streets, she was able to enter drug treatment. She also learned a new skill
that provided her with income. In effect, the services offered at Mith
Samlanh enabled Chai to add significantly to her social capital by making
new friends, while acquiring financial capital through sewing. This result was
affected through using the organizing principle of recovery capital within the
multipronged framework of Sustainable Livelihoods.

Testimonial

I am Chai, and I am 19 years old. I started living on the streets when I was 17. I come from a
middle-class family. My mother was very good to me, and my father, who led the family,
unfortunately, died in a traffic accident. Things changed when my mother took a second
husband who was as cunning as a fox. But, mother loved him very much, and they had a
good life together.

One day, when my mother’s husband was drunk, he raped me. Later, he tried to rape me
again, so I decided to run away. I went to live on the streets and quickly made new friends
who introduced me to Yama (methamphetamine) that helped me to be happy for a short
while. I kept using and my new friends, who had been good to me, started treating me badly.

Fortunately, on the streets, I met a social worker who introduced me to Mith Samlanh
services, a drop-in centre for drug users. I met many new friends there with the same
problems. I was supported in preparing a plan for my future, which I’d never done before. I
decided to enter a drug treatment programme to get clean.

After treatment, I learned to sew at the training centre. I was very happy because I found
many good new friends. The new environment helped me to make a new life without returning
to drugs. My life is good with my new job, money, and good friends.

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DOMAIN: CULTURAL SUPPORT

CASE STUDY: ALKALI LAKE COMMUNITY STORY, CANADA

Issue That Has Been Dealt with in the Case Study:

Recovery supported by the traditions and culture of the community

Project Background:

Alkali Lake is a Native Reserve in British Columbia, Canada. Alcohol
dependence was a major problem on the reserve and every man, woman,
and child was seriously affected by it. With alcoholism, came poverty,
hunger, sickness, and physical and sexual abuse. The Shuswap tribal
community in Alkali Lake was plagued by alcohol dependence until two local
tribal members made a commitment in 1972 to stop alcohol use and to
address the alcohol dependence that affected their community.

Objectives:

The aim is to work towards community healing, which is considered as
moving individuals, families, and communities into a state of optimum well-
being and prosperity.

BACKGROUND INFORMATION

Project Name: Alkali Lake Community Story (Aboriginal healing movement in
Canada)

City/Country: British Columbia, Canada

Contact Details Including Contact Person: Edna Robbins, Executive
Assistant, Esketemc First Nation, P.O. Box 4479, Williams Lake, British
Columbia, V2G 2V5, Canada

Tel: 250-440-5611, Fax: 250-440-5721; E-mail: alib5@wlake.com

Website: http://www.aboriginalcanada.gc.ca, http://www.esketemc.ca/start.htm,
http://www.aboriginalcanada.gc.ca/acp/site.nsf/en/ao26134.html

Project Status: Ongoing, since 1975

Funding Source: No information available

Years of Operation: 32 years

Target Group: The Shuswap Tribe

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Process/Activities:

Some community members managed to stop drinking and maintain a non-
drinking lifestyle. They became an example of positive role modeling and it
was attractive for others to follow.

One of them, by then chief of the reserve, used his formal leadership
capacity to start a core group of non-drinking community members. Some of
the initiatives introduced were:

• Banning bootlegging;
• Giving welfare money in the form of vouchers, not cash, which could

be exchanged for food or other necessities;
• Giving persons who committed alcohol-related crimes, such as drunk

driving and assault, the choice to go for treatment instead of
prison/jail; and

• Creating a safe place (i.e., a caring environment) within the larger
community.

This approach led to having a group of people in the community who
mutually supported one another in their recovery process. The group
gradually developed new and healthier ways of relating to each other, and
new approaches to pursuing the goals of a successful life. They created a
social space for others to move into when they wanted to make the shift.

Lessons Learned:

Through sharing their story, the people of Alkali Lake Community helped
other communities deal with similar issues. One of the communities that
benefited is Hollow Water, Manitoba.

Outcome/Achievements:

Initiating an incentives-and-opportunities-chain provided the support needed
by community members to ensure the best possible chance of succeeding in
recovery. Thus, the following actions were undertaken:

• Children were taken care of while their parents were in recovery
treatment.

• Their homes were cleaned up and repaired.
• A variety of economic enterprises were initiated to provide

employment (e.g., a piggery, laundromat services, restaurants, and a
mechanic shop.

• A strong self-help group, culturally adapted and changed to fit the
community reality was available.

• Opportunities were provided for personal growth through training to
help community members rebuild their internal lives.

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Challenges:

In order for people to be able to imagine themselves living a healthier,
alcohol-free life there had to be tangible opportunities and incentives that
could support a new way of life. Opportunities were needed for meaningful
employment, recreation, and a social life that was alcohol free. Most
immediately, there had to be accessible and fairly continuous opportunities
for healing, personal growth, and learning. What, in fact, was developed in
Alkali Lake was a series of interconnected interventions and opportunities as
well as built-in rewards and consequences that constituted a healing
pathway.

Cultural or Situational Issues Related to This Project:

A key element in the transformation of Alkali Lake Community was the
conscious decision to put spirituality at the centre of the process. This
approach involved a rediscovery of native spiritual traditions and tools such
as the sweat lodge, the sacred pipe, and other healing ceremonies.

Evaluative Data Available Related to the Project:

• By the end of 1973, less than a dozen members were non-drinking.
• By 1975, 40% of the community abstained from alcohol through

treatment and community support. By 1979, that number had risen to
98%. No information could be obtained on the current situation.

Key Findings:

Over a period of 10 years, the community’s sustained effort at achieving
sobriety reduced the tribe’s alcohol dependence rate from nearly 100% to
less than five percent (Chelsea and Chelsea, 1985; Taylor, 1987). This kind
of approach rests on the premise that personal and community sobriety
flourish in a climate of family health, cultural vitality, political sovereignty,
and economic security. The following anecdote describes conditions as they
existed in Alkali Lake before recovery action was taken:

64

This anecdote points out the importance that various aspects of the Asset
Pentagon play in attaining recovery capital. Drawing on previously dormant
social and spiritual capitals, in the form of returning to the teachings of their
Native heritage, allowed the community in Alkali Lake to affect Wellbriety.

Testimonial

“It was one day in 1972 when seven-year-old Ivy C. refused to go home with her
mother, because of the severe drinking of both her parents. Her mother, Phyllis,
made a decision to stop drinking. After four days, Ivy’s father, Andy, also stopped
drinking. They were now the only two non-drinking people in the entire community.

As a result of that decision, Phyllis and Andy C. decided to confront the problem of
alcohol dependence in their community. Subsequently, Andy, was elected Chief of
the Shuswap Tribe. He promoted AA meetings, addressed the drunkenness of public
officials, and initiated interventions to motivate community members to seek
treatment. Tribal traditions were revitalized for both adults and children in the
community. Educational and job development programmes were initiated for those in
recovery.”

For more on this story of recovery capital, see the following website:
http://www.4worlds.org/4w/ssr/Partiv.htm. (Last accessed February 9, 2008.)

65

DOMAIN: VOCATIONAL SKILLS TRAINING AND EMPLOYMENT

CASE STUDY: NUREMBERG, GERMANY

Issue That Has Been Dealt with in the Case Study: Vocational
training for persons in recovery from drug dependence

Project Background:

Mudra, located in the South of Germany, is a vocational training centre
that provides diversified and integrated treatment approaches for persons
with a history of long years of drug dependence. It has been operational
since 1980. In addition to vocational training, Mudra manages a
street-work programme, a drop-in centre, a counselling centre, an
abstinence programme, and pharmacological treatment. Clients with
long years of drug dependence have had difficulties in finding jobs,
and unemployment was seen as one of the major reasons for relapses.

Objective:

To provide vocational training for persons recovering from drug
dependence, including those receiving pharmacological treatment, who
need support in reintegrating into the job market

BACKGROUND INFORMATION

Project Name: Mudra Alternative Jugend und Drogenhilfe

City/Country: Nuremberg, Germany

Contact Details Including Contact Person: Mr. Max Hopperdietzel, Sturmstr. 6–8,
90478, Nuremberg, Germany, Tel: + 49 911 24 13 87

Website: www.mudra-online.de; www.mudra-arbeitsprojekte.de

Project Status: Ongoing since 1980

Funding Source: Employment Agencies, other government institutions, local
governments and some private donations. Thirty to 60% of the vocational training and
employment services budget is covered by selling goods and services.

Years of Operation: 28 years since 1980

Target Group: Persons in recovery from drug dependence

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Process/Activities:

Some of the vocational training services available are:

• The Forest Project that is responsible for the production of firewood,
various forest operations, and a carpentry workshop;

• Costume jewellery making and tailoring (since 1989) to provide jobs
for women;

• The Day Labour Project (since 1994) that entails clearing out flats and
houses (short-term employment that usually lasts not more than one
day a week);

• The Landscaping and Gardening Project (since 1995);
• The Office Project (since 2004) that supports four commercial

apprentices;
• Teaching key job skills that are useful for a variety of job settings; and
• Motivational counselling as part of vocational training.

Lessons Learned:

• Getting a job helps clients to build self-confidence and recovery
capital.

• Work has to be challenging but easy to learn. Work that brings visible
results, such as chopping a huge stack of firewood or making some
nice costume jewellery, enhances motivation and increases
continuation rates.

• Even after many years of drug dependence, most clients can do hard
physical work. They also enjoy the feeling of being tired at the end of
the day as a result of their work.

• Networking with other institutions, such as employment agencies,
plays a major role in sustaining the project.

• It is a good idea to consider vocational training and job projects as
part of the continuum of care services needed to support clients in
recovering from drug dependence.

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Outcome/Achievements:

The office project, which is recognized by the government, provided
commercial apprenticeship for two years. Usually, three apprentices are
provided work experiences after inpatient treatment.

Challenges:

• It is difficult for clients to enter the job market, partly due to the
overall situation on the labour market. Besides recovering from drug
dependence, many have other health problems such as Hepatitis C, or
legal problems such as criminal records. Therefore, training has to be
especially well tailored to the needs of young persons in recovery.

• Clients who are HIV+ find it difficult to do hard physical labour.
• Relapse is common in the process of rehabilitation. In case of relapses,

wherein the client is unable to function, he or she is discharged from
the centre with a clear message that the door is always open.

Cultural or Situational Issues Related to This Project:

None has been noted.

Evaluative Data Available Related to the Project:

A small study conducted at Mudra documents that health-related costs for
insurance companies decreased during and after employment in the
programme.

Key Findings:

• Forty to 50% of clients are immigrants; 75% are male, and 70% use
either methadone or buprenorphine in their pharmacological
treatment.

• Twenty clients who were long-time drug users use the forestry
services. Some have been doing so for more than 30 years, as well as
some young persons with no education or job experience. Participants
must be relatively clean or be in pharmacological treatment, and be
capable of doing physical work. The average age of clients is 30–35;
few are under 18 or above 50 years of age.

• Seven women made costume jewellery, did tailoring, and cleaning
services.

• Clients who are capable of doing physical labour do manual work.
• Approximately 20 younger clients from in-patient therapy on

apprenticeship training do landscaping and gardening work.

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Michael’s story shows the importance of diversified treatment approaches in
building recovery capital. Namely, it is helpful to focus not only on individual
strengths and goals that can support the recovery of those seeking
rehabilitation and social reintegration, but also on the ranges of capital that
may already be part of their repertoire. In Michael’s case, he was encouraged
to draw on his already existing spiritual and physical capital—his love for
outdoor activities. This preference, together with his desire for a job that
connected him with nature, was crucial to his success in recovery. The
current social capital that he built up with the Mudra staff was another aspect
of support that enabled him to remain drug free.

Testimonial

Michael had been heroin dependent for over 25 years. Repeated attempts to provide
pharmacological treatment with methadone were unsuccessful. After brief periods of
abstinence following treatment, he always returned to using heroin.

For many months, Michael had sought to enrol in an employment programme at Mudra, a
drug dependence treatment organization in Nuremberg, Germany. This programme
provides a livelihood for persons in substitution treatment through their participation in one
of the Mudra work projects. In Michael’s case, it was the Forest Project. The work involves
cutting down trees in coordination with the local forest administration, and producing
firewood for sale.

The director of the Mudra programme had been repeatedly warned not to hire Michael
based on his history of repeated failures in treatment and return to active drug use. But the
director decided to give Michael a chance to recover. To everyone’s surprise, Michael did
very well. He went to work every day and remained in pharmacological treatment. Michael
told the staff at Mudra that he had been raised on a farm and loved working outdoors.

Michael had a criminal charge pending, and when he appeared in court, the staff from
Mudra testified about how well he was doing, and requested that he be spared a prison
sentence. Unfortunately, the judge sentenced him to four months in jail. Nevertheless,
Michael assured the Mudra staff that he would serve his term, remain off all drugs, and
return to work when released. That is exactly what he did, and he is still doing well.

69

DOMAIN: SPECIAL EMPLOYMENT PROGRAMME FOR AT-RISK YOUTH

CASE STUDY: HONDURAS, CENTRAL AMERICA

Issue That Has Been Dealt with in the Case Study:

Reintegration of at-risk youth and former drug dependent persons into
special employment programmes in Honduras

Project Background:

The partners of this cooperative pilot project were the central government,
the municipality, the civil society, private enterprises and UNODC (project
AD/HON/04/H88). An inter-institutional technical council was established for
the coordination of the activities, along with financial assistance from
UNODC. A social and labour integration office was established in February
2005 by the project and within the structure of the Municipality’s (Mayor’s)
office as part of the project’s log frame and work plan.

Objectives:

The general objective of this programme was to promote the inclusion of
social and labour integration initiatives into the political youth and
employment strategies in Central America. The more specific project
objectives were to a) validate a model of special employment programmes

BACKGROUND INFORMATION

Project Name: Special Employment Program for Unemployed Youth Without Professional
Training, and at Risk of Psychosocial Disintegration in Honduras

City/Country: Tegucigalpa, Honduras, Central America

Contact Details Including Contact Person: Ms Marlene Zacapa, Project Coordinator
HON/H88, United Nations Office on Drugs and Crime, Mexico

Website: http://www.unodc.org/mexico/index.html

Project Status: Ongoing since 2004; first phase closed

Funding Source and In-Kind Contributions: United Nations Office on Drugs and Crime
(ONUDD); National Anti- Drug Council of Honduras (CNCN); Municipality of Tegucigalpa
(AMDC); Honduran Institute for Professional Training (INFOP); Honduran Institute to
Prevent Alcoholism and Drug Dependence (IHADFA); a local NGO

Years of Operation: 3 years, November 2004–October 2007

Target Group: At-risk youth with problems of substance dependence and delinquency

70

for the integration of unemployed and at-risk youth into the labour market,
and b) identify the means necessary to integrate such types of programmes
into the political strategies at the municipality level.

Process/Activities:

The main project activities were:

• The identification and assessment of youth to participate in the
project. The youths who were selected as beneficiaries of the
programme were awarded scholarships and given school supplies and
uniforms. Psychosocial support was provided.

• Training activities. Seven one-year professional training courses
were initiated. Training workshops were set up to provide training in
car painting, air conditioning and refrigeration, bartending and
restaurant services, carpentry, cooking, graphic design, and working
as an electrician. At the end of the course, certification was awarded
by the Honduran Institute of Professional Training, one of the
participating institutions. Education about alcohol and drug abuse was
provided as part of the “Formation on Values” component.

• Integration into the labour market. The social and labour insertion
office of the Municipality of Tegucigalpa established contacts with
private companies and organizations for the integration of the
beneficiaries at the end of the training period.

Lessons Learned:

• Inter-institutional agreements between organisations that work
towards the same goal have created an environment of mutual
collaboration and sustainability.

• The staff does not only need technical expertise, but also dedication
and commitment to work with marginalized populations as well as a
good knowledge of their living environment and realities.

• The social and labour integration of youth at risk initiative through the
establishment of local labour offices is an experience worth repeating
in other municipalities, but more cooperative agreements with the
private sector would make the programme more effective.

• To be effective and efficient, projects of this type need to address
different levels of intervention, such as with youth, families, and
communities.

• The integration of health and drug dependence status, if included in
the psychosocial assessment, would address the problem of co-
occurring diseases.

• Mainstreaming education on values has been successful and,
therefore, needs to be systematized.

• It is necessary to provide an alternative choice for those youth
interested in professional training, but who did not fulfill the entry
requirements of a completed primary education. Otherwise, these

71

youth might be at especially high risk for delinquency and drug
dependence.

Outcome/Achievements:

• The project’s first phase ended in December 2007. A second phase is
planned.

• One hundred and nine young persons between 15 and 20 years of age
were trained by the project. Seventy-nine of them have entered the
labour force already. Five are in the process of entering employment.
The rest have not entered the work market as yet for a number of
reasons: Some are furthering their education, others have entered the
military service, and some had personal problems.

• Five institutions participated in the project and made satisfactory
contributions.

• The employment agency that was created by the project offers
services not only to the young project beneficiaries, but also to the
broader population in need of this type of support. Three hundred
persons were assisted in 2007.

• A training curriculum was developed that could be shared with others
who are developing similar initiatives in this area.

• Establishing strategies for the expansion of the project in the region is
envisioned.

Challenges:

• The inter-institutional collaboration was sometimes challenging,
especially due to changes in political institutions.

• Some young persons were already earning an income in the informal
labour market. But, upon entering the programme they had to give up
their source of income. Therefore, some families wanted their children
to leave the programme.

• The programme budget did not allow for capacity building for more
young people.

• The difficult living circumstances of the youth made it hard at times for
them to comply with course requirements.

Cultural or Situational Issues Related to This Project:

In Honduras, 30.4% of the economically active population is either
underemployed or unemployed. There are 745,500 people without sufficient
employment. The population of Honduras is young, with 41.6% being under
15 years of age.

The three neighbourhoods of Tegucigalpa in which the project took place are
known for high population density, lack of public infrastructure services,
poverty, juvenile delinquency groups or maras (gangs), crime and drug
consumption. Therefore, they are at high risk of social disintegration.

72

Evaluative Data Available Related to the Project:

• A project evaluation/systematization report was published in October
2007 (“La inserción laboral a partir de la formación técnica vocacional
de jóvenes en riesgo social”).

• The project has trained 109 young people, 9 more than was originally
envisaged. Thirty-seven percent of the participants were female and
63% were male.

• Graphic design, cooking and training to be an electrician were the
most popular courses.

• Social reintegration initiatives have been included into labour and
youth politics.

• Because of missing data, acquiring information about the level of the
national labour market needs and developments was problematic.

• Data collection, monitoring, evaluation, and follow-up could be
improved.

Key Findings:

• The project gained strength and sustainability through working
collaboratively with the inter-institutional technical council established
by the project. Some form of professional and institutional
development could be seen as a secondary outcome of the project.
Forms of co-financing are currently being explored.

• The close cooperation with the community and its institutions has
helped to achieve project goals.

• A second chance to acquire professional training and social and labour
integration seems to reduce risks for social disintegration of the direct
beneficiary. This initiative also helped families to increase their income
through having a member in their household with marketable job
skills.

• There is a need for continuing programmes for youth, especially for
those in this at-risk target group.

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Denis’ access to financial capital ended with his grandmother’s death.
However, drawing on his social capital, in the form of a friend who told him
about the course, he was able to develop financial capital in the form of a
job, and provide for himself and family. He also developed a sense of
meaning and purpose in his life; “his days of … agony are gone.”

Testimonial

My name is Cecia Patricia Mejia and I am 20 years old. I live in Colonia Villa Nueva,
and finished the sixth grade at school. There are seven persons in my family. Before I
entered the project, I was at home and took care of my nephews. I entered the project
through a friend who was already enrolled in it. I thought that the project would be very
good; so I went. Later, they asked for my papers and said I should come to the training
centre for an interview; and then they called me.

I chose cooking because I like it; we also did a pastry and baking course, which were
great. The cooking classes were also great, because, thanks to the course, many
doors opened for me. Participating in the project and talking with the psychologist
helped me to feel more self-assured.

They took us to youth meetings, and we had a lot of fun being with the others. They
also talked with us about drugs. Later, we did our cooking internships. I did mine at the
Hotel Honduras Maya, and it was a very good experience. I like the way we were
treated—with friendliness and respect.

After my internship, I found work and I feel very happy now because, thanks to the
project, I have changed in many ways. For example, in the meetings with the
psychologist I felt that I could achieve things for myself. I would like to be a better cook
or a well-known chef; be able to work to help my mother and move on and stand out;
be happy to see and feel I am useful for something; and to be better every day—a
better person and a better daughter.

Testimonial

Denis is 18 years old and lives in Colonia Nueva Suyapa. He is married and father of
a four-month-old daughter. His wife is not employed. Before entering the project,
Denis did not work, did not study, and basically “did nothing.” He was dependent on
financial support from his grandmother, until she died in November 2006.

Denis learned about the course through a friend who also participated. He decided to
take part in professional training to qualify himself for employment in the hospitality
services sector. The project supported him in many ways: he earned a scholarship,
and was given a uniform and materials. Denis now works in a hotel in the city where,
he says, “he has good working hours and a good working atmosphere.”

He states that the course has helped him a lot, because, without the project, he
would not be working at all. He has a minimum wage salary, which is not much, but
at least he has enough to respond to his and his family’s basic needs. Denis feels
content and likes working with people. His days of unhappiness and agony are gone.

74

Like Denis, Cecia drew on her social capital in the form of a friend who was
already enrolled in the project. Prior to taking cooking classes, Cecia took
care of her nephews. But after completing her course and her internship, she
began to notice that “many doors opened for [her].”

Cecia was able to add several of the domains of recovery capital to her
repertoire of assets capital: developing a vocation skill; obtaining
employment; and developing her own meaning and purpose in life.

DOMAIN: FAMILY THERAPY PROGRAMME AND VOCATIONAL
TRAINING

CASE STUDY: CHENAI, INDIA

BACKGROUND INFORMATION

Project Name: Family Therapy Programme of the TT Ranganathan Clinical
Research Foundation and TEJAS Vocational Training Centre

City/Country: Chennai, India

Contact Details Including Contact Person: Dr. Shanthi Ranganathan, Honorary
Secretary,TT Ranganathan Clinical Research Foundation , TTK Hospital, IV Main
Road, Indira Nagar, Chennai 600020, India

Tel: 0091 44 24426193 / 24918461 / 24912948; Fax: 0091 44 24456078
E-mail: ttrcrf@md2.vsnl.net.in / ttrcrf@eth.net

Website: www.addictionindia.org

Project Status: Ongoing, since 1985

Funding Source: Self-funded

Years of Operation: Family therapy programme since 1985, and Vocational training
since 1999

Target Group: Wives and parents of drug-dependent persons

75

Issues That Have Been Dealt with in the Case Study:

Family programme for the wives and parents of drug-dependent persons;
vocational training for some women; and helping families to recover and
become functional through family therapy

Project Background:

TT Ranganathan Clinical Research Foundation (also known as TTK Hospital)
started their primary care treatment programme for drug-dependent
individuals in 1982. The families who accompanied clients for treatment were
deeply affected emotionally and economically through the drug dependence
of their family member, especially in the case of relapses. Recognizing the
fact that relationship with the family is an essential element in recovery, in
1985, TTK Hospital developed and initiated an exclusive two-week
programme for families. One family member must attend this free
programme, which was designed with the twin purposes of helping families
to get out of their problems and become functional while, at the same time,
developing their preparedness to support the patient in recovery.
At some point, the centre felt the need to equip some family members with a
vocational skill leading to economic and social rehabilitation. TEJAS
Vocational Training Centre was set up at the TTK Hospital in 1999 with
support from Deutscher Orden and the European Commission. Tejas, which
means “brightness” in Sanskrit, offers a safe and supportive environment for
family members to acquire training in a vocational skill.

Objectives:

• To provide information about drug dependence and its effects on the
family system;

• To provide a safe and acceptable environment for families to express
their feelings and to discuss their issues;

• To enable families to recognize and grow out of their dysfunctional
coping behaviour and negative personality traits; and

• To provide opportunities for some of the women to acquire a
vocational skill that leads to economic empowerment.

76

Process/Activities:

In the family therapy programme, the day starts with the serenity prayer and
a meaningful story conveying a thought for the day. This approach gives
families an opportunity to reflect on and share their feelings about the
thought. This is followed by input sessions that provide information about
drug dependence and practical coping methods. Trained counsellors provide
group therapy and individual counselling. Al-Anon meetings are also held
twice a week at the premises to enable mutual assistance in handling
problems.

On completion of the two-week programme, family members who are looking
for vocational skills training to earn a livelihood join TEJAS to learn tailoring.
Tailoring was identified as a viable vocation skill because of market demand.
It is also easy to learn, and entrepreneurship is possible with a small
investment.

Contact was made with potential buyers. A ready market was found in
industrial areas in the form of cooking contractors who would place orders for
bags. Once training was completed, small loans were made available to those
interested in buying tailoring machines to work on their own; others would
take orders from the centre and work from their homes. Some persons in
recovery and their families continue to work in the unit and earn a stable
income.

Lessons Learned:

• The centre found that family therapy, including learning a vocational
skill, empowers families, which is the ultimate gain.

• By learning tailoring skills, family members are able to be economically
independent and take care of their children in spite of their spouses’
repeated relapses. This has also contributed to the strengthening of
self-confidence in family members.

• Many women have established their own small tailoring units in their
homes, and are able to manage their families’ needs with the income
earned.

Outcome/Achievements:

• The family therapy, and vocational training units were initially
functioning in a very small area. At that time, a former client, who has
been sober for more than 15 years, donated a wing (to show his
gratitude) to establish the vocational centre.

• The TT Ranganathan Clinical Research Foundation now enjoys greater
recognition due to the popularity of their products.

Challenges:

77

• Initially, the organisation’s management was sceptical about the ability
of the women to make jute bags, because this was the first time they
had worked in this capacity.

• Since they were promoting jute bags in place of polythene ones for the
first time, they were not too sure about the marketability of their new
products.

Cultural or Situational Issues Related to This Project:

During weddings and other auspicious occasions, it is customary in South
India to give betel leaves and coconut in polythene bags to invitees. On these
occasions, generally, 500 to 2000 bags are ordered. In Tamil Nadu, the
government banned the production of polythene bags. At that juncture, the
tailoring unit came up with eco-friendly jute bags that found a niche in the
open market. Now the unit attracts regular orders for bags used during
weddings and conferences. Other items produced in the unit are industrial
uniforms, fancy silk, cotton, and jute bags that are given as gifts on special
occasions.

Almost all the family members of recovering users are women. Many would
have had minimal education and no vocational skills and, thus, would never
have had gainful employment. This programme allows women to be self-
reliant. Also, since it is a women-only environment, women feel comfortable
and have developed a sense of fellowship among themselves.

Evaluative Data Available Related to the Project:

The TATA Institute of Social Sciences in Mumbai conducted an evaluation of
the family programme to assess its effectiveness through individual
interviews and focus group discussions. Families whose dependent partners
had not recovered were also interviewed.

The number of beneficiaries who attended the two-week programme in the
last five years is around 3,026, with the majority being wives. Around 90
women in the age group between 25–40 years, many of whom had never
worked before, were trained as tailors.

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Key Findings:

• A dramatic improvement in the health status of family members;
• Awareness of family members about their dysfunctional and enabling

behaviour leading to a paradigm shift in their lives;
• Improved harmony in family life; and
• Incorporation of a planned pattern of living and effective use of leisure

time.

As part of the funding procedure, Deutscher Orden and the European
Commission conducted an evaluation of the TEJAS project.

Once Anu was persuaded to enter into treatment along with her alcohol-
dependent husband, she built social capital through sharing feelings with
others in group therapy. As a result, she was able to learn coping skills, and
acquire a vocational skill that added to her recovery capital. In this way, she
was able to effect a profound change in her own life and that of her family.

Testimonial

Anu’s husband had been alcohol dependent for the past 20 years. After several
months of persuasion, she was able to take him to the TTK Hospital for treatment.
When Anu was told that she had to attend the family programme as well, she was
visibly upset and responded, “It is only my husband who drinks without control. You
treat him and set him right. I don’t need to attend any programme.” The counsellor
spent time with her and made her understand the benefits she would derive by
attending the programme. A few other family members who were already in therapy
shared their experiences with her. Finally, she reluctantly agreed to participate in the
programme.

After treatment, Anu went home and attended follow-up sessions with her husband.
She was looking different; she was no longer the angry, confused and desperate Anu
from before. She met her counsellor and said, “It was beyond my understanding then
how profoundly treatment was going to help me. Initially, I found it excruciating to
share my feelings in group therapy with people I’d never seen before, or to listen to
their problems. Yet, it was in this group that I learned how to manage.”

Through her counsellor, Anu came to know about the availability of free training in
tailoring for family members of recovering drug-dependent persons. Since she was
very comfortable in the environment, she opted for training in tailoring. She also
regularly attended Al-anon meetings conducted at the centre for families, and worked
towards her own recovery.

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DOMAIN: VOCATIONAL SKILLS TRAINING AND EMPLOYMENT

CASE STUDY: ABEOKUTA, NIGERIA

Issue That Has Been Dealt with in the Case Study:

Treatment and vocational training for drug-dependent persons

Project Background:

The Drug Abuse Treatment, Education, and Research Centre (DATER) is a
32-bed unit with occupational and vocational facilities. It is located on the
premises of the Neuropsychiatric Hospital, Abeokuta, Nigeria. DATER was
established in 1983 for the treatment and rehabilitation of drug-dependent
persons. In 2004, a vocational rehabilitation unit was established at the
Centre with equipment donated by UNODC. Since the establishment of this
unit, DATER has been offering a formal vocational training programme in a
hospital-based treatment setting as part of its treatment package.

Objectives:

The aim of the programme is to provide treatment for drug-dependent
persons, and to equip them with different vocational skills.

BACKGROUND INFORMATION

Project Name: Dater Unit, Aro Neuro Psychiatric Hospital

City/Country: Abeokuta, Nigeria

Contact Details Including Contact Person: Dr. T.A. Adamson, Provost and Medical
Director, Neuropsychiatric Hospital, P.M.B. 2002, Abeokuta, Ogun State. Nigeria.

Tel.: +234-803-3081461/+234-39-240571
E-mail: adamson@hyperia.com

Website: None, at present

Project Status: Ongoing since 2004

Funding Source: The federal government (75%); clients/relatives (25%)

Years of Operation: Three

Target Group: Drug-dependent persons seeking treatment and rehabilitation

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Process/Activities:

• Family members bring clients to the centre for treatment.
• Treatment is provided at DATER for 12 weeks. This process consists of

drug education sessions; individual, group, and family therapy; and a
12-step programme (AA/NA). Follow-up is provided for two years.

• A three-month vocational training in computer appreciation, tailoring,
hairdressing, and barbering is offered.

• Vocational training runs concurrently with treatment programmes.
• Qualified persons are assisted to obtain jobs appropriate to their

skillsets.

Lessons Learned:

The centre can further achieve its objectives by sharing experiences and
exchanging resources with other centres.

Outcome/Achievements:

• Dater Unit, Aro Neuropsychiatric Hospital is the first modern drug
treatment centre in the country.

• The centre specializes in the management of patients with dual
diagnoses.

• It is also a main centre for providing specialized training in alcohol and
drug dependence treatment.

Challenges:

The centre is looking into ways of improving its vocational training facilities.
To further improve its services, the centre is also in the process of
developing a treatment evaluation programme.

Cultural or Situational Issues Related to This Project:

• Patients are admitted to Dater Unit, Aro Neuro Psychiatric Hospital
from every part of the country.

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• It is also the coordinating centre for the proposed National Network of
Drug Abuse Treatment and Rehabilitation Resource Centres.

Evaluative Data Available Related to the Project:

On average, 21 drug dependent persons are admitted to the centre every
year. Most of them are male (95%), single (80%) and their mean age is 32.4
years (range 17–52 years). About half of the persons admitted have had, or
are currently enrolled in, post-secondary education. Only a quarter of them
was employed at the time of admission. The mean length of stay on
admission is 23 weeks, with about 70% of them staying for at least a
minimum of 12 weeks, which is the time needed to complete the treatment
programme.

Key Findings:

Of the 47 patients who completed the centre’s treatment programme
between 2005 and 2007, only nine were readmitted during that period.

Testimonial

Many of the centre’s ex-patients have been able to sustain their recovery.
Some of them have been invited back to the centre as motivational
speakers for the benefit of those currently in treatment.

In addition to benefiting from the centre’s vocational training programme,
some of these ex-patients have gone ahead to develop themselves
educationally, while some have benefited from tremendous social support.
For example, following discharge from the centre, two ex-patients had
attended a vocational training centre owned and managed by a Christian
religious organization and have since been very involved in the activities of
the religious group. One of them is now employed by the religious group,
while the other is self-employed.

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Participants in the programme run by the Drug Abuse Treatment, Education
and Research Centre drew on their existing social capital in the form of their
family support system. The centre’s vocational training programme provided
them the opportunity, while seeking treatment, to expand their domains of
recovery capital by developing a vocational skill, which led to them obtaining
employment and (re)developing meaning and purpose in life. Many of the
graduates of the programme who sustain their recovery return as
motivational speakers to encourage those currently in treatment.

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DOMAIN: LEGAL SUPPORT

CASE STUDY: THE PROVINCES OF ALICANTE, CASTELLON, AND

VALENCIA, SPAIN

Issue That Has Been Dealt with in the Case Study:

Providing services to drug dependent persons in courts, prisons, and police
stations

Project Background:

The programme was initiated to provide support units for drug dependent
persons in courts, prisons and police stations. Concurrently, it intends to help
the court system apply the most suitable security measures to persons with
legal problems due to drug dependence. Its aim is also to ensure that drug
dependent persons’ living circumstances play a relevant role in their legal
proceedings. This approach can lead to a reduction in the charges and the
adoption of alternatives to imprisonment, which, in turn, enhances the
possibility of social mainstreaming.

The organisations involved in this programme are:

BACKGROUND INFORMATION

Project Name: Support Units for People with drug problems/drug dependent persons in
Courts and Police Stations

City/Country: The provinces of Alicante, Castellon, and Valencia, Spain

Contact Details Including Contact Person: Snr. Miguel Castellano Gómez Paseo de la
Alameda, 16, 46010, Valencia, Spain

Tel: +34 96 3428 605; Fax: +34 96 3424 988
E-mail: castellano_mig@gva.es

Website: www.gva.es

Project Status: Ongoing since 1997

Funding Source: Ninety percent comes from the national government, and 10% comes
from regional authorities.

Years of Operation: 10 years since 1997

Target Group: Drug-dependent persons in the criminal justice settings, namely, courts,
detention centres and police stations

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• Asociación AVANT (Padres y Familiares para la Lucha contra la

Drogodependencia): NGO/Voluntary organisation;
• Asociación para la Prevención, Asesoramiento, Tratamiento e

Investigación en Temas de Marginación y Drogas (P.A.T.I.M.):
NGO/Voluntary organisation; and

• Asociación Provincial Alicantina de ayuda al Drogodependiente
(APRALAD): NGO/Voluntary organization

Objectives:

The goal is to enforce the law while bearing in mind persons’ drug
dependence, and their social environment and conditions, to be able to
objectively and judiciously apply the most appropriate alternative measure in
each case. The belief being that, most of the time, if drug dependence is
treated, criminal behaviour disappears.

Process/Activities:

• Counselling drug users arrested for offences relating to their drug
dependence;

• Providing an alternative to imprisonment by admission into treatment
centres and providing follow-up;

• Sensitizing the judicial bodies about the psychosocial situation,
diagnosis, treatment guidelines, prognosis, and follow-up in connection
with each case;

• Assessing clients regarding drug-related problems; and
• Referring clients for medical, methadone maintenance or conventional

treatment.

Lessons Learned:

• Many drug dependent persons are engaged in criminal behaviour to
support their dependence. Sixty-seven percent of the offences were
related to property, and 12% related to public health.

• Individualized treatment significantly lowers drug-dependence-related
offences.

• Sensitizing law enforcement officials and providing direct assistance to
arrested drug-dependent persons help in achieving the above-stated
objectives.

Outcome/Achievements:

• One thousand and twenty-four clients received treatment in various
centres in 2002; of these, 523 did so for the first time.

• Assistance was given to 324 clients to reduce their penal liability.
• Alternatives to imprisonment were offered to 153 clients.

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• Two thousand eight hundred and sixty persons were either initiated or
continued treatment in 2002. Of these, 829 did so for the first time,
and 1,273 used follow-up support.

• Since 1997, specific units (UVADS–Drug addiction evaluation and
support units) have been created in the central police court and
detention centres in three provincial capitals.

Challenges:

It was realized that professionals working in the field of drug dependence had
no knowledge of legal issues as it applied to their clients. Thus, it became
necessary to provide seminars and conferences geared to informing them
about relevant legal, judicial, and technical aspects. Conversely, police
officers, particularly community police, had no knowledge of issues related to
drug dependence. So, basic training courses on drug dependence,
particularly for the “community police”, were provided.

Cultural or Situational Issues Related to This Project:

Though it has taken the better part of 10 years, there has been a major shift
in how persons in the legal system now view persons with drug dependence
issues. They are no longer seen as delinquents and transmitters of diseases,
but as persons in need of support to recover their health and lives.

Evaluative Data Available Related to the Project:

Many drug dependent persons engage in marginal or criminal behaviour to
support their habit. The programme catered to 3,884 patients. In our
sample, 67% of the offences were against property, 12% against public
health, and 11% against persons.

Global and individualized treatment, according to different patient needs,
significantly lowers drug-related offences. Intervention was provided in over
2,130 cases. The most prominent types of intervention included: information
guidance (32%); follow-up reports (28%); legal counsel (18%); and expert
reports (10%).

In 2002, 2860 persons were visited, including 829 for the first time; 12.18%
of these were referred to conventional treatment centres. This would not be
possible without the appropriate training for and co-ordination among the
various professionals taking part in the process. In addition to co-ordination
meetings, seminars and conferences were organized for the various
communities of people concerned.

Key Findings:

The above-mentioned cross-pollination of knowledge domains between
professionals working in the field of drug dependence and community police

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has proved helpful in contributing to providing the best possible community
services for drug-dependent persons.

DOMAIN: PEER-BASED SUPPORT

CASE STUDY: FAYETTE COMPANIES, PEORIA, ILLINOIS, USA

Issue That Has Been Dealt with in the Case Study:

Recovery coaching and personal recovery planning for women

Project Background:

Recovery coaching services is a voluntary, peer-based intervention
programme for women, coordinated with drug-dependence treatment
services, but operates independently of these services. All women who have
entered a drug dependence treatment programme, including detoxification
services, can receive recovery coach services. Referrals to recovery coaches
are made at any point during a treatment episode. For residential
programmes, referrals occur mostly during the last month of treatment.
Recovery coach services are provided to women in any setting (e.g.,
residential treatment, jail, on-the-job, or in a shelter), but most of the
contacts and activities occur in the community or home. Women receive
recovery coach services onsite while they are in a residential treatment
programme. However, most of these contacts occur in the community to help

BACKGROUND INFORMATION

Project Name: Recovery Coaching and Personal Recovery Planning

City/Country: Peoria, Illinois, USA

Contact Details Including Contact Person: Michael Boyle, President; David Loveland,
Director of Research

Tel: 309-671-8005; Fax: 309-671-8021

Websites: www.bhrm.org; www.fayettecompanies.org

Project Status: Ongoing

Funding Source: Illinois Division of Alcoholism and Substance Abuse

Years of Operation: Since 2004

Target Group: Drug-dependent women in any setting (e.g., residential treatment, jail, on-
the-job, in a shelter, community, or home)

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women’s transition from residential treatment (e.g., searching for housing,
employment, or completing forms for entitlements). Recovery coach services
are time unlimited; women have the option of receiving these services after
completing the continuum of drug dependence treatment or in place of
treatment for those who have left treatment against medical advice.

Objectives:

The objectives are to help women establish a recovery plan that they can
manage and sustain over time. The intention is to help women’s transition
back into the community and develop a sustainable recovery plan. Therefore,
the programme is designed to help women for three to six months with
extended services for those who need it.

Process/Activities:

Fayette’s three residential programmes for women provide most of the
referrals to the programme. Eighty percent of the women referred to the
programme receive a minimum of three face-to-face contacts with recovery
coaches.

Recovery coaches contact individuals within seven days after a referral has
been made while they are still in treatment. Recovery coaches use multiple
techniques to keep women engaged in the programme and in the recovery
process. The recovery coaches are trained in techniques, including strengths-
based case management practices, behavioural technologies, and
motivational interviewing. The programme is designed to:

• Help women develop a recovery plan that identifies their self-defined
goals (e.g., getting a job, finding an apartment, or returning to
school);

• Highlight existing assets and resources they can use to achieve their
goals (e.g., work experience or vocational training, access to
supportive family members, having positive personal attributes, or
having some college education);

• Help them identify barriers/problems that can undermine the
achievement of each goal (e.g., lack of transportation, no access to
medications/medical care, unstable housing, legal problems,
outstanding debt, or being anxious in social settings);

• Help women acquire needed resources in the community (e.g.,
affordable housing, medical care and medication, psychiatric services,
transportation, food stamps, public aid, or childcare services) that can
help them achieve long-term recovery; and

• Coach women on how to manage symptoms, such as panic attacks or
depression, or to walk them through a relapse prevention plan.

Specific techniques used by recovery coaches include the following:

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• Functional analysis to help women understand how certain behaviours
occur (e.g., relapse or over eating) or do not occur (e.g., exercising or
socializing without alcohol);

• Motivational interviewing to explore ambiguity over certain behaviours
(e.g., pros and cons of staying in a relationship or smoking marijuana
while on probation);

• Application of weekly behavioural plans that help women translate
broad goals into functional and achievable steps, such as the multiple
steps required for acquiring a job, meeting new friends, or finding
activities that de-emphasize the use of alcohol or other drugs;

• Coping skills training to teach women how to manage certain
situations (e.g., modelling and role playing a job interview,
participating in an AA meeting, or being assertive with family
members). Coping skills training can also involve helping women
manage symptoms of anxiety, PTSD, or depression in public settings,
such as during an AA meeting or on the job;

• Contingency management to reward participants for working on a
recovery plan or for completing a step in a behavioural plan. Recovery
coaches have access to discretionary funds to help women cover the
cost of transportation (bus passes); clothing ($5.00 coupons for
goodwill); food ($5.00 supermarket coupons); vocational issues
(training books, notebooks, or a calculator); or basic rewards (movie
tickets or restaurant coupons). Coaches can also use the fund to
reward participants for maintaining contact (cover the cost of lunch or
a coffee);

• Behavioural plans and steps that help women learn how to find
rewarding activities that promote recovery and avoid activities that
promote substance use. These plans usually involve family members
or friends in the process;

• Helping women link with community mental health services and assist
them in finding resources to cover the cost of psychotropic
medications (Because Human Service Centre (HSC) is also the primary
provider of community mental health services, women assigned to the
recovery coach programme are given priority for enrolment in the
mental health division at HSC.); and finally

• Using recovery coaches to help women expand their recovery support
network. This process includes working with family and friends and
engaging these individuals in all phases of the recovery planning
process. Recovery coaches can provide family and friends with
information on addiction or how to help women manage symptoms of
their psychiatric disorder. Coaches can also help women connect with
self-help groups and faith-based organizations.

Lessons Learned:

On average, women who received recovery coach services attended more
days of outpatient treatment than women who did not receive these services
after discharge from a residential programme. These results suggest that the
Recovery Coach Programme can be used to complement existing services

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and keep women engaged in treatment. Preliminary results of the
programme indicate that recovery coaches have been successful at helping
women acquire essential resources in the community.

Outcome/Achievements:

Service data from the first 18 months indicated that recovery coaches have
approximately three to five contacts a month with women in the programme
(range 1 to 15). Total contact time averages 1 to 1.5 hours/month. Monthly
contact rates remain fairly constant over time while women are enrolled in
the programme. Seventy-five percent of women leave the recovery coach
programme within six months (average is five months) and 25% remain
open to coaching for 7 to 16 months. Most contacts occur in person,
however, about 30% occur by phone, again mostly for women who require
less coaching services. More phone contacts are used in the later months.

Phone contacts are also used to keep women who are struggling to manage
their recovery, but are resistant about receiving more services or returning to
treatment in an engaged manner. Coaches are encouraged to take women
out for coffee, breakfast or lunch to keep lines of communication open and to
provide women with resources (e.g., housing leads, food stamps, or linkages
to mental health services) while they work through their ambiguity regarding
their substance use.

Challenges:

• Keeping individuals engaged in the programme; (Approximately 30%
of the individuals referred to the recovery coach programme are
difficult to engage.)

• Conflict between the treatment goals of the addiction treatment
programme and the model of recovery coaches;

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• The likely possibility that a client will leave treatment against medical
advice or be administratively discharged for ongoing use of alcohol or
other drugs, but remain open and active with a recovery coach;

• Ideological conflict between the professional-based primary addiction
treatment model and the strengths-based, consumer driven model of
recovery coaches;

• Rules within the residential programme that may conflict with recovery
coach services, such as meeting off grounds; leaving a group to work
on another activity; working on other issues before completing specific
phases of treatment;

• Rules within the outpatient programmes that discourage working with
other agencies or programmes during hours of treatment;

• Changes in peoples’ treatment needs as a result of receiving recovery
coach services during a waiting period (e.g., no longer needing
residential treatment after achieving some level of control with a
recovery coach); and

• Increased ambiguity in the definition of “actively enrolled in treatment”
as a result of offering the recovery coach programme as an alternative
to primary treatment. (E.g., can people who are court ordered to drug
dependence treatment receive only recovery coach services and still
be considered “actively enrolled in treatment”?)

Cultural or Situational Issues Related to This Project:

Since there is funding for only two recovery coaches, it is difficult to have a
complement of recovery coaches who fully reflect the cultural diversity of
individuals receiving these services.

Evaluative Data Available Related to the Project:

Preliminary results of the programme indicate that recovery coaches have
been successful in helping women acquire essential resources in the
community. A five-month follow-up on 73 women has revealed:

• Four percent were employed at baseline; at follow-up, 57% (37/65) of
those who were able to work (eight were in a residential programme
or incarcerated) have acquired a part-time (20) or a full-time job (17).

• Seventy-one percent have seen an improvement in their living
situation after leaving residential treatment or while receiving
outpatient services. Many have moved from a shelter or transitional
housing to independent apartments. At follow-up, 40% were in an
unstable living situation (e.g., shelter, transitional housing or
incarcerated), and 60% were living independently or with a partner or
family member. Although 40% were living in transitional housing at
the time of this report, most of these women were homeless at
discharge from a residential treatment programme. Recovery coaches
usually helped them connect with shelter resources and, therefore,
improved their housing situation as well.

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• Twenty-six percent were in the process of enrolling in school (e.g.,
obtaining financial aid or completing applications) or actively enrolled
in General Equivalency Diploma or college courses.

Key Findings:

• Recovery coaches have been successful at linking women with the
Federal Qualified Health Clinic in Peoria for medical and psychiatric
services (N=27) and HSC’s mental health services (N=21). They have
also linked women with food stamps and food banks, temporary
housing assistance (e.g., coverage for electric bills or down
payments), and clothing.

• Recovery coaches routinely advocated for women involved with the
Department of Children and Family Services (DCFS), a child protection
agency, or the criminal justice system. Recovery coaches frequently
attended DCFS or other court proceedings on behalf of women and
often testified on their behalf.

Many of the women in the programme were able to build social capital by
developing trusting relationships with their recovery coaches. Through the
support and advocacy of their coaches, some of them were able to improve
their living situations after leaving residential treatment by getting jobs,
moving from transitional housing to independent apartments and enrolling in
school. Thus, in addition to social capital, they were able to develop the
physical/mental health, housing and financial aspects of recovery capital.

Testimonial

My name is Tiffany. I entered residential treatment on September 18, 2007. During my
stay, I was able to begin a new, drug-free life and was referred to a Recovery Coach,
Beth. At the time, I was clueless about what a Recovery Coach was until I met her.

To say the least, I was surprised. Beth has gotten to know me and understand my needs.
She was very knowledgeable. She linked me to all community resources, including
housing, the Department of Human Services, available jobs, and women’s 12-step
meetings to keep me comfortable in my early sobriety among other things.

Beth isn’t only my Recovery Coach but also a mentor and a wonderful friend in recovery. I
now have been drug-free for five months. I was blessed to have a Recovery Coach who
has helped me in many ways. I think all women in early sobriety should have an
opportunity to have a Recovery Coach and the services they offer. Thanks Beth!

For more on peer-based supports, see the US case study in Chapter IV.

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Chapter Five: Advocacy

Chapters III and IV provide practical suggestions for actions to implement
sustained recovery management and strengthen the eight domains of
recovery capital. The focus of this chapter is on how to convince decision
makers to increase recovery supports for drug dependent persons5 through
advocacy by aiming at target groups at every level of society.

This chapter is divided into three parts:

• The first identifies target groups for advocacy on the personal,
community, institutional, and national levels;

• The second suggests ways to raise public awareness on the issues of
rehabilitation and social reintegration for drug dependent persons; and

• The third provides a short list of easily accessible information sources
on the emerging concepts that are part of the sustained recovery
management framework (mainly, sustainable livelihoods and recovery
capital).

Advocating for policy, structure, and process changes is required to
overcome the economic and political barriers and the social stigma that
usually slow or prevent the achievement of sustainable livelihoods, social
reintegration, and sustained recovery for drug dependent individuals
(Braithwaite, 1999, 2001). Advocacy, of course, has to take into account the
overall situation of the community in achieving a sustainable livelihood.
Positively transforming the institutions, organizations, policies, and legislation
that influence drug dependent individuals’ access to sustainable livelihoods
and recovery capital would enable these individuals to earn an income and
reduce their vulnerability context and need to engage in illegal activities.
Overall, it encourages a shift to environments that are more conducive to
health and social reintegration.

Sustained recovery management—an emerging approach—recognizes just
that. It places equal attention on:

(a) Reinforcing the client’s ability to draw on her or his past and present
resources; and

(b) Transforming the broader contextual environment.

5
1961 Single Convention on Narcotic Drugs, Article 38: Measures against the abuse of drugs: 1. The

parties shall give special attention to and take all practicable measures for the prevention of abuse of
drugs and for the early identification, treatment, education, after-care, rehabilitation and social
reintegration of the persons involved and shall co-ordinate their efforts to these ends. 2. The Parties shall
as far as possible promote the training of personnel in the treatment, after-care, rehabilitation and social
reintegration of abusers of drugs. 3. The Parties shall take all practicable measures to assist persons
whose work so requires to gain an understanding of the problems of abuse of drugs and of its prevention,
and shall also promote such understanding among the general public if there is a risk that abuse of drugs
will become widespread.

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Sustained recovery management moves away from the identification of
risk factors for relapse only. Instead, it supports the client’s desire to work
towards a “healthy, productive, and meaningful life” by integrating all eight
domains of recovery capital (e.g., physical/mental health, housing,
employment, and family supports) in the treatment of drug dependence and
through the continuum of recovery. It also takes into account that not having
an environment that supports recovery seriously puts at risk the chances for
rehabilitation and social reintegration.

Figure I, Appendix I gives an adapted version of the Sustainable Livelihoods
framework. It shows the inherent interdependence between building recovery
capital and the vulnerability context of drug dependent persons. It also
shows how the external environment—which comprises, among other things,
policies, legislation, institutions, structures, and processes—can influence the
interaction and, therefore, outcomes.

Given that drug dependence often brings with it concurrent health and
psychosocial problems, nothing less than the broad, systematic, science-
based approach that has been guaranteed for many other chronic diseases is
required for the treatment and rehabilitation of drug dependent persons.
Emerging good practice from existing drug dependence treatment
programmes, as described in case studies (Chapter IV), and related excerpts
in this manual, show the value of adopting an integrated, broad-based,
continuum of care approach such as sustained recovery management.

In order to raise awareness at every level of society about this promising
practice, two things are needed: advocacy and wide outreach.

Target groups at the personal and community levels include: Families, the
neighbourhood/community, treatment professionals, related service
providers, health professionals, law enforcement/the legal system,
educators, employers, local media, self-help/peer groups, religious groups,
formal/informal community leaders, and community donors.

At the more arms-length institutional and national levels, target groups can
be: Local governments, regional, state, and national governments,
international organizations, donor organizations, national media, and health
insurance companies.

Target Groups at the Personal and Community Levels

Families

A sustained recovery management approach makes client- and family-
generated recovery plans central to the process of rehabilitation and social
reintegration. Since families of recovering persons usually play a crucial role
in the rehabilitation process, they need to be involved in creating a
supportive environment for their recovering family members. Unrealistic

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expectations of a straightforward “healing” after treatment need to be
replaced, however, by a more realistic approach.

Understanding, empathy, and a commitment to wellness on the part of
family members and the entire community support building recovery capital.
This is where the task of overcoming stigma and discrimination begins.

Neighbourhood/Community

Social reintegration into the home community of persons in the process of
rehabilitation and social reintegration plays an important role in (re)building
recovery capital. It helps communities overcome the stigma often attached to
drug dependence, and creates a broader supportive environment for persons
in recovery. Therefore, advocating in the neighbourhood directly affected is
crucial.

Treatment professionals

Since recovery capital and sustained recovery management are somewhat
new approaches to drug dependence treatment, they need to be promoted
and discussed further in the community of treatment professionals.
Furthermore, gaining acceptance of these approaches requires that they be
presented not as rivalling existing treatment systems but, rather, as
complementing them.

The Central Roles of Family and Community in the “Journey to Wellness”

The fact that most Alkali Lake people had gone to treatment and stopped
drinking did not mean that their healing process was complete. Years of
accumulated loss and hurt do not simply disappear as a result of one
therapeutic experience. What remains is a life-long journey into wellness that
is exceedingly demanding because it requires that the traveller learn beliefs
and values and new habits of thinking, feeling, acting and being in
relationships with others…. Alkali Lake people became avid learners,
involving themselves in many different kinds of training to strengthen their
capacity to make this journey.

Another strategy that became very much a part of life in the “new” Alkali Lake
was healing circles, A.A. meetings and other kinds of support groups. These
meetings contributed significantly to rebuilding bonds of love, trust, and
acceptance among the people. Gradually, as people began to feel that it was
safe to do so, they began to talk about some of the deeper hurts they were
carrying that had been covered up by alcoholism.

Excerpted from the Alkali Lake Community Story, Canada at:
http://www.4worlds.org/4w/ssr/Partiv.htm. Last accessed February 9, 2008

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Related service providers

The efforts to assist individuals needing treatment require the combined
efforts of all institutions and authorities involved, such as work agencies, the
broader health system, and social welfare institutions. Case management can
help link the work of treatment professionals on different levels of care in a
meaningful way, thereby providing a necessary continuum of care. Case
management is also essential to improving cooperation with other service
providers. However, developing this mindset needs work, and this is where
broad and concerted advocacy comes in.

Health professionals

As noted in Chapter II, a significant portion of individuals entering drug
dependence treatment does not have an ongoing relationship with a primary
care physician. Considering the important role of health care in building
recovery capital, primary care physicians are an essential part of the
rehabilitation team. Moreover, the availability of specialists for all kinds of co-
occurring disorders would be immensely helpful.

Law enforcement/Legal system

Law enforcement officers and members of the legal system who have a
positive attitude towards recovering persons can be very motivating for
individuals and their families. They can also be a good influence and can
change the mindset of neighbourhoods and communities by their example.
The following excerpt shows the importance of creating linkages between law
enforcers and community-based treatment services.

Transforming Perceptions about Drug Dependence and Recovery through

Partnership Building

Mudra is an NGO in Nuremberg, Germany, that started to work with drug dependent
persons in 1980. The government and police caused many problems for the budding
organization because, back then, street work and drop-in centres were seen as rivals
to abstinence-orientated therapy. Aftercare and vocational training were seen as
rather a waste of money.

At first, police raids and judicial enquiries plagued the centre. So Mudra started to
contact senior police officers and tried to convince them of the benefits of its work. It
was an uphill battle, but 25 years later, Mudra staff conduct training for new police
officers in the region on a regular basis, and coordination meetings between Mudra
and senior police officers are frequently held.

For more on this centre, see the German case study in Chapter IV.

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Educators

Given their role in drug dependence prevention, teachers and other
educators are an important advocacy group for also promoting sustained
recovery management. Moreover, they can publicize the principles of
recovery capital and make it easy for others to understand the needs,
vulnerabilities, and strengths of drug dependent persons who are in the
process of rehabilitation and social reintegration.

Employers

(Re-)entering the workforce and earning one’s own livelihood can be a crucial
part of the reintegration process that helps to stabilize rehabilitation and
raise self-confidence. Thus, it is important for drug dependence treatment
and recovery services to establish partnerships with potential employers in
the community.

Local media

Local newspapers, radio stations, and television can strongly influence public
opinion towards supporting persons struggling with drug dependence. If they
report recovery success stories and not just drug-related crimes, the local
media can play an important role in the advocacy work for rehabilitation and
social reintegration. Media skills trainings could be offered to staff of
treatment and rehabilitation services so that they can advocate directly on
television shows and radio stations.

Self-help/Peer groups

It is important that the different self-help and peer groups be involved,
wherever available, in the process of recovery.

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Self-help and peer-based groups have extensive experience with all areas of
treatment, and might promote the concept of recovery capital from their
side. A promising new approach is the use of web-based peer support
services.

Religious groups

In many parts of the world, religious groups are among the first
organizations to offer help to persons with drug dependence problems and an
interest in religion; in some countries they are the only ones who do so. They
can support the rehabilitation process substantially by offering those in need
of it the possibility of finding a deeper meaning in life. Further, they can help
to (re)integrate persons in recovery into supportive social systems.

Formal/ informal community leaders

Enlisting both formal and informal community leaders in the task of
rehabilitation and social reintegration can open many doors to healing and
well-being. Thus, the influence of informal leaders in particular needs to be
taken seriously. The following excerpt shows the healing influence that
community leaders can have on promoting and supporting rehabilitation and
social reintegration.

Gender Notes on the Value of Peer-based Support for Drug Dependent Women

On average, women who received recovery coach services attended more days of outpatient
treatment than those who did not receive these services after discharge from a residential
programme. Results suggest that the Recovery Coach Programme can be used to
complement existing services and keep women engaged in treatment.

Preliminary results of the programme indicate that recovery coaches have been successful in
helping women acquire essential resources in the community. A 29-month assessment of 166
women (i.e., complete data on 166/186) has revealed:

Forty-seven percent of women improved their employment situation from baseline to
follow-up (5% experienced a decline in employment over time). At baseline, 15% were
employed, at follow up, 57% were employed at least part time. Another 28% were
looking at follow-up, 13% were not looking for employment, and 2% were volunteering.

Sixty-four percent of women have improved their living situation after leaving residential
treatment or while they were receiving outpatient services (10% experienced a decline
in their housing situation). Many have moved from a shelter or transitional housing to
independent apartments.

Twenty-four percent of women were in the process of enrolling in school (e.g., financial
aid or completing applications) or actively enrolled in General Education Development
or college courses.

Women were also connected to a range of services and resources in the community,
including the Federal Qualified Health Clinic (30%), food stamps (31%), and resources
for medication (26%). On average, women were connected to 1.75 additional resources
in the community (beyond employment, housing or education) with a range of 0 to 11.

Source: Excerpted from a Report on the Recovery Coach Programme (Fayette Companies,
Peoria, Illinois, USA) outlining the value of peer support for drug dependent women.

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Community donors

Since drug dependence is still widely regarded more as a weakness of
character than as a chronic disease, it is not always easy to gain the funding
support of local donors. Nonetheless, it is important that advocacy efforts
target potential community donors, as reluctant as they may seem initially.

Target Groups at the Institutional and National Levels

Local governments

Local governments focus on local problems. To enlist their support in
promoting the benefits of recovery capital, it helps to make them aware of
the effectiveness of sustained recovery management. Where possible,
success stories could be drawn from local examples as living proof of the
impact of sustained recovery management. Support from local governments
is crucial to the implementation of community-based systems for
rehabilitation and reintegration.

Regional, state, and national governments

When persuaded of its benefits, the state and national levels of governments
are the ones concerned both with funding and determining the legal
framework for sustained recovery management initiatives. Consequently,
they are among the most important target groups for advocacy. Government
representatives are suitable contact persons for advocacy, since they can
bridge the gap between regional initiatives and national government policy.
Political parties are potentially valuable advocates for getting the word out on

The Transformative Power of Community Leaders

The Shuswap tribal community in Alkali Lake was plagued by alcoholism. In 1972, two
local tribal members, Phyllis and Andy, made a commitment to stop using alcohol. The
following anecdote describes conditions before recovery action was taken:

One day, seven-year-old Ivy refused to go home, because of the severe drinking of
both her parents, Phyllis and Andy. Phyllis decided to stop drinking; four days later, so
did Andy. Now the only two non-drinking members of their tribe, they decided to
confront alcohol dependence.

Eventually, Andy was elected Chief of the Tribe. He promoted AA meetings, arrested
bootleggers, confronted the drunkenness of public officials, and staged interventions to
get community members into treatment. Tribal traditions were revitalized for everyone
in the community. A range of support systems, including educational and job
development programmes, were developed and made available for those in the
recovery process.

For more details, see the Canadian Alkali case study in Chapter IV.

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the value of building recovery capital in a sustained recovery management
setting. The publication Investing in Drug Abuse Treatment: A discussion
Paper for Policy Makerswas prepared by UNODC especially for this target
group.

International organizations

International organizations often take the lead in advocating for
disadvantaged persons. Their mandates, high profile, and global reach make
them excellent agents for spreading information worldwide and to many
levels of stakeholders: from local neighbourhoods to regional, state, and
national governments. Advocacy material prepared by international
organizations such as the United Nations Office on Drugs and Crime and the
World Health Organization may be adapted to support local or regional
advocacy strategies.

Donor organizations

Similar to local donors, nationwide and international donor organizations
often do not see substance dependence problems as the most deserving of
attention. When government funding is scarce, however, donor organizations
can be an alternative source of funding and co-financing. Thus, advocacy
work in this area is urgently needed, and it is important to highlight the link
between drug dependence treatment and social (re)integration and the
reduction in crime and poverty. It might also be pointed out that a sustained
recovery management approach may help to promote other goals that a
particular foundation is focusing on. So it is very important to develop tailor-
made proposals for each foundation.

National media

Politicians and other decision makers tend to watch the media closely. So,
just as local media can help to change attitudes towards substance
dependence, likewise, national and some international media can have
considerable influence on swaying public opinion. Therefore, it is a good idea
to partner with other actors in the field of drug dependence treatment and
rehabilitation to establish and maintain good relations with the media, and to
participate, when and where possible, in media-based advocacy campaigns,
or provide journalists with accurate information.

Health and social security insurance companies

Even where health and social security insurances are widely available and
affordable, their services do not always cover the various kinds of drug
dependence treatment, let alone provide benefits towards building recovery
capital in a sustainable livelihoods context. Thus, it would be a good idea to
provide data that show how rehabilitation and reintegration can lead to a
reduction in relapse rates. And that this, in turn, can lead to a reduction in
repeated inpatient treatments and, ultimately, saves money. Also it would be

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worth exploring further the benefits of community based social security
schemes and how they could be linked with the approach of sustained
recovery management.

Advocacy Methods

One-on-one interaction

A cost effective and efficient way to share the concept of recovery capital and
the creation of sustainable livelihoods through a sustained recovery
management approach is by talking to others such as colleagues, decision
makers, and clients, during informal meetings, conferences, presentations, or
on other occasions.

Case studies and stories

Case studies and stories are good ways to attract attention, and are
considered a main medium in knowledge transfer concepts. Case studies can
prepare the ground for circulating the principles of recovery capital,
sustainable livelihoods, and sustained recovery management.

Case studies and stories are especially suitable for all kinds of media. They
help to attract the attention of politicians and decision makers, and
sometimes can change public opinion easier than can theoretical concepts. It
is a good idea to place more emphasis on sharing the positive aspects and
the success stories of recovery. (“Faces and Voices of Recovery” is an
excellent example of this approach.)

Branded products

Many vocational training programmes, occupational therapies, and sheltered
workshops sell excellent products to the public. When these brands are
connected with high quality and beautiful work, they can go a long way in
creating a positive view in the public’s mind about the benefits of
rehabilitation and social reintegration.

From Drug Dependence to Self-Sufficiency through Production and Creativity

The TT Ranganathan Clinical Research Foundation in Chennai, India, runs a vocational
training programme. Its workshop, Tejas, makes beautiful bags that are traditionally used
as wedding presents. The product has become so sought after that Tejas is now a well-
known brand.

The success of the product contributes to the funding of the institution. Moreover, it is
also helping to shift public opinion about persons with drug dependence problems and
their families.

For more details on this project, see the Indian case study in Chapter IV.

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Articles in popular magazines

Popular magazines can be one of several ways to use print media as an
avenue for advocacy, because they can reach readers who are usually not
aware of the issues of drug dependence and the positive results of sustained
recovery management. For example, articles and case studies that share an
understanding of drug dependence and the benefits of treatment and
recovery, based on success stories, can be submitted for publication. Also,
profiling a centre and its success stories in ways that others can relate to can
change public opinion towards drug dependence.

Brochures and posters

Brochures and posters succeed as instruments of advocacy when there is
already some interest in the topic. Brochures are relatively costly to produce,
and work best when used specifically to target events and lectures. Well-
designed, eye-catching posters can have broad visual appeal.

Professional conferences/meetings, and articles in professional
journals

Sustained recovery management is still new to practitioners in the drug
treatment and rehabilitation community; recovery capital is also a
comparatively new concept. So, an excellent avenue for advocacy among
peers is using attendance at professional conferences, meetings, and
presentations as opportunities to engage colleagues in discussion on the
issues. Articles published in professional journals are other ways to promote
dialogue on these topics. Further, since evidence-based results are of special
importance to this community, it would be important to conduct or support
evaluation studies on sustained recovery management projects, and provide
data in a way that satisfies close scrutiny.

Training programmes

Training programmes addressing the opportunities and problems connected
with sustained recovery management could be made available to different
target groups at all levels: e.g., parents, health professionals, law
enforcement authorities, all kinds of service and drug treatment
professionals, educators, and peer groups.

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Websites

Creating new websites about recovery capital and sustained recovery
management, or linking them to existing websites is an effective means of
advocacy.

Change, though sometimes slow, does come. However, it does not come
about in a vacuum, and that is why advocacy is so important. To promote
change, advocacy is key.

Information Sources

The following sources are just a few examples of easily accessible documents
on the web. Search engines help to identify more publications on specific
approaches.

• UNODC

The United Nations Office on Drugs and Crime has published a wide range of
documents that deal with aspects of rehabilitation and reintegration. A good
example is the drug dependence treatment toolkit, which is also available on
CD. In 2003, as part of this series, UNODC published “Investing in Drug
Abuse Treatment: A discussion Paper for Policy Makers.” That is of special
relevance for advocacy purposes. Please see:
http://www.unodc.org/unodc/en/treatment_toolkit.html for more
information.

• WHO

The World Health Organisation supports countries in advocacy and capacity
building for the prevention and management of substance use disorders in all
vulnerable groups. It seeks an integrated approach to all substance use
problems within the health care system, in particular primary care.
See http://www.who.int/substance_abuse/en/

• HBO Addiction Series

This series, supported by the Robert Wood Johnson Foundation, brings
together North American experts on drug dependence treatment and
rehabilitation, to provide information on the disease and possible
interventions to a general public. Please see, http://www.hbo.com/addiction/
for more information.

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• Sustainable Livelihoods

“Livelihoods Connect,” which bills itself as the learning platform for creating
sustainable livelihoods to eliminate poverty, delivers information about the
concept of sustainable livelihoods in general, and includes a toolbox:
http://www.livelihoods.org/newuser.html, and
http://www.livelihoods.org/index.html.

For guidance sheets on the SL approach, methods and tools, please see the
following:
http://www.livelihoods.org/info/info_guidancesheets.html#1.

• Faces and Voices of Recovery

The homepage of “Faces and Voices of Recovery” contains many success
stories about rehabilitating and reintegrating drug dependent persons, and
other helpful information. See
http://www.facesandvoicesofrecovery.org/main/index.php.

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Chapter Six: Sustained Recovery Management:
Documentation, Monitoring and Evaluation6

“With only scarce resources for treatment,
duplication and inefficiency in the delivery of
services cannot be tolerated.”

WHO 20007

Ensuring long-term, sustainable, positive outcomes for people with drug
dependence problems is a major challenge for drug dependence treatment
and rehabilitation service providers. Evidence-based programmes, research
findings and knowledge of good practices are not always available or easily
applicable to different geographic areas. Therefore, it is necessary to utilize
evaluation methods that guaranty good practices and services to ensure
long-term rehabilitation and social reintegration of drug dependent
individuals.

This chapter focuses on the needed components to help your organization in
documenting, monitoring and evaluating sustained recovery management
programmes. As noted in Chapter I, such an approach includes key
theoretical concepts taken from a variety of areas: Sustainable Livelihoods,
recovery framework, and recovery capital. Some of these approaches are
emerging, while others are mostly not yet applied in the area of drug
dependence treatment. Because of the broad scope of areas covered by
sustained recovery management services, an evaluation needs to be well
designed to allow a meaningful interpretation of the data gathered.

Systematic data collection, monitoring and evaluation efforts are important,
because they can provide critical information about how to:

• Conceptualize and design interventions and programmes;
• Provide critical information on programme implementation problems or

deviations from the initial plan;
• Monitor how closely the programme adheres to an Evidence- Based

Model;
• Make proper decisions (e.g., a programme that has proven

effectiveness may also be implemented in other centres);
• Conduct advocacy campaigns;
• Develop persuasive arguments for funding needs to facilitate the

integration of established and emerging interventions to create a
continuum of care framework;

6 More information on service evaluation can be found in Volume D of the UNODC/Treatnet training
package and the WHO/UNDCP/EMCDDA Evaluation Workbooks
Serieshttp://www.unodc.org/treatment/en/UNODC_documents.html
7 Quoted in Treatnet Evaluation of Substance Abuse Treatment Programmes

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• Assure drug dependent persons and their families that they are
receiving adequate supports to initiate and sustain recovery in their
own communities; and

• Insure that resources are not wasted.

A Step-by-Step Evaluation Approach

The following steps need to be considered8 when deciding to conduct a
programme evaluation:

Step 1: Set up an evaluation group

The evaluation needs to engage people affected by the programme. It is
important to establish a multi-professional evaluation team (e.g., managers,
therapists, researchers, community representatives, potential employers, and
local businesses) together with the programme-affected individuals such as
clients, family members, and community leaders. The evaluation team
requires different members to contribute their unique talents and
experiences to the group’s work. Also, close and collaborative involvement in
the planning and implementation phases of the documentation and
evaluation processes can contribute significantly to favourable outcomes.

Step 2: Describe the programme in detail

A successful evaluation is more likely when a detailed description and clear
statement of the programme’s goals, objectives (as shown below), resources
and products are outlined from the start. Although a vocational programme
was used to illustrate the components required for the evaluation, a similar
procedure can be used for any programme in any of the other domains of
recovery capital described in Figure III, Chapter I. In fact, a comprehensive
assessment of all eight domains of recovery capital is always recommended.

Step 3: Assess the resources available for conducting an evaluation

An inventory of necessary resource components includes the following:

• Existing and/or potential financial and material assets;
• Human resources and available expertise; and
• Time availability and allocation.

The following example outlines the steps needed to evaluate a programme.
In this case, the focus is on building sustainable livelihoods through
vocational skills development.

8
Cf. WHO/UNDCP/EMCDDA Evaluation Workbooks Series

http://www.unodc.org/treatment/en/UNODC_documents.html

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Step 4: Identify and prioritize areas of evaluation

After describing the programme in detail, the evaluation team agrees on
which aspect(s) of the programme will be evaluated, and why. Using the
given example, the group may only be interested in studying the effects or
benefits of setting up the clothing and textiles industrial unit as a Sustainable
Livelihoods programme among the clients. So, they may be interested in
conducting an outcome evaluation rather than a cost or economic one, which
would provide additional information for the centre, but would also require a
different type of data collection procedure.

Ideally, the evaluation of a programme would start before the programme is
actually launched. Evaluations have an important role in the planning and

Example: A treatment centre plans to set up a clothing and textiles industrial unit as its sustainable
livelihoods (vocational) programme. The programme components are:

Programme Resources:

Industrial equipment: Sewing machines (5), embroidery machines (2), weaving looms (2)
Building: To house the equipment
Staff members: (10)
Annual budget: $100,000.00

Programme Objectives:

(Number of clients in recovery) trained and assisted in acquiring vocational skills in various
aspects of clothing and textile design, production, and marketing;

Short-term employment provided for (number of) recovering drug dependent persons;
(Number of participants) assisted in setting up their own small-scale industrial units (or in

securing employment) after completing the training programme;
Basic job interviewing skills taught to (number of clients); and
Evaluation instruments used at various stages of the programme.

Short-term Programme Outcomes:

Increase (number of clients’) motivation to comply with the treatment centre’s after-care plans
and reduce attrition rate;

(Number of clients’) whose situation after completing the initial treatment programme stabilized;
(Percentage of drug dependent persons) begin the process of rehabilitation and social

reintegration after completing the initial treatment programme with the aim of reducing relapse
rates; and

(Percentage of clients) reduces risky behaviour that can injure their health.

Long-term Programme Outcomes:

Reduced illegal activities among (number of clients);
Improved (number of clients’) employability; and
Improved (number of clients’) overall health and quality of life.

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designing of new programmes or interventions. Also, other types of
evaluation can be conducted with existing programmes as follows:

1. Needs assessment evaluation needs to be the first step in the
design of a programme. This evaluation ideally takes place before the
programme is planned. The needs assessment attempts to determine
the needs of the substance using community and helps prioritise the
necessary services. (See WHO, 2000, Workbook 3.)

2. Cost evaluation aims to trace the resources used in treatment.

E.g., what is the cost of treatment, and what other approaches are
producing equivalent outcomes, if any? How do changes in cost
relate to activity levels? (See WHO, 2000, Workbook 5.)

3. Client satisfaction evaluation gathers information from client

feedback on the programme’s services and activities. E.g., has the
treatment programme met clients’ needs and expectations? (See
WHO, 2000, Workbook 6.)

4. Economic evaluations can determine the options that give the best

value for the resources expended. These evaluations help policy
makers decide on resource distribution among different programmes.
It involves comparing costs and outcomes of different programmes
or alternative interventions .E.g., should investment be made in
treatment A or B? (See WHO, 2000, Workbook 8.)

This chapter discusses two types of evaluation that might be implemented on
existing programmes: the process and outcome evaluations.

Process evaluation seeks to determine if the treatment programme is
operating as planned and, if not, to document and study any deviations. The
focus of the process evaluation is on the clients’ coverage. Namely, is the
programme reaching the intended clients?. Regarding programme
operations, the focus is on the manner in which the programme is being
delivered. Namely, is the programme being implemented as intended and is
it proceeding in an integrated manner?

Outcome evaluation measures how clients and their circumstances change
following participation in treatment and/or rehabilitation programmes, and
whether this experience has been a factor in causing this change (WHO,
2000).

Step 5: Generate evaluation questions

Evaluation begins with taking small steps and continuously questioning the
relevance and effects of a given intervention and programme. Generating
precise questions at the start of the evaluation process helps to narrow its
focus. Some of the following questions were applied to the clothing and
textiles evaluation, and are presented here as an example:

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Questions on clients’ characteristics:

• Of the clients completing the initial treatment programme, what
proportion goes on to participate in the Sustainable Livelihoods (i.e.,
clothing and textiles) programme?

• What are the characteristics (i.e., social, demographic, health, drug
dependence profile) of clients participating in the Sustainable
Livelihoods programme?

• Are the characteristics of clients participating in the Sustainable
Livelihoods programme similar to those of clients entering the
treatment programme initially?

• Has the treatment admission rate increased since the establishment of
the Sustainable Livelihoods programme?

Questions on programme processes:

• What is the programme retention rate?
• Were all training sessions conducted as planned (number and

contents)?
• Is the programme reaching the targeted clients (e.g., sex, age,

primary drug of use, socio-economic situation)?
• Are there any significant deviations from the initial plan?

Questions on programme outcomes:

• What sorts of changes (e.g., related to their substance use, physical
and mental health, quality of life, family and social relations) occur in
clients during and after they have participated in the Sustainable
Livelihoods programme?

• What proportion of clients that completed vocational training in the

previous year were:

1. Offered full employment in the vocational programme?
2. Employed outside of the centre’s programme?
3. Assisted to set up their own vocational programmes?

• What proportion of clients have relapsed 6, 12, and 24 months after
being discharged from treatment and having entered the Sustainable
Livelihoods programme?

Step 6: Programme design

There are typically two possible evaluation designs—randomized controlled
design and full-coverage programme evaluations employing time series and
pre- and post-comparison methods. The randomized controlled design is
more resource intensive and complicated to conduct, and may be extremely

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difficult to incorporate into the routine programme of a treatment centre with
limited resources and time.

A full-coverage evaluation, using either time series or pre-post designs, can
be more realistically incorporated into the routine programme of each
treatment centre. These designs enable clients to be assessed on the same
outcome domains before, during and after undergoing the programme and at
follow-up data collection points. Clients participating in any of the sustainable
livelihood projects (e.g., vocational activities) complete several instruments
at programme commencement and at pre-determined intervals while in the
programme.

The following two methods can be relatively easily conducted in community-
based organizations and sustained recovery management programmes by
professionals with little or no experience in conducting programme
evaluation:

1) A time series data collection method. This method uses fixed data
collection points through the entire programme implementation. For
instance, at three-month intervals, starting at programme
commencement, with follow-up at 3, 6, 9 and 12 months. Outcomes
differences among the intervals are used as indicators of programme
effects over time.

2) A simple pre- and post-comparison design. This method assesses
the programme impact on the clients’ outcome domains before and
after completing the programme. Clients participating in any of the
Sustainable Livelihood programmes (e.g., vocational activities) are
asked to fill in or provide information for relevant data collection
instruments upon entry into the programme and at pre-determined
intervals during and after its conclusion.

Step 7: Selecting measures or instruments

Sustainable Livelihoods programmes aim at assisting clients to develop the
supports they need to sustain recovery in the community. Programme
evaluation efforts may focus on monitoring the implementation and
measuring the extent to which the programme has contributed towards
supporting recovery in the community.

Data collection may be performed by examining routine records, using
questionnaires and standardized instruments, having focus group discussions
or interviews or any combination of these methods. See Appendix II for a list
of data collection instruments.
For instance, baseline data could be collected from all clients upon their
entrance into treatment using a specially designed intake form or other
selected instrument/s such as the Addiction Severity Index (ASI) Treatnet
Version – 2.9 (or ASI-5.0 available in different languages). Appendix II

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provides an overview of suggested instruments. It is desirable to use well-
established instruments with strong validity and reliability properties.

Process measures are intended to assess the extent to which the
programme has followed a detailed plan such as number of sessions and
nature of activities, and if the programme was actually conducted with the
specified target population. Process measures include indicators or variables
on clients’ demographic data (e.g., age, sex, primary drug use, socio-
economic situation, health status, drug of primary use), the nature and the
number of sessions, if clients actually attended, and the number of products
produced in a programme (e.g. number of T-shirts made). Process measures
may include instruments to evaluate the degree to which the programme
adheres to the model; for instance, when a new evidence-based model is
implemented.

Programme measures may include the following qualitative and quantitative
methods:

a. Trained staff observations of selected and/or randomized sessions;
b. Audiotape or videotape selected and/or randomized sessions;
c. Reviewing of programme records;
d. Participants’ attendance lists and monitoring tables or documents;
e. Demographic data of clients and family members;
f. Clients’ satisfaction questionnaires; and
g. Focus groups and interviews with clients, family members (e.g.,
how would you improve the programme?), therapists and other key
informants on the programme processes.

Outcome measures are intended to assess the programme’s utility. For
instance, the extent to which the client has been able to sustain recovery
after treatment and other programme results such as physical and mental
health, quality of life, economic situation, skills development, and number of
patients that found jobs. They may be selected from five broad areas,
namely:

1. Maintenance of abstinence or reduction in substance dependence;
2. Improvement in personal and social functioning;
3. Improvement in mental and physical health;
4. Reduction in risky behaviour that could affect health, and
5. Overall improvements in increasing access to livelihoods assets and

recovery capital.

Appendix II lists suggested instruments to measure outcomes in these areas.
The recovery capital model, including the eight domains, and the Sustainable
Livelihoods framework (Figure I, Appendix I) can be used as guides and
assessment tools.

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Step 8: Managing data

Data management is a critical component of the evaluation process.
Therefore, a staff member or a data management group of two or more
needs to be responsible for the coordination of the centre’s data
management activities. The duties of the data usually include:

• Monitoring the data collection process (handing out forms and
questionnaires, supervising dates and procedures;

• Enforcing local data protection laws, good practices and ethics for
evaluation studies and research studies;

• Ensuring privacy and security of all collected data; (It is recommended
that signed, informed consent be obtained from all participants—
clients and a family member—to ensure that they understand the
purpose of the evaluation, data collection methods—such as
instruments, data collection points—potential benefits and risks of
participating in the evaluation process, confidentiality assurance of
collected data and their right to withdrawal from the evaluation study
at any time, among others.)

• Maintaining proper storage and retrieval of all collected data; and

GENDER NOTES ON THE IMPORTANCE OF CONDUCTING GENDER-SPECIFIC ANALYSIS

Keeping in mind that women often are a more vulnerable group, conducting a
gender analysis is important to reveal gender differences across all recovery
capital domains. Therefore, it would be useful to collect and evaluate gender-
specific data that provide useful insights on:

The specific needs and vulnerabilities of women, and how their inherent
strengths assist them in overcoming their drug dependence;

The barriers (social, personal, and structural) to their gaining access to
and control of valuable resources, thereby increasing their recovery
capital assets, and making the best use of treatment services;

The livelihoods assets and activities that would most facilitate their
recovery, and help them (re)gain a sense of safety, financial security, and
social reintegration; and

The social relations and networks that can either hamper and/or facilitate
women’s recovery.

Case studies and lessons provide a more comprehensive outlook at gender-
responsive substance dependence treatment services for women and their
treatment needs. See UNODC Drug Abuse Treatment Toolkit on Substance
Abuse Treatment and Care for Women available at the following link:
http://www.unodc.org/docs/treatment/Case_Studies_E .

112

• Transferring information (data) to a central database

Step 9: Analysing and interpreting data

Data analysis does not necessarily entail complex statistical procedures.
However, the assistance of a statistician or other technical person is always
recommended. Part of the evaluation team set-up plan could be to establish
collaboration with universities and research institutes that could ease the
burden of data base maintenance and statistical analysis of different degrees
of complexity.

Careful discussion and interpretation of data allows a better understanding of
the programme’s success or limitations, namely:

• Did the programme reach its goals?
• If not, why? How could it be done differently, including redefining

unrealistic goals?
• What were the challenges encountered?
• What contributed to the different challenges, and how could they

be overcome in future?
• What are other programme effects?

Step 10: Using the results and lessons learned

Once results are obtained and interpreted, the following step is to utilize
them. Although it is important to share feedback on the outcomes of the
evaluation with all stakeholders, and implement lessons on how the
programme can be improved, it is also critical to use the results to market
the programme in order to directly benefit the clients. Results may be useful
to different individuals for different reasons as follows:

a. Programme administrators:
Programme evaluation is critical for most managers to make sure that human
resources, such as effort, time, activities, and other material resources such
as money are not wasted but are allocated in the most efficient and effective
way. Evaluation results could also provide the evidence that would convince
policy makers and funding agencies of the need for such treatment
programmes and centres.

b. Programme staff
Staff can benefit from the evaluation in many ways, such as making sure
that their efforts and services are reported, which, in turn, helps them to
justify continuous education, improve their services, and provide an
increasingly high quality of care.

c. Programme clients and their families
Clients are the ultimate beneficiaries of the evaluation results. An effective
programme evaluation reflects the results of treatment and (if applicable)
client satisfaction with the services received. If programme planners, service

113

providers, and other staff apply the recommendations made from the
evaluation, clients quality of care will be directly affected. The results of the
evaluation could also encourage drug users and their families to remain in
treatment long enough to achieve effectiveness, knowing that they will be
provided with adequate care and support to maximise their recovery.

d. Potential employers, businesses and community leaders
Successful programmes can convince business and local employers to
provide professional opportunities to people in recovery by hiring graduated
clients.. The programme could establish collaboration with diverse local
businesses to train individuals and provide funding for sustainability.

Conclusions and Recommendations
Sustained recovery management is an emerging approach. There is a need
to test programmes and interventions that demonstrate significantly positive
effects. Given its broader scope—which focuses on both the individual and
the context in which rehabilitation and social reintegration takes place—it is
important to promote design evaluation models that reflect the all-inclusive
nature of sustained recovery management. Evaluation models need to
include assessments of all its essential components, as well as the eight
domains of recovery capital.

Sustained recovery management as an integrated, continuum of care
approach (which depends on the cooperation and contributions of multi-
disciplinary teams across different sets of agencies, organizations,
institutions, structures, and processes), needs to have equal attention given
to ensuring ongoing institutional assessments and performance management
evaluations. As the Sustainable Livelihoods framework emphasizes,
facilitating the road to rehabilitation and recovery for drug dependent
persons often begins with transforming and improving the institutional
context in which recovery supports services take place. Evaluation studies
can clearly support institutions by providing the necessary data to
demonstrate the benefits of their programmes.

114

Appendix I: Figures for Chapters I and III

KEY DETERMINANTS OF LIVELIHOODS-BUILDING BLOCKS:

THE VULNERABILITY CONTEXT

Understanding the nature of vulnerability is a key step in analysing sustainable livelihoods
and identifying key factors that have a direct impact upon persons’ assets and the options
available for them to pursue positive livelihoods outcomes. Vulnerability decreases as people
learn to positively influence their immediate and external environment.

TRANSFORMING STRUCTURES AND PROCESSES (TSP)

The TSP component of the SL Framework includes the institutions, organizations, policies,
legislation and processes that can determine persons’ access to capital, the terms of
exchanges, and the return to any given livelihoods strategy. It also includes persons’ abilities
to feel socially and politically included. It helps gain a better understanding of the
relationships between the personal and impersonal spheres, and highlights potential
opportunities and/or constraints within the two-way governance, “Influence-Access” arrow
linking assets and TSP. (Refer to Figure III.)

Chapter I, Figure I: The Sustainable Livelihoods Framework

Source: DFID Guidance Sheets on Sustainable Livelihoods

115

CHAPTER I, FIGURE II: THE SUSTAINABLE LIVELIHOODS ASSET PENTAGON

It identifies appropriate entry points and tracks changes in the accumulation and loss of five core
livelihoods building blocks, and also depicts important inter-relationships between them:

Human Capital represents a basic requirement to gaining access to other livelihoods’ building
blocks. It includes good health, knowledge, skills (e.g., college education and vocational skills),
all of which can ease the way to entering the labour market. It is the sum of all personal
resources that can be utilized to combat poverty in the context of recovery and substance
dependence.

Social Capital includes all the resources that can be drawn from social networks, memberships,
and relationships of trust and reciprocity that can support the creation of “safety nets.” High levels
of Social Capital add significantly to Human Capital and positive livelihoods outcomes.

Natural Capital consists of natural resources from which livelihoods are derived (e.g., land,
trees, key environmental services, and food).

Financial and Physical Capital comprise economic and financial assets (e.g., income, property,
and investments), basic infrastructure, and producer goods such as tools and equipment)
needed to support livelihoods: transport, secure shelter, water supply and sanitation, clean and
affordable energy.

The centre of the asset pentagon represents zero access. Maximum access to a single
livelihood building block (shown at the outer perimeter) would be insufficient on its own
to achieve livelihood outcomes, attesting to the interdependence of each components
of the Asset Pentagon.

Source: DFID Guidance Sheets on Sustainable Livelihoods

The Pentagon on the left indicates the need
for services that could enhance social and
physical (financial and infrastructure) assets,
shown here in decline.

116

CHAPTER III, FIGURE IV: SUSTAINED RECOVERY MANAGEMENT FRAMEWORK (SRMF)
The SRMF Framework uses both the Sustainable Livelihoods Framework and the recovery capital model, with its eight domains, to better understand and analyse the
contextual opportunities and obstacles easing or hampering livelihoods and recovery capital development along the road to rehabilitation and social reintegration. As an
assessment tool, it can help practitioners develop a realistic treatment and rehabilitation plan, as well track progress, measure effectiveness, and evaluate outcomes.

Contextual and policy

analysis: Analysis of the 8 domains of RC:
Analysis of institutional

governance:

Analysis of strategies to
achieve substance abuse
rehabilitation and social

reintegration:

Analysis of substance abuse
rehabilitation and social
reintegration outcomes:

To identify and understand the
“Vulnerability Context” limiting drug
dependent clients’ access to
recovery capital:

Vulnerability decreases as clients
increasingly learn to influence their
immediate and external
environments. Shifting away from
punitive policies and measures that
consolidate social discrimination
and promote social alienation is key.

To provide an understanding of the separate
components of resources and assets available to
clients, their households, and social groups:

Using the recovery capital model as an assessment
tool helps identify entry points and track changes in
the accumulation and loss of any of the eight
domains of recovery capital. Building recovery
capital is just one component of sustained recovery
management, and cannot exist apart from drug
dependent persons’ relationships to their families
and communities. The broader socio-economic,
political, environmental, and institutional contexts
play an important role, and often limit access to
recovery capital resources.

To assess the extent to which
institutional approaches,
structures, and processes ease or
get in the way of the ability of drug
dependent persons to achieve
recovery capital:

As indicated in the two-way
“influence-access” arrows,
transforming the institutional
governance set-up have a direct
impact on both the external and
personal (recovery capital)
contexts.

This is based on a comprehensive
assessment of all contextual factors
and potential barriers, as well as on
taking into account individual client’s
needs and vulnerabilities, while
building on their strengths.

Ongoing monitoring of progress and
evaluation of outcomes achieved,
against clear goals and benchmarks
established by each client:

This process allows for continued
adjustments in the treatment plan,
and identification of potential barriers
that need further addressing.

Source: Adapted from DFID’s Sustainable Livelihoods Framework and Shankland’s. (2001)

117

Appendix II: Screening and Assessment Instruments

Useful References, Assessment Tools, and Links

• Treatnet ASI

http://www.unodc.org/docs/treatment/asi/Treatnet%20Version%203.0%20050907

• Treatnet ASI Supplement

http://www.unodc.org/docs/treatment/asi/ASI%20Treatnet%20Supplement%20Ve
rsion%203%20050907

• Treatnet Checker’s Manual

http://www.uclaisap.org/InternationalProjects/html/unodc/UN%20September%202
007/Volume%20A/Module%202/Supplementary%20Materials/Treatnet%20ASI%2
0Checker’s%20Manual

• Treatnet Training Package, Volume D on Programme Evaluation
Methods

(http://www.uclaisap.org/InternationalProjects/html/unodc/UN%20September%20
2007/Volume%20D/training-package-volD.html

• The World Health Organization Quality of Life Assessment Instrument

This is an international, cross-culturally relevant assessment tool. It includes 26
items encompassing such broad domains as physical and mental health, social
relationships and the environment. It is aimed at measuring clients’ perceptions,
personal goals, standards and concerns, in the context of their culture and value
systems.

http://www.who.int/substance_abuse/research_tools/en/english_whoqol

• WHO/UNODC/EMCDDA Evaluation Workbook Series

http://www.unodc.org/docs/treatment//framework_workbook

• Treatnet Evaluation of Substance Use Treatment Programmes

See Topic 3: Programme Evaluation Methods, Sample Programme Visual at the
following link:

http://www.uclaisap.org/InternationalProjects/html/unodc/UN%20September%202
007/Volume%20D/training-package-volD.html

118

Appendix III: Chapter References and Further Reading

Introduction and Overview:

British Hypertension Society. (2001). Quoted from ZaeFQ Das Leitlinien-manual von AWMF
und ÄZQ. Systematische Evidenz-Recherche. See, also,
http://www.bmj.com/cgi/content/full/328/7440/634/DC1, 9.9. 2007

Chapter I:

Betty Ford Institute Consensus Panel (2007). What is recovery? A working definition from
the Betty Ford Institute. Journal of Substance Abuse Treatment 33, 221-228

Boyle MG, White WL, Corrigan PW, Loveland DL. Behavioral Health Recovery Management:
A Statement of Principles, available at
http://www.bhrm.org/papers/principles/BHRMprinciples.htm, accessed 16.05.2008

Bradstreet, S. (2004). Elements of Recovery: International Learning and the Scottish
Context. SNN Discussion Paper Series: Paper 1, Scottish Recovery Network

Cloud, W. and Granfield, R. (2001) Natural recovery from substance dependency: Lessons
for treatment providers. Journal of Social Work Practice in the Addictions, 1(1).

Cloud, W. and Granfield, R. (2002). A life course perspective on exiting addiction: The
relevance of recovery capital in treatment. Presented at the Kettil Brunn Society for
Social and Epidemiological Research on Alcohol. Stockholm, October.
http://www.nad.fi/pdf/44/William%20Cloud

Dennis. M.L., Scott, C.K., and Funk, R. (2003). An experimental evaluation of recovery
management checkups (RMC) for people with chronic substance use disorders.
Evaluation and Program Planning, 26(3), 339–352.

Department for International Development (DFID). Sustainable livelihoods guidance sheets.
Overview. http://www.livelihoods.org/info/guidance_sheets_pdfs/section1 ,
accessed 16.05.2008

Food and Agricultural Organization of the United Nations (FAO)
http://www.fao.org/sd/pe4_en.htm, accessed 05.06.2008

Godley, M.D., Godley, S.H., Dennis, M.L., et al. (2002). Preliminary outcomes from the
assertive continuing care experiment for adolescents discharged from residential
treatment. Journal of Substance Abuse Treatment, 23(1), 21–32.

Granfield, R. and Cloud, W. (2001) Social context and “natural recovery”: The role of social
capital in the resolution of drug-associated problems. Substance Use and Misuse,
36(11), 1543–1570.

Jacobson, N. and Greenley, D. (2001). What is recovery? A conceptual model and
explication. Psychiatric Services, 52:482–485.

Laudet, A.B. (2007). What does recovery mean to you? Lessons from the recovery
experience for research and practice. Journal for Substance Abuse Treatment, 33,
243-256

McKay, J. R. (2005). Is there a case for extended interventions for alcohol and drug use
disorders? Addiction, 100(11), 1594–1610.

McLellan, A.T. and Wisner. C. (1996) Achieving the public health potential of substance
abuse treatment: implications for patient referral, treatment ‘matching’ and
outcome evaluation”. In Drug Policy and Human Nature, W. Bickel and R. De
Grandpré (Eds.), Philadelphia, PA: Wilkins and Wilkins.

McLellan, A.T., Lewis, D. C., O’Brien, et al. (2000). Drug dependence, a chronic medical
illness: Implications for treatment, insurance, and outcomes evaluation. Journal of

119

the American Medical Association, 284(13), 1689–1695.
McLellan A.T., Chalk M., and Bartlett, J. (2007). Outcomes, performances, and quality:

What’s the difference? Journal of Substance Abuse Treatment, 32(4), 331–340.
White, W. (2002). An addiction recovery glossary: The languages of American
communities of recovery. See http://www.bhrm.org/advocacy/add-rec-glossary .
October 23, 2002.

White, W. (in press) “With a Little Help from my Friends”: The development and
mobilization of community resources for the initiation and maintenance of addiction
recovery. Journal of Substance Abuse Treatment.

White, W. (2007) Addiction Recovery: Its Definition and Conceptual Boundaries. Journal of
Substance Abuse Treatment, 33: 229–241.

White, W. (in press) Recovery: Old Wine, Flavor of the Month or New Organizing
Paradigm? Substance Use and Misuse.

White, W. (2007) An Integrated Model of Recovery-Oriented Behavioral Health Care.
Philadelphia: Department of Behavioral Health, City Philadelphia.

White, W., Boyle, M., and Loveland, D. (2002). Alcoholism/addiction as a chronic disease:
From rhetoric to clinical reality. Alcoholism Treatment Quarterly, 20(3/4), 107–130.

White, W. and Kurtz, E. (2005). The Varieties of Recovery Experience. Chicago, IL: Great
Lakes Addiction Technology Transfer Center.

White, W. and Davidson, L. (2006) Recovery: The Bridge to Integration? Behavioral
Healthcare, 26(11), 22-25.

White, W. and Kurtz, E. (2006). Linking Addiction Treatment and Communities of Recovery:
A Primer for Addiction Counselors and Recovery Coaches. Pittsburgh, PA: Northeast
Addiction Technology Transfer Center.

World Health Organization (1986). Ottawa Charter for Health Promotion.
WHO/HPR/HEP/95.1

Chapter II:

Ashley, O.S., Marsden, M.E., and Brady, T.M. (2003). Effectiveness of substance abuse
treatment programming for women: A review. American Journal of Drug and Alcohol
Abuse, 29, 19–53.

Belenko, S. (2001) Research on drug courts. A Critical review. The National Center on
Addiction and Substance Abuse (CASA) at Columbia University

Blum, T., and Roman, P. (1985). The social transformation of alcoholism intervention:
Comparison of job attitudes and performance of recovered alcoholics and non-
alcoholic alcoholism counselors. Journal of Health and Social Behavior, 26(4), 365–
378.

Boyce-Reid, K. (1995). The challenge for women with a drug-abusing family member: The
Jamaican Perspective. Bulletin on Narcotics, 47(1–2), 23–30.

Braithwaite, J. (1999). Crime, shame and reintegration. In Criminiological Theory: Past to
Present. Los Angeles: CA. Roxbury Publishing Company.

Braithwaite, J. (2001). Restorative justice and a new criminal law of substance abuse.
Youth and Society, 33(2), 227–248.

Brown, S.A. (1993). Recovery patterns in adolescent substance abuse. In J.S. Baer, G.A.,
Marlatt, and J. McMahon (Eds.), Addictive Behavior Across the Life Span: Preventive
Treatment and Policy Issues (pp.161–183). Beverly Hills, CA: Sage Publications.

Brown, S., and Lewis, V. (1999). The Alcoholic Family in Recovery: A Developmental Model.
New York and London: Guilford Press.

Bullock, K.D., Reed, R.J., and Grant, I. (1992). Reduced mortality risk in alcoholics who
achieve long-term abstinence. Journal of the American Medical Association 267(5),
668–672.

120

Carten, A. J. (1996). Mothers in recovery: Rebuilding families in the aftermath of addiction.
Social Work, 4(2), 214–223.

Catalano, R.F., Hawkins, J.D., Wells, E.A., et al. (1991). Evaluation of the effectiveness of
adolescent drug abuse treatment, assessment of risks for relapse, and promising
approaches for relapse prevention. International Journal of the Addictions, 25(9A–
10A), 1085–1140.

Centre for Substance Abuse Treatment (1994). TAP 11: Treatment for Alcohol and Other
Drug Abuse Treatment: Opportunities for Coordination (PHD663)

Chen, X., Burgdorf, K., Dowell, K., et al. (2004). Factors associated with retention of drug-
abusing women in long-term residential treatment. Evaluation and Program Planning,
27, 205–212.

Cho, M. J., Hamh, B. J., Suh, T., et al. (2002). Comorbid mental disorders among the
patients with alcohol abuse and dependence in Korea. Journal of Korean Medical
Science, 17(2), 236–241.

Claus, R.E., Orwin, R.G., Kissin, W. et al. (2007). Does gender-specific substance abuse
treatment for women promote continuity of care? Journal of Substance Abuse
Treatment, 32, 27–39.

Cloud, W. and Granfield, R. (2002). A life course perspective on exiting addiction: The
relevance of recovery capital in treatment. Presented at the Kettil Brunn Society for
Social and Epidemiological Research on Alcohol. Stockholm, October.
http://www.nad.fi/pdf/44/William%20Cloud

Coletti, S. D., Hughes, P. H., Landress, H. J., et al. (1992). PAR Village. Specialized
intervention for cocaine abusing women and their children. Journal of Florida Medical
Association, 79, 701–705.

Connett, G. (1980). Comparison of progress of patients with professional and
paraprofessional counselors in a methadone maintenance program. The International
Journal of the Addictions, 15(4), 585–589.

DeAlba, I., Samet, J.H., and Saitz, R. (2004). Burden of medical illness in drug- and
alcohol-dependent persons without primary care. The American Journal on
Addictions, 13(1), 33–45.

Durlak, J. (1979). Comparative effectiveness of professional and paraprofessional helpers.
Psychological Bulletin, 86, 80–92.

Edwards, G. (1989) As the years go rolling by: Drinking problems in the time dimension.
British Journal of Psychiatry 154:18-26.

Falkin, G.P. and Straus, S.M. (2003). Social supporters and drug use enablers: A dilemma
for women in recovery. Addictive Behaviors, 28, 141–155.

Fleming, M. F., Barry, K. L., Manwell, L. B., et al. (1997). Brief physician advice for problem
alcohol drinkers: A randomized controlled trial in community-based primary care
practices, Journal of the American Medical Association, 277(13), 1039–1045.

Godley, M.D., Kahn, J.H., Dennis, M.L., et al. (2005). The stability and impact of
environmental factors on substance use and problems after adolescent outpatient
treatment for cannabis use or dependence. Psychology of Addictive Behaviors, 19(1),
62–70.

Graham, A.V., Graham, N.R., Sowell, A., et al. (1997). Miracle Village: A recovery
community for addicted women and their children in public housing. Journal of
Substance Abuse Treatment, 14(1), 275–284.

Granfield, R. and Cloud, W. (2001). Social context and “natural recovery”: The role of social
capital in the resolution of drug-associated problems. Substance Use and Misuse,
36(11), 1543–1570.

Greenfield, S.F., Brooks, A.J., Gordon, S.M., et al. (2007). Substance abuse treatment
entry, retention, and outcome in women: A review of the literature. Drug and Alcohol
Dependence, 86, 1–21.

121

Gregoire, T.K., and Snively, C.A. (2001). The relationship of social support and economic
self-sufficiency to substance abuse outcomes in a long-term recovery program for
women. Journal of Drug Education, 31(3), 221–237.

Grella, C.E. and Greenwell, L. (2004). Substance abuse treatment for women: Changes in
settings where women received treatment and types of services provided, 1987–
1998. Journal of Behavioral Health Services and Research, 31.

Hattie, J.A., Sharpley, C.F., and Rogers, H.J. (1984). Comparative effectiveness of
professional and paraprofessional helpers. Psychological Bulletin, 95(3), 534–541.

Henkel, D, Dornbusch P, Zemlin U (2005). Praediktoren der Alkoholrueckfaelligkeit bei
Arbeitslosen 6 Monate nach Behandlung: Empirische Ergebnisse und
Schlussfolgerungen fuer die Suchtrehabilitation. Suchtrehabilitation, 6(4), 165-175

Hingson, R., Mangione, T., Meyers, A., et al. (1982). Seeking help for drinking problems: A
study in the Boston metropolitan area. Journal of Studies on Alcohol, 43(3), 273–
288.

Hodgins, D. C., el-Guebaly, N., and Addington, J. (1997). Treatment of substance abusers:
Single or mixed gender programs? Addiction, 92, 805–812.

Hser, Y., Polinsky, M.L., Maglione, M.,et al. (1999). Matching clients’ needs with drug
treatment services. Journal of Substance Abuse Treatment, 16(4), 299–305.

Hughes, P.H., Coletti, S.D., Neri, R.L., et al. (1995). Retaining cocaine-abusing women in a
therapeutic community: The effect of a child live-in program. American Journal of
Public Health, 85, 1149–1152.

Humphreys, K., Moos, R.H., and Finney, J.W. (1995). Two pathways out of drinking
problems without professional treatment. Addictive Behaviors, 20(4), 427–441.

Isaacson, E.B. (1991). Chemical addiction: Individuals and family systems. Journal of
Chemical Dependency Treatment, 4(1), 7–27.

Jason, L., Davis, M., Ferrari, J., et al. (2001). Oxford House: A review of research and
implications for substance abuse recovery and community research. Journal of Drug
Education 31(1), 1–27.

Jason, L.A., Olson, B.D., Ferrari, J.R., et al. (2006). Communal housing settings enhance
substance abuse recovery. American Journal of Public Health, 96, 1727–1729.

Kaskutas, L.A., Ammon, L.N., and Weisner, C. (2004). A naturalistic analysis comparing
outcomes of substance abuse treatment programs with different philosophies: Social
and clinical model perspectives, International Journal of Self Help and Self Care, 2,
111–133.

Kessler R.C., Nelson, C.B., McGonagle, K.A., et al. (1996). The epidemiology of co-occurring
addictive and mental disorders: Implications for prevention and service utilization.
American Journal of Orthopsychiatry 66(1), 17–31.

King, M.P. & Tucker, J.A. (1998). Natural resolution of alcohol problems without treatment:
Environmental contexts surrounding the initiation and maintenance of stable
abstinence or moderation drinking. Addictive Behaviors, 23(4), 537-541.

Koerkel J, Soyka M, Bottlender M, Spanagel (2005). For and against: controlled drinking as
useful and necessary treatment alternative. Psychiatr Prax, 32 (7), 324-326

Krausz, M., et al. (1998). Comorbidity of opiate dependence and mental disorders. Addictive
Behaviors 23, 767–783.

Leaf, P.J., Thompson, K.S., Lam, J.A., et al. (1993). Partnerships in recovery: Shelter-based
services for homeless cocaine abusers. New Haven. Alcoholism Treatment Quarterly,
10(3-4), 77–90.

Lincoln A., Liebschutz J.M., Chernoff, M. et al. (2006). Brief screening for co-occuring
disorders among women entering substance abuse treatment. Substance Abuse
Treatments, Prevention and Policy, 1(26).

Lipton, D. (1995). The Effectiveness of Treatment for Drug Abusers Under Criminal Justice
Supervision. NIJ Research Report.

122

Magura, S. (2003). The role of work in substance dependency treatment: A preliminary
overview. Substance Use and Misuse, 38(11-13), 1865–1876.

Magura, S., Staines, G.L., Blankertz, L., et al. (2004). The effectiveness of vocational
services for substance users in treatment. Substance Use and Misuse, 39(13 and
14), 2165–2213.

Mangrum, L.F., Spence, R.T., and Lopez, M. (2006). Integrated versus parallel treatment of
co-occurring psychiatric and substance use disorders. Journal of Substance Abuse
Treatment, 30(1), 79–84.

Marsden, J., Gossop, M., Stewart, D., (2000). Psychiatric symptoms among clients seeking
treatment for drug dependence. British Journal of Psychiatry,174, 185–209.

Marsh J, D’Aunno T, Smith B. “Increasing Access and Providing Social Services to Improve
Drug Abuse Treatment for Women with Children” Addiction. 2000;95(8):1237–47.

McAweeney, M.J., Zucker, R.A., Fitzgerald, H.E., et al. (2005). Individual and partner
predictors of recovery from alcohol use disorder over a nine-year interval: Findings
from a community sample of married men. Journal of Studies on Alcohol, 66(2),
220–228.

McLellan, A. T., Luborsky, L., Woody, G. E., et al. (1983). Predicting response to alcohol and
drug abuse treatments. Role of psychiatric severity. Archives of General Psychiatry,
40(6), 620–625.

McLellan, A.T., Arndt, I.O., Metzger, D.S., et al. (1993). The effects of psychosocial services
in substance abuse treatment. The Journal of the American Medical Association,
269(15) 1953–1959.

McLellan, A.T., Alterman, A.I., Metzger, D.S., et al. (1994). Similarity of outcome predictors
across opiate, cocaine, and alcohol treatments: Role of treatment services. Journal of
Consulting and Clinical Psychology, 62(6), 1141–1158.

McLellan, A.T., Grissom, G.R., Zanis, D., et al. (1997). Problem-service “matching” in
addiction treatment: A perspective study in 4 programs. Archives of General
Psychiatry, 54(8), 730–735.

McLellan, A.T., Hagan, T.A., Levine, M., et al. (1998). Supplemental social services improve
outcomes in public addiction treatment. Addiction, 93(10), 1489–1499.

McLellan, A.T., Lewis, D.C., O’Brien, C.P., et al. (2000). Drug dependence, a chronic medical
illness: Implications for treatment, insurance, and outcomes evaluation. Journal of
the American Medical Association, 284(13), 1689–1695.

Miller, W.R. (1983). Motivational interviewing with problem drinkers. Behavioural
Psychotherapy, 11, 147-172

Minkoff, K. (1989). An integrated treatment model for dual diagnosis of psychosis and
addiction. Hospital and Community Psychiatry, 40(10), 1031–1036.

Morrissey, J.P., Ellis, A.R., Gatz, M., et al, (2005). Outcomes for women with co-occurring
disorders and trauma: Program and person-level characteristics. Journal of
Substance Abuse Treatment, 28, 121–133.

Muser, K.T., Noordsy, D.L., Drake, R.E., et al. (2003). Research on integrated dual
diagnosis treatment. In D.H. Barlow (Ed.), Integrated Treatment for Dual Disorders:
A Guide to Effective Practice (pp. 301–305). New York: Guilford Press.

Nemes, S., Libretto, S., Skinstad, A.H., et al. (2005). Promising practices in drug treatment:
Findings from Europe. Journal of Teaching in the Addictions, 4(1), 89–109.

O’Brien, C., and McLellan, T. (1996). Myths about the treatment of addiction. Lancet, 347,
237–240.

Office of Justice Programs. (1997). Defining Drug Courts: The Key Components,
Washington, DC: Office of Justice Programs, Drug Courts Program Office.

Rache-Beisel, J., Scott, J., and Dixon, L. (1999). Co-occurring severe mental illness and
substance use disorders: A review of recent research. Psychiatric Services, 50(11),
1427–1434.

123

Regier, D., Farmer, M., Rae, D., et al. (1990). Comorbidity of mental disorders with alcohol
and other drug abuse. Journal of the American Medical Association. 264(19), 2511–
2518.

Reif, S., Horgan, C.M., Ritter, G.A., et al. (2004). The impact of employment counseling on
substance user treatment participation and outcomes. Substance Use and Misuse,
39(13 & 14), 2391–2004.

Riessman, F. (1990). Restructuring help: A human service paradigm for the 1990s.
American Journal of Community Psychiatry, 18(2), 221–230.

Risberg, R., and Funk, R.R. (2000). Evaluating the perceived helpfulness of a family night
program for adolescent substance abusers. Journal of Child and Adolescent
Substance Abuse, 10(1), 51–66.

Room, J. (1998). Work and identity in substance abuse recovery. Journal of Substance
Abuse Treatment, 15(1), 65–74.

Rosen C.S., Ouimette P.C., Sheikh, J.I., et al. (2002). Physical and sexual abuse history and
addiction treatment outcomes. Journal of Studies on Alcohol, 63, 683–687.

Samet, J. H., Friedmann, P., and Saitz, R. (2001). Benefits of linking primary medical care
and substance abuse services: Patient, provider and societal perspectives. Archives
of Internal Medicine, 161(1), 85–91.

Samet, J. H., Larson, M. J., Horton, N. J., et al. (2003). Linking alcohol and drug-dependent
adults to primary medical care: A randomized controlled trial of a multi-disciplinary
health intervention in a detoxification unit. Addiction, 98(4), 509–516.

Saunders, B., Bailey, S., Phillips, M., et al. (1993). Women with alcohol problems: Do they
relapse for reasons different to their male counterparts? Addiction, 88, 1413–1422.

Siegal, H., Rapp, R. C., Li, L., et al. (1997). The role of class management in retaining
clients in substance abuse treatment: An exploratory analysis. Journal of Drug
Issues, 27(4), 821–831.

Simmons, J. (2006). The interplay between interpersonal dynamics, treatment barriers, and
larger social forces: An exploratory study of drug-using couples in Hartford, CT.
Substance Abuse Treatment, Prevention, and Policy, 1(12).

Spielmann, S. (1994). The family in Thailand and drug demand reduction: Problems of
urban Thai society in transition. Bulletin on Narcotics, 46(1), 45–66.

Stark, M. (1992). Dropping out of substance abuse treatment: A clinically oriented review.
Clinical Psychology Review, 12, 93–116.

Tsemberis, S., Gulcur, L., and Nakae, M. (2004). Housing first, consumer choice, and harm
reduction for homeless individuals with a dual diagnosis. American Journal of Public
Health, 94(4), 651–656.

United Nations Office on Drugs and Crime (UNODC). (2008). Discussion paper on Principles
of Drug Dependence Treatment. New York, NY: United Nations Publications.

VanDeMark, N.R., (2007). Policy on reintegration of women with histories of substance
abuse: A mixed methods study of predictors of relapse and facilitators of recovery.
Substance Abuse Treatment, Prevention and Policy, 2(28).

Weisner, C., Mertens, J., Pathasarathy, S., et al. (2002). Integrating primary medical care
with addiction treatment: A randomized controlled trial. Journal of the American
Medical Association, 286(14), 1715–1723.

White, W. (1998). Slaying the dragon: The history of addiction treatment and recovery in
America. Bloomington, IL: Chestnut Health Systems.

White, W. (2001). Recovery university: The campus as a recovering community. Student
Assistance Journal, 13(2), 24–26.

White, W. (2004b). The history and future of peer-based addiction recovery support
services. Prepared for the SAMHSA Consumer and Family Direction Initiative 2004
Summit, March 22-23, Washington, DC. Retrieved on September 19, 2005 from
http://www.facesandvoicesofrecovery.org/pdf/peer-based_recovery

124

White, W., and Nicolaus, M. (2005). Styles of secular recovery. Counselor, 6(4), 58–61.
White, W., and Whiters, D. (2005). Faith-based recovery: Its historical roots. Counselor,

6(5), 58–62.
White, W. and Finch, A. (2006). The recovery school movement: Its history and future.

Counselor, 7(2), 54–58.
White, W. (in press) The culture of recovery in America: Recent developments and their

significance. Counselor.
Wittman, F.D. (1993). Affordable housing for people with alcohol and other drug problems.

Contemporary Drug Problems, 20(3), 541–609.

Chapter III:

United Nations Office on Drugs and Crime (UNODC). (2008). “Reducing the adverse health
and social consequences of drug abuse: A comprehensive approach.” See:
http://www.unodc.org/unodc/en/frontpage/reducing-the-harm-of-drugs.html)

Winkelman, M. (2003). Complementary Therapy for Addiction: Drumming Out Drugs.
American Journal of Public Health. 93(4), 647–651.

Chapter V:

Braithwaite, J. (1999). Crime, shame and reintegration. In Criminiological Theory: Past to

Present. Los Angeles: CA. Roxbury Publishing Company.
Braithwaite, J. (2001). Restorative justice and a new criminal law of substance abuse.

Youth and Society, 33(2), 227–248.

Effectiveness of Different Models
of Case Management for

Substance-Abusing Populations

Wouter Vanderplasschen, Ph.D.*; Judith Wolf, Ph.D.**;
Richard C. Rapp, M.S.W.*** & Eric Broekaert, Ph.D.****

Abstract—Case management has been implemented in substance abuse treatment to improve (cost-)
efTectiveness, but controversy exists about its potential to realize this objective. A systematic and
comprehensive review of peer-reviewed articles (n = 48) published between 1993 and 2003 is presented,
focusing on the effects of different models of case management among various substance-abusing
populations. Results show that several studies have reported positive effects, but only some randomized
and controlled trials have demonstrated the effectiveness of case management compared with other
interventions. Lx>ngitudinal effects of this intervention remain unclear. Although no compelling evidence
was found for the effectiveness of case management, some evidence is available about the (differential)
effectiveness of intensive case management and assertive community treatment for homeless and
dually-diagnosed substance abusers. Strengths-based and generalist case management have proven to
be relatively effective for substance abusers in general. Most positive effects concern reduced use of
inpatient services and increased utilization of community-based services, prolonged treatment retention,
improved quality of life, and high client satisfaction. Outcomes concerning drug use and psychosocial
functioning are less consistent, but seem to be mediated by retention in treatment and case management.
Further research is required to leam more about the extent of the effects of this intervention, how long
these are sustained and what specific elements cause particular outcomes.

Keywords—case management, effectiveness, review, substance abuse, treatment

Despite several reports of positive outcomes (Sindelar
et al. 2004; Gossop et al. 2003; Simpson et al. 1999), some
observations raise questions concerning the effectiveness

‘Research and Teaching Assistant, Ghent University, Department of
Orthopedagogics, Gent, Belgium.

••Senior Researcher, Trimbos Institute, PO Box 725, 3500 AS
Utrecht, the Netherlands; Professor in Public Mental Health, University
Medical Center St-Radboud, Nijmegen, the Netherlands.

•••Assistant Professor, Wright State University, School of Medicine,
Center for Interventions, Treatment and Addictions Research (CITAR),
Dayton, Ohio, United States.

••••Professor in Orthopedagogy, Ghent University, Department of
Orthopedagogics, Gent, Belgium.

Please address correspondence and reprint requests to Wouter
Vanderplasschen, Ghent University, Department of Orthopedagogics, H.
DunanUaan 2, B-9000 Gent, Belgium. Tel. 32-9-264 63 64, Fax. 32-9-264
64 91: Email: Wouter.Vanderplasschen@UGenLbe

Journal of Psychoactive Drugs 81

of substance abuse treatment, such as the limited acces-
sibility of treatment agencies (Brindis & Theidon 1997),
relatively high dropout and low completion rates (Sindelar
& Fiellin 2001), frequent and multiple service utilization
(Thomquist et al. 2002; Cox et al. 1998), and long treatment
careers (Hser et al. 1997). Due to the partial and limited
successes of substance abuse treatment, this field is charac-
terized by a constant search for new interventions that yield
better outcomes and decreased costs (Saleh et al. 2002).
Several strategies have been developed to increase access
and participation and to reduce attrition from treatment,
e.g. motivational interviewing, low threshold programs,
client-treatment matching, and contingency management
(Broekaert & Vanderplasschen 2003; Griffith et al. 2000;

Volume 39(1). March 2007

Vanderplasschen et al. Models of Case Management

Miller 1996). Also, case management was implemented to
improve (cost-) effectiveness of substance abuse treatment
(McLellan etal. 1999; SAMHSA 1998; Brindis & Theidon
1997; Mejta et al. 1997) after it had been successfully ap-
plied among persons with psychiatric disorders.

The first implementation of case management for
substance-abusing populations goes back to the beginning
of the 1980s and was based on the recognition that these
persons often have significant problems in addition to
their substance abuse (Vanderplasschen et al. 2004). This
intervention is regarded as an important supplement to
traditional substance abuse agencies, since it provides an
array of wrap-around services that are^usually not part of
standard treatment (SAMHSA 1998). Case management is
generally described as a coordinated and integrated approach
to service delivery, intended to provide ongoing supportive
care and to help people access the resources they need for
living and functioning in the community (Hall et al. 2002;
Birchmore-Timney & Graham 1989).

Four models of case management are usually dis-
tinguished for working with substance abusers: the
brokerage/generalist model, assertive community treat-
ment/intensive case management, the clinical/rehabilitation
model, and strengths-based case management (Vanderplass-
chen et al. 2004; SAMHSA 1998; Ridgely & Willenbring
1992). Although these models apply the same core functions
(assessment, planning, linking, monitoring, and advocacy),
they can be distinguished based on, among other character-
istics, the degree of service provision, client participation,
and case manager involvement (cf. Table 1)

The brokerage model is a very brief approach to case
management in which case workers attempt to help clients
identify their needs and broker ancillary or supportive ser-
vices, all in one or two contacts (SAMHSA 1998; Stahler
et al. 1995). Generalist or standard models utilize the
commonly accepted functions of case management and
are characterized by a closer involvement between case
manager and client (Woodside & McClam 2002). Assertive
community treatment assumes a comprehensive role for a
team of case managers by providing assertive outreach and
direct counseling services, including skills-building, family
consultations and crisis intervention (Stein & Test 1980).
Similarly, intensive case management applies the same prin-
ciples, usually with a smaller caseload and without a team
approach. Clinical or rehabilitation approaches combine
resources acquisition (case management) and clinical or
rehabilitation activities, which might include psychotherapy
for clients and their families or teaching of specific skills
(Kanter 1989). Finally, strengths-based case management
focuses on clients’ strengths, self-direction, and the use of
informal help networks (as opposed to agency resources)
(Siegal et al. 1995). It further stresses the primacy of the
client-case manager relationship and applies an active form
of outreach.

EVALUATION OF ITS EFFECTIVENESS

One of the first studies of case management showed
that it could reduce attrition and improve both psychosocial
and drug and alcohol outcomes, especially among the most
problematic clients (Lightfoot et al. 1982). Willenbring and
his colleagues (1991) later demonstrated the effectiveness of
case management as it helped keep public inebriates engaged
in treatment, stabilize their situation, improve access to
service providers, reduce clinical deterioration, and provide
continuity of care. On the other hand, Pearlman (1984) found
case management had no effect on reducing the dropout rate
among clients entering treatment, but observed a substantial
increase in the proportion of persons entering treatment after
intake. Other authors (Falck, Siegal & Carlson 1992; Lidz et
al. 1992) have reported few or no effects of this intervention,
when compared with non case-managed control groups.

As these early studies illustrate, controversy exists
about the effectiveness of this intervention, resulting in a
lack of evidence about which model should be applied for
what population (Vanderplasschen et al. 2004; Sorensen et
al. 2003). Moreover, most publications refer only selectively
to available studies, which may result in the underreporting
of particular outcomes. Therefore, we made a systematic
and comprehensive narrative review of available research,
focusing on the effectiveness of different models of case
management for various substance-abusing populations,
such as mothers, dually-diagnosed persons, chronic public
inebriates, HIV-infected individuals, offenders, and home-
less persons.

The objectives of this intervention can be established
on the client level as well as on the system level and may
include ameliorating client outcomes, service utilization,
clients’ satisfaction, and quality of life, and improving ac-
cessibility, accountability, coordination and continuity of
care, and cost containment (SAMHSA 1998; Willenbring
1996). We assessed the extent to which (models oO case
management help achieve the postulated goals.

METHODS

We restricted our review to articles published in peer-
reviewed journals between 1993 and 2003. Peer review
was postulated as a minimal guarantee for the quality of the
selected studies and 1993 seemed an appropriate starting
date, since no evaluation studies were published before that
date in these types of journals (Mejta et al. 1997). In order
to be included, a study had to evaluate at least one model
of case management, focus on substance abusers (possibly
in combination with another co-occurring, but not primary,
psychiatric disorder), and report at least one outcome vari-
able. While controlled trials are generally regarded as the
strongest form of evidence of treatment efficacy (Miller &
Wilboume 2002; Ziguras & Stuart 2000), we chose not to

Journal of Psychoactive Drugs 82 Volume 39 (1), March 2007

Vanderplasschen et al.
Models of Case Management

Characteristics

Discriminating
characteristic

Outreaching

Importance of client-
case manager relation

Coordination or
service provision

Service provision at home

Case worker’s or
team responsibility

Multidisciplinary team

Growth or stabilization
stabilization of clients

Paternalism or
paternalism

Empowerment

Average Caseload

TABLE 1
Main Characteristics of Distinguished Models of Case

Brokerage and
Generalist
Case Management

Coordination

No

Somewhat
important

Coordination, little
or no service provision

No

Case worker

No

Rather stabilization

Rather empowerment

35
•Vanderplasschen & Wolf 2005.

Models
Assertive Community
IVeatment and Intensive
Case Management

Comprehensive
approach

Yes

Important

Service provision

Yes

Team

Yes

Growth

Paternalism

15

Management*

Strengths-Based
Case Management

Stress on strengths
and empowerment

Yes
Important

Service provision
and coordination

Yes
Case worker
No
Growth
Empowerment
15

Clinical
Case
Management

Case manager
as role-model
and therapist

Yes

Very important

Service provision
and coordination
Yes
Case worker
No

Rather

Rather

10

restrict our review to studies that include a comparison con-
dition and use a procedure to yield equivalent groups before
treatment (randomization), since the number of randomized
and controlled studies concerning case management for
substance abusers is still relatively small (Vanderplasschen
et al. 2004). Moreover, this type of study is nor the sole
nor the most ideal design to evaluate the effectiveness of
psychosocial interventions (Koski-Jannes 2005).

We used the terms “case management”, “substance
abuse/drug abuse/addiction” and “evaluation/outcomes/ef-
fects/effectiveness” for computer keyword searches in the
following comprehensive, but partly overlapping databases:
(Social) Sciences Databases of the Institute of Scientific
Information, Medline, Psyclnfo, and PubMed. Further, we
made hand searches of the cited references from selected
articles. After eliminating double counts, 87 articles were
identified that contained all three search criteria. Based on an
initial analysis of the abstract and/or full text of these articles,
it appeared that 38 articles were not eligible for this review
because: some did not concern outcome studies, but rather

an evaluation of implementation issues (n =12); the primary
focus was people with severe mental illness (n = 11); case
management was part of a comprehensive intervention and
the authors did not report on the effects of this intervention
separately (n = 7); no outcome measure was included (n =
5); or they were review articles and the original article was
already included in our review (n = 3).

A group of American and European experts examined
the preliminary list of references and made suggestions for
outcome studies that had been missed. One study was added
that is frequently cited in peer-reviewed articles, but was
only published as aresearch report (Rhodes & Gross 1997).
The paper or electronic versions of four selected articles
could not be accessed, even after contacting the principal
author, and were thus not included in this study. Finally, we
selected 46 articles that will be further analyzed in this article.

Peer-reviewed journals as a data source may induce
a publication bias since these journals are usually ed-
ited in English (Miller & Wilboume 2002). Consequently,
evaluation studies by non-English-speaking authors may

Journal of Psychoactive Drugs 83 Volume39(l), March 2007

Vanderplasschen et al. Models of Case Management

TABLE 2
Overview of Studies That Reported Effects of Intensive Case Management and

Assertive Community Treatment Among Substance Abusing Populations (N = 24)

Model of Case g
Management Population

Intensive case

Homeless persons

management
(ICM)

Homeless persons

Homeless males

Homeless chronic
public inebriates

Chronic inebriates

Dtially diagnosed
persons

Dually diagnosed
persons

Dually diagnosed
homeless persons

Drug-involved
arrestees

Dually diagnosed
persons involved
in the criminal
justice system

Adolescents in
residential treat-
ment

Study Design +
Intervention

Partially randomized
and controlled trial
(n = 930)
ICM compared with
standard care

Randomized and con-
trolled trial (n=323)
Standard treatment
compared with condition
with additional ICM

Randomized and con-
trolled trial (n = 722)
ICM compared with
two conditions of
standard care

Randomized and con-
trolled trial (n = 193)
ICM compared with
standard treatment

Retrospective study
(n = 92)
Comparison of two
programs of standard
care and ICM

Uncontrolled pre-post
test (n = 84)

Partially randomized
and controlled trial
(n = 143)
ICM compared with
two other interven-
tions

Randomized and con-
trolled trial (n = 18)
ICM compared with
standard care

Randomized and con-
tidled trial (n=l’«X))
ICM compared with
two less intensive
control conditions

Uncontrolled pre-post
test (n = 54)

Randomized and con-
trolled trial (n = 114)
Standard treatment
compared with condi-
tion with additional
ICM

Authors

Orwin et al.
1994

Braucht et al.
1995

Stahler et al.
1995

Cox et al.
1998

Thomquist et
al.2002

Durell et al.
1993

Jerrell et al.
1994
Ridgely &
JeiTell 1996
Jerrell &
Ridgely 1999

Witbeck et al.
2000

Rhodes &
Gross 1997

Godley et al.
2000

Godley et al.
2002

Main Effects Reported

ICM more effective for improving housing (S) +
substance abuse and employment outcomes (NS)
at one of three sites after nine months.

Small differences between both groups (NS), but
significant improvement within groups concern-
ing substance abuse, housing status, physical and
mental health, employment and quality of life
after 4 and 10 months.

No between-group differences, but significant
improvements concerning cocaine and alcohol
use, employment and housing at six-month
follow-up.

Both groups improved over time, favoring ICM-
group on total income from public sources, nights
spent in own place and days of drinking after 24
months (S).
ICM-group received more substance abuse and
other services (S).

Reduction in median number of detox and medi-
cal visits (S) and of medical and total health care
charges (S) in ICM-group after 24 months.
ICM was most cost-effective.

Modest reduction of substance abuse problems
and changing pattern of service utilization (NS).

All three interventions led to reduced use of
(sub)aa]te services and increased involvement with outpa-
tient and community-based treatment after 24 months (S).
ICM-group had hi^iest satisfaction with quality of life,
most substance abuse symptoms, lowest costs rf mental
health services + lowest buxlen for family (NS).
Robust ICM associated with higher rates cf psychosocial
functioning, less alcdnl and dnlg symptoms and lower
cost of intensive services (S).

Significant decrease of utilization of emergency and
ambulance services.
Substantial cost-savings and enhanced recovery and
psychosocial functioning after 12 months (NS).

Reduced drug use at one site and less recidivism
and increased treatment participation at both sites
after six months (S).
Reduction of injecting and sexual risk behavior not
different between groups (NS).

Reduced legal problems at six-month follow-up
(S) + also other drug-related problems improved
(NS). Generally very satisfied with the program.

No between-group differences concerning length
of stay and treatment completion, but ICM-condi-
tion more likely to initiate and receive continuing
care services (S) and to be abstinent from marijua-
na and less days of alcohol use three months after
discharge (S).

Journal of Psychoactive Drugs 84 Volume 39(1), March 2007

Vanderplasschen et al. Models of Case Management

Model of Case
Management

Assertive
Commnity
Treatment
(ACT)

Target
Population

Pregnant and post-
partum women

Infants of cocaine
abusing women

Persons with
HIV/AIDS

HIV-positive
persons released
from prison

Persons in U-eat-
ment

Multi-impaired
chronic abusers

Persons with mul-
tiple and complex
problems

I ^ o l e e s with
history of drug
use and HIV-risk
behaviour

Dually diagnosed
persons

TABLE 2 (Continued)

Study Design -i- Authors
Intervention
Uncontrolled pre-post Lanehart et al.
test ( n = 152) 19%

Non-randomized,
controlled study
(n = 70)
Comparison of ICM
and routine follow-up

Randomized and con-
trolled trial (n = 190)
ICM compared with
brokerage CM

Uncontrolled pre-post
test (n = 97)

Retrospective study
of comprehensive
program including
ICM (n = 280)

Uncontrolled pre-post
test (n = 1660)

Uncontrolled pre-post
test (n = 24)

Randomized and con-
trolled trial (n = 258)
ACT compared with
standard intervention

Randomized and con-
trolled trial (n = 203)
ACT compared with
standard CM

Kilbride et al.
2000

Sorensen et al.
2003

Rich et al.
2001

Evenson et al.
1998

Oliva et al.
2001

V îndeipiasschen
etal. 2001

Martin &
Scarpitti 1993
Inciardi et al.
1994

Drake et al.
1998
Clark et al.
1998

Main Effects Reported

Significant improvements across all outcome
indicators after six months.
Longer length of stay associated with more
drug-free days (S).

Few between-group differences, except that ICM-
infants had better cognitive outcomes after six
months and better verbal scores after 36 months
(S).

Both groups improved equally over time (NS), ex-
cept more sexual risk behavior in BCM-group (S).
Significant reduction of problem severity after six
months, but no longer after 12 and 18 months.

High rate of participation and retention in the 18-
month program and utilization of related services.
Intervention perceived as beneficial by most
clients.

Positive outcomes across almost all areas affected
by substance abuse after 10 months (S).
High degree of satisfaction with treatment services.
Longer length of stay associated with better out-
comes (NS).

Overall situation of clients improved or was stabi-
lized after 12 months.
Positive outcomes were related to longer retention.
Most clients very satisfied (74.2%) or satisfied
(21.5%) with the intervention.

Reduction of substance use, legal, employment
and family problems after 12 months (S).

Few and modest differences between both groups
after six months (NS).
Length of treatment related to self-report of
weekly drug use (S).

Substantial improvements in both groups over 36
months concerning U’eatment retention, substance
abuse and stable days in community (S).
ACT-group showed greater improvement on some
measures of substance abuse and quality of life (S),
but equivalent outcomes on most other indicators.
No difference in cost-effectiveness over three-
year period when focusing on substance abuse
and quality of life (NS).

be underrepresented in the international peer-reviewed
literature. Despite the increased implementation of case
management in Europe (Vanderplasschen et al. 2004), we
could not find any English-language articles that evaluated
the effectiveness of this intervention for substance abusers
on this continent. We compensate for this possible bias by
including two original research reports that focused on this
issue in Germany and Belgium (Oliva et al. 2001; Vander-
plasschen, Lievens & Broekaert 2(X)1).

Moreover, selection of peer-reviewed published mate-
rials may have resulted in an analysis of studies that have

demonstrated significant outcomes, while insignificant or
even adverse outcomes tend to remain unpublished (Rosen
& Teeson 2001). To partly address this potential bias, we
did not focus exclusively on studies with a rigorous design,
but also included results from descriptive and retrospective
studies. While reporting on the effectiveness of different
models of case management, we will examine the quality
of the research design (type and extent of the study) and the
direction and significance of reported effects, but not the
size of these effects.

Journal of Psychoactive Drugs 85 Volume 39(1), March 2007

Vanderplasschen et al. Models of Case Management

RESULTS

Analysis of the selected articles (n = 48) shows that half
of all studies have evaluated the effectiveness of intensive
case management (n = 20) and assertive community treat-
ment (n = 4) (cf. Table 2). Strengths-based (n = 11) and
generalist case management (n = 10) have been evaluated
to a lesser extent, while relatively few studies have focused
on the effects of clinical (n = 2) and brokerage (n = 1) case
management (cf. Table 3).

We identified several articles (n = 18) that referred to
only six original studies. In total, 36 original studies were
analyzed. Further, some studies have applied brokerage
(n = 2) or generalist case management (n = 2) as a control
condition for evaluating more specialized models of case
management.

Intensive Case Management
The effectiveness of intensive case management (cf.

Table 2) has been tested for assisting diverse substance-
abusing populations, especially homeless and alcohol
dependent persons. Although all studies (n = 5) have shown
significant improvements at time of follow-up (e.g. housing
status, substance abuse, psychical and mental health, quality
of life, employment), only one study clearly showed that
chronic public inebriates benefited more from intensive
case management than from standard care (Cox et al. 1998).
Significantly better outcomes were observed concerning
income from public sources, nights spent in own place,
and days of drinking. It was assumed that these effects
were mediated by the amount of substance abuse and other
services received. Also, Orwin and colleagues (1994) found
some evidence for an effect of intensive case management
on housing status, but only in one of three cities studied
and if it was assumed that persons who dropped out of the
control group deteriorated.

Homeless persons with more severe substance use his-
tories usually showed significantly poorer outcomes (Cox et
al. 1998; Stahler et al. 1995). Between-group effects were
especially small in randomized clinical trials (RCTs) that
compared intensive case management with comprehensive
standard care (cf. Braucht et al. 1995; Stahler et al. 1995).
Based on a retrospective study, Thomquist and colleagues
(2002) proved that intensive case management was more
cost-effective than standard care for chronic inebriates who
frequently utilize emergency services and that it contributed
significantly to more appropriate service utilization and
reduction of health care costs.

Also, persons with severe mental illness and co-occur-
ring substance use disorders can benefit from intensive and
outreach case management (Durell et al. 1993). A comparison
of the (cost-)effectiveness of three interventions— 12-Step
recovery program, intensive case management, and behav-
ioral skills training—over a 24-month period showed an
impressive, though not significant, impact of the latter two

interventions on the use of inpatient services, involvement
with outpatient services, and total health care costs, without
transferring the burden to the family or legal system (Jerreli,
Hu & Ridgely 1994). Robustness of program implementa-
tion was a crucial factor, and robustly implemented case
management led to improved psychosocial functioning,
fewer alcohol and drug symptoms, and lower health care
costs (Jerreli & Ridgely 1999; Ridgely & Jerreli 1996).
Witbeck and colleagues (2000) found very similar results
among a small sample of chronically addicted, mentally ill
homeless individuals who made frequent use of emergency
services.

The effectiveness of intensive case management for
other substance-abusing populations has only been assessed
in a limited number of studies. Some evidence is available
that this intervention is more effective than less intensive
referral contacts for reducing recidivism and increasing treat-
ment participation among drug-involved arrestees (Rhodes
& Gross 1997). Godley and colleagues (2000) found a sig-
nificant reduction of legal problems and improved outcomes
conceming other drug-related problems and quality of life
after six months among dually-diagnosed persons involved
in the criminal justice system. Overall, clients were (very)
satisfied with the services received.

The application of intensive case management among
HIV-infected individuals has generated rather modest re-
sults, but improved access to (medical) services and retention
in the program (Rich et al. 2001). Comparison of the effec-
tiveness of intensive and brokerage case management did
not reveal many between-group differences and the initial
(after six months) significant reduction of problem severity
within both groups had disappeared after 12 and 18 months
(Sorensen et al. 2003).

More favorable outcomes have been found for adoles-
cent substance abusers, since program access, participation
and retention and marijuana and alcohol use at three-month
follow-up were significantly better among case managed
adolescents (Godley et al. 2002). On the other hand, inten-
sive family case management for infants of cocaine-abusing
women only generated better outcomes on some aspects
of their cognitive and verbal development, but case man-
aged and non-case managed parents were as likely to lose
custody of their children (Kilbride et al. 2000). Impressive
positive results were observed at the time the intervention
was stopped in an uncontrolled study with pregnant and post-
partum women (Lanehart et al. 1996) and in a retrospective
study of a mixed population of substance abusers (Evenson
et al. 1998). Clients’ situations improved across most out-
come indicators (e.g. global level of functioning, substance
use, employment, legal difficulties, parenting, baby’s birth
weight, interpersonal relations and social agency support).
Better outcomes were associated with longer lengths of
stay.

The implementation of intensive case management
in Europe has mainly focused on multi-impaired chronic

Journal of Psychoactive Drugs 86 Volume 39 (1), March 2007

Vanderplasschen et al. Models of Case Management

addicts and contributed to better monitoring and ameliora-
tion or stabilization of most clients’ situations (Oliva et al.
2001; Vanderplasschen, Lievens & Broekaert 2001). Again,
positive outcomes were related to longer retention in case
management and the vast majority of clients appeared to be
(very) satisfied with this type of support.

Assertive Community Treatment
More evidence is available about the effectiveness of

assertive community treatment, since this intervention has
only been evaluated based on RCTs. Its potential for reduc-
ing recidivism, sexual risk behavior and relapse among
parolees with drug use histories differed little from that
of conventional parole (Martin & Scarpitti 1993). Given
the modest effects of assertive community treatment, it
was concluded that this intervention was of limited value
for clients who were not merely unable to access services
(Inciardi, Martin, & Scarpitti 1994).

Application of assertive community treatment among
patients with dual disorders has been more successful, al-
though few differences appeared from a comparison of the
effectiveness of assertive community treatment and general-
ist case management over a three-year period (Drake et al.
1998). The ACT group improved more on some measures of
substance abuse and quality of life, but overall both groups
ameliorated equally over time on several outcome measures.
Also, cost-effectiveness was equal, except that standard case
management was more efficient during the first two years
and assertive community treatment during the third year
(Clark et al. 1998).

Strengths-Based Case Management
Although the application of strengths-based case

management is limited to a few projects, some evidence of
effectiveness is available based on two large NIDA-funded
studies in Iowa and Ohio (cf. Table 3).

The Iowa case management study demonstrated a
significant impact of case management inside a treatment
facility on the utilization of medical and substance abuse
services (Vaughan-Sarrazin, Hall & Rick 2000). Few dif-
ferences conceming client outcomes were found, except
better legal outcomes after six months and an improved
employment situation after 12 months in one modality
(inside case management) and reduced drug use at the
three-month and decreased psychological problems at the
three- and 12-month follow-up in another modality (outside
case management). Moreover, these differences, especially
conceming drug use, tended to decline over time (Saleh et
al. 2002; Vaughan-Sarrazin, Hall & Rick 2000). A significant
impact of all three modalities of Iowa case management was
found on family relationships and parental attitudes after six
months, but these effects were not apparent after three and
12 months (Sarrazin, Huber & Hall 2001). Face-to-face,
instead of telecommunication, case management led to bet-
ter outcomes (Saleh et al. 2002), although the latter group

received significantly higher dosages (amount, frequency,
breadth, duration) of case management (Huber et al. 2003).
Telecommunication case management appeared to be most
suited for persons with higher premorbid cognitive abilities
(Block, Bates & Hall 2003).

In the Ohio study, Siegal and colleagues found evi-
dence for an effect of strengths-based case management
on employment functioning after six months (Siegal et
al. 1996) and treatment retention, which was related to
reduced drug use and improved legal outcomes (Siegal, Li
& Rapp 2002; Rapp et al. 1998; Siegal et al. 1997). This
intervention further contributed to after-care participation at
12-month follow-up, which was associated with less post-
treatment criminality (Siegal et al. 2002). No direct impact
of strengths-based case management on drug use severity
could be demonstrated, but this effect was mediated by its
role in enhancing treatment participation and retention (Rapp
etal. 1998).

Further support for an effect on the employment situa-
tion appeared from two articles that assessed the application
of strength-based principles to assist amphetamine abus-
ers (Cretzmeyer et al. 2003) and chronically unemployed
methadone clients (Zanis & Coviello 2001), respectively.

Generalist Case Management
Generalist or standard case management has been ap-

plied among similar populations as more specialized models.
Some evidence has been found for an effect on homeless sub-
stance abusers, as standard residential care with additional
case management (compared with standard treatment alone)
led to longer treatment retention and better alcohol, medical,
employment, and housing scores for the first nine months
after admission (Conrad et al. 1998). However, these effects
diminished after 12 months; this result was also observed
by Mercier and Racine (1993) in their study of homeless
substance-abusing women. Differential between-group ef-
fects were not demonstrated in another study (Lapham, Hall
& Skipper 1995), although significant within-group differ-
ences were found conceming days of alcohol use, housing
stability, and employment status, especially among program
graduates.

Similarly, significant effects of generalist case manage-
ment conceming several aspects of psychosocial functioning
were reported for cocaine-dependent mothers (Volpicelli et
al. 2000). Still, women receiving psychosocially enhanced
treatment including psychotherapy showed superior treat-
ment attendance and greater reductions in cocaine use. Since
a significant but fading effect on drug use after delivery was
demonstrated (Eisen et al. 2000), it can be concluded that
case management, particularly the availability of transporta-
tion, facilitates treatment access and retention for pregnant
substance-abusing women (Laken & Ager 1996).

Mejta and colleagues (1997) demonstrated similar find-
ings on treatment access and retention among case managed
intravenous drug users, especially when case managers had

Journal of Psychoactive Drugs 87 Volume 39(1). March 2007

Vanderplasschen et al. Models of Case Management

Overview of Studies That Reported 1

Model of Case
Management

Strengths-based
case manage-
ment (SBCM)

Generalist case
management
(GCM)

TABLE 3
•Iffects of Strengths-Based, Generalist, Brokerage

and Clinical Case Management Among Substance Abusing Populations (N = 24)

Target
Population

Veterans
seeking
treatment

Persons
admitted in
residential
treatment

Chronically
unemployed
MMT-clients

IV drug
users

IV drug
users

Homeless
women

Homeless
alcohol
abusers

Study Design +
Intervention

Randomized and
controlled trial
(n = 632)
Standard treatment
and aftercare com-
pared with
additional SBCM

Randomized and
controlled trial
(n = 662)
Standard treatment
control condition
compared with
three modalities of
SBCM: inside the
facility, in social
agency, telecommu-
nication model

Case study (n = 10)

Randomized and con-
tr[:dledtnal(n=316)
GCM ocxî xued with
slandaid refenal services

Randomized and con-
tidled trial (n=200)
GCM conqaied with
standaid irfenal sovices

Retrospective study
(n = 25)
GCM

Randomized and con-
tioUed trial (n=<469) Standard care and additional GCM compared with two control conditions

Authors

Siegal etal. 1996
Siegal etaL 1997
Siegal, Li & Rapp 2002
Rapp et al. 1998

Vaughan-Sarrazin, Hall
& Rick 2000
Sarrazin, Huber & Hall
2001
Saleh et al. 2002
Block, Bates & Hall
2003
Huber etal. 2003

Cretzmeyer et al. 2003

Zanis & Coviello 2001

Mejta etal. 1997

Levy, Strenski & Amick
1995

Mercier & Racine 1993

Lapham, Hall &
Skipper 1995

Main Effects Reported

SBCM: led to additional improvement con-
ceming employment situation (S).
Positive relation between length of time in
treatment and outcomes (S).
SBCM: additional improvement conceming
drug use and self-help group attendance after
six months (S).
SBCM-clients stayed longer in after-care ser-
vices (S), which was related with better out-
comes conceming post-treatment criminality
and drug use at 12-month follow-up (S).
SBCM had no direct impact on drug use severity.
but indirectly mediated by treatment retentioa

Substanoe abuse improved after 12 months (S), but
no differences between modalities (NS).
SBCM had significant impact on perceptions
of family relations and parental attitudes
after six months (S), but not on [perception of
partner abuse
Inside SBCM: significant impact on utiliza-
tion of medical and substance abuse services
after 12 months.
Telecommunication CM better outcomes for
clients with higher premortid cognitive abilities (S).
Dosage of SBCM differed across modalities
(S), favoring telecommunication CM (greater
breadth and frequency of services).
No different outcomes between methamphet-
amine abusers and clients reporting primary
abuse of other drugs (NS).

Positive effects on employment outcomes at
eight-month follow-up, but discontinuation of
SBCM after six months led to unemployment
in three cases. SBCM regarded as effective
and valuable intervention by participants.

GCM-group: better access to and longer
retention in treatment (S).
GCM: better trealment outcomes, including re-
duced alcohol and dmg use after 36 months (NS).

Dmg use markedly decreased after 36
months among GCM-group (NS) and to a
lesser extent eunong the control group.

GCM led to improved or stabilized living
conditions for most clients after 12 months.
but acquisitions not maintained over time (36
months). Deterioration related with physical
and mental health problems.

Significant within-group (alcohol use, hous-
ing, employment), but no between-group
differences at 10-month follow-up.
Program graduates had more favorable out-
comes than dropouts (S).

Journal of Psychoactive Drugs 88 Volume 39 (1), March 2007

Vanderplasschen et al. Models of Case Management

TABLE 3 (Continued)

Model of Case
Management

l^rget
Population
Homeless
veterans

Pregnant
women

Study Design +
Intervention
Randomized and con-
trolled trial (n = 358)
Standard residential
care compared with
condition with ad-
ditional GCM

Retrospective study
(n = 225)

Authors

Conrad etal. 1998

Laken & Ager 1996

Brokerage case
management
(BCM)

Clinical case
management
(CCM)

Cocaine
dependent
mothers

Pregnant and
post-partum
women

Offenders

Persons
discharged
from treat-
ment

Persons
presenting at
a centralized
intake unit

Persons in
outpatient
treatment

Randomized and con-
troUed trial (n = 84)
GCM compared
with comprehensive
treatment, including
psychotherapy

Quasi-experimental
study (n = 658)
Community-based
programs (including
GCM/day treatment)
compared with stan-
dard care

Retrospective study
(n=259)
GCM in Treat-
ment Altematives
Program

Retrospective study
(n = 21,207)
GCM after discharge
from treatment

Randomized and
controlled trial
(n = 692)
BCM compared with
no case management

Quasi-experimental
study (n = 537)
CCM compared with
standard outpatient
treatment

Volpicelli et al. 2000

Eisen et al. 2000

Van Stelle, Mauser &
Moberg. 1994

Shwartzetal. 1997

Scott et al. 2002

McLellan et al. 1999

Revolving
door clients

Pre-post test design
(n = 53)
Intensive CCM

Okin et al. 2000

Main Effects Reported

Both groups improved over time (S), but
GCM-group had better outcomes conceming
medical, alcohol, employment and housing
status at 24-month follow-up (S); however,
effects were mainly observed in the first year
and diminished during the second year.

GCM helped to overcome barriers to treat-
ment and to promote retention after 18
months (S). GCM, including availability of
transportation, correlated with treatment at-
tendance and retention (S)

Psychosocial functioning and cocaine use
improved among both groups after 12 months
(S), but higher program retention and less
cocaine use in comprehensive treatment
condition (S).

CM-programs had lower prevalence of any
illicit drug use and crack use 30 days after
delivery (S), but these outcomes were not
maintained 6 months after delivery. Out-
comes mediated by amount of dmg abuse
prevention and education.

Rearrest and reconviction rates significantly
higher among noncompleters than among
program completers at 18-month follow-up.
GCM more cost-^ective than incarceration (NS).

CM-dients stayed longer in treatment and
were less likely to be readmitted to detox af-
ter discharge (S). CM-clients followed more
often post-primary treatment (S). Length of
stay correlated with improved outcomes (S).

CM-group was more likely to show up for
treatment and received more referrals to
ancillary services (S), but no differences In
number of services and length of substance
abuse treatment.

Wave 1(12 months after implementation):
within-group improvements conceming substaiKe
use, psychiatric and family problems after six
months (S); but no between-group differences,
^ v e 2 (26 months after implementation): CCM-
group received mere medical (S), alcohol, employ-
ment and legal services (NS) and had significantly
better alcohol, drug, medical, psychiatric -t- employ-
ment status after six mcnths.

Reduction of ED visits and health care costs
+ number of outpatient visits increased 12
months later (S). Reduction of homelessness,
alcohol use and dmg use (S). Increased link-
age to primary care and outpatient services,
reduced utilization of acute and ED services
and reduction in hospital costs (S).

Journal of Psychoactive Drugs 89 Volume 39(1), March 2007

Vanderplasschen et al. Models of Case Management

money to purchase treatment. Based on this and another
study (Levy, Strenski & Amick 1995), a clear but not sig-
nificant between-group effect on alcohol and drug use was
observed favoring the case management condition. A large
retrospective study among substance abusers discharged
from different treatment settings confirmed that case man-
aged clients had significantly better retention, post-primary
treatment participation and rehospitalization rates (Shwartz
etal. 1997).

One Treatment Alternatives Program (TAP) that applied
generalist case management was regarded as an effective
intervention for offenders, since treatment completers were
significantly less likely to be rearrested than treatment
noncompleters (Van Stelle, Mauser & Moberg 1994). This
intervention was more cost-effective than incarceration and
also successful among offenders with extensive criminal
records.

Brokerage Case Management
Since only one study has evaluated the effectiveness

of brokerage case management, little evidence exists that
this intervention contributes to treatment participation and
referral to ancillary services (Scott et al. 2002). On the
other hand, when a brokerage model was used as a controi
condition for more specialized models of case management,
this intervention was not less effective for affecting client
outcomes and service utilization (Sorensen et al. 2003;
Stahler etal. 1995).

Clinical Case Management
Little evidence is available about the effectiveness of

clinical case management, but this intervention has been
associated with an increase in the provision of services and
significant improvements conceming alcohol and drug use,
medical and psychiatric status, and employment functioning
after six months (McLellan et al. 1999). Similar outcomes
were found among frequent users of emergency services,
as they used significantly less emergency and inpatient ser-
vices, had more primary care contacts and showed improved
psychosocial functioning after being monitored by a clinical
case manager (Okin et al. 2000).

DISCUSSION

This narrative review of peer-reviewed articles that
have evaluated the effectiveness of case management does
not show compelling evidence for the effectiveness of this
intervention, although several studies have reported posi-
tive effects conceming client outcomes, service utilization,
treatment access and retention, quality of life, consumers’
satisfaction, and cost savings (Vanderplasschen et al. 2005).
It appears that especially descriptive, retrospective, and
quasi-experimental studies have shown beneficial outcomes,
while studies applying a methodologically stronger design
(randomized and controlled trials) have often failed to prove

the effectiveness of case management compared with other
interventions, particularly over a longer period of time.

Effectiveness of Different Modeis of Case
Management for Specific Populations

Intensive case management has mostly been applied for
severely affected substance-abusing populations, such as
chronic public inebriates and dually-diagnosed individuals.
Although relatively few differences have been observed with
control groups receiving standard or other viable treatment,
significant improvements over time have been consistently
reported concerning various client outcomes (Thomquist et
al. 2002; Cox et al. 1998; Braucht et al. 1995; Stahler et al.
1995). Clear gains among intensively case managed clients
were more appropriate service utilization, reduced health
care costs and high satisfaction with the services received
(Thomquist et al. 2002; Witbeck et al. 2000; Jerrell et al.
1994). However, robustness of program implementation
appeared to be a decisive factor for its effectiveness (Jerrell
& Ridgely 1999), while persons with extensive histories of
homelessness, medical and substance abuse problems had
worse outcomes (Cox et al. 1998; Stahler et al. 1995). These
observations stress the importance of deliberate implementa-
tion of case management programs and their integration in
the existing network of services for adequate matching and
referral (Vanderplasschen et al. 2004).

Also assertive community treatment helped patients
with dual disorders improve over a three-year period, but not
any differently as compared to standard case management.
On the other hand, some evidence is available that the latter
intervention affects treatment retention and client outcomes
among homeless individuals (Conrad et al. 1998; Lapham,
Hall & Skipper 1995). Outcomes from both studies show
that for severely affected populations, case management
efforts should be sustained over long enough periods.

Offenders can benefit from intensive case manage-
ment for reducing legal problems and increasing treatment
participation, but assertive community treatment is only
recommended for persons who are not able to access services
themselves (Inciardi, Martin & Scarpitti 1994). Also, gen-
eralist case management may be a valuable intervention for
this population, although program completion seems a pre-
requisite (Van Stelle, Mauser & Moberg 1994). As in many
other studies, retention in case management appears to be
crucial and can be influenced by elements like the client-case
manager relationship, comprehensiveness and flexibility of
the program, assertive outreach and client-driven goal setting
(Vanderplasschen & Wolf 2005; SAMHSA 1998).

Given the significant drug-related problems and nu-
merous barriers to treatment that HIV-infected individuals
experience, it may not be surprising that the effects of in-
tensive case management are limited to improving access
to medical services and increasing retention in the program
(Rich et al. 2001). Significant changes in clients’ situations
are feasible, but difficult to maintain (Sorenson et al. 2003).

Journal of Psychoactive Drugs 90 Volume 39(1). March 2007

Vanderplasschen et al. Models of Case Management

Intensive case management may fill up an important gap,
as linkage to services and treatment participation are often
problematic among persons with HIV/AIDS (Nebelkopf &
Penagos 2005).

One of the most successful experiments with intensive
case management concerned adolescent substance abusers
(Godley et al. 2002). Given the nature of this intervention
and of adolescents’ problems, this intervention may be an
important Instrument for providing effective continuing care
and monitoring if the promising results can be confirmed at
subsequent follow-up measurements.

Also, substance-abusing pregnant women and mothers
have generally benefited from (intensive) case manage-
ment, both concerning their psychosocial functioning and
children’s development and their treatment access and reten-
tion (Volpicelli et al. 2000; Laken & Ager 1996; Lanehart
et al. 1996). However, no randomized and controlled study
has yet shown its effectiveness compared with other inter-
ventions. Similarly, the implementation of intensive case
management for multi-impaired chronic substance abusers
in Europe has generated significant gains which need to be
confirmed in large-scale experimental studies.

Some evidence is available for the effectiveness of
strengths-based case management, as at least two studies
showed significant effects on service utilization and legal
and employment outcomes for persons seeking treatment
(Saleh et al. 2002; Siegal, Li & Rapp 2002; Zanis & Coviello
2001; Vaughan-Sarrazin, Hall & Rick. 2000; Siegal et al.
1997,19%). Controversy exists as to whether these effects
can be maintained over time (Saleh et al. 2002; Siegal, Li &
Rapp 2002), although treatment retention clearly has a posi-
tive impact on clients’ psychosocial functioning (Rapp et al.
1998). Given its role in addressing denial and resistance, its
appreciation among clients and its potential positive effects
(Brun & Rapp 2001; Zanis & Coviello 2001), it is recom-
mended that this strengths-perspective is applied in other
programs, mainly to enhance treatment participation and
retention among persons with little motivation for change.

Intensive and generalist case management have not
always been directed at specific groups of substance abusers.
Studies of the latter consistently show an impact on treat-
ment access, participation and retention, and relapse and
rehospitalization (Evenson et al. 1998; Mejta et al. 1997;
Shwartz et al. 1997; Levy, Strenski & Amick 1995). These
findings illustrate what may realistically be expected from
the implementation of case management, if this intervention
is robustly implemented and continued during a substantial
period.

Although brokerage models of case management
include a very brief intervention and have been evaluated
negatively among psychiatric patients, available research
shows that this intervention was not always inferior to more
specialized models for reducing drug-related problems and
stimulating service utilization (Sorensen et al. 2003; Stahler
et al. 1995). On the other hand, brokerage case management

seems to affect in particular initial treatment participation
and linking to services and should thus be applied for this
specific purpose, e.g. at centralized intake facilities (Scott
et al. 2002).

Little empirical data are available about the effec-
tiveness of clinical case management, but results from
nonexperimental studies are promising (Okin et al. 2000;
McLellan et al. 1999). A combination of psychotherapy and
resource acquisition can affect substance abusers’ psychoso-
cial functioning and service utilization and appeared to be
more cost effective than standard treatment, particularly for
frequent users of inpatient services or so-called “revolving
door clients” (Sindelar et al. 2004; Okin et al. 2000). Also,
intensive case management has some potential for helping
persons who make disproportionate use of available services
and resources (Witbeck, Hornfeld & Dalack 2000).

What makes Case Management Effective (or not)?
This review showed that many studies have failed to

demonstrate a significant between-group effect favoring the
case management condition, although almost all RCTs have
revealed significant positive effects when compared with
baseline assessments, e.g. concerning substance abuse, hous-
ing, employment, quality of life, psychological functioning,
and service utilization (Witbeck, Hornfeld & Dalack 2000;
Drake et al. 1998; Siegal et al. 1997; Braucht et al. 1995;
Jerrell & Ridgely 1995; Lapham, Hall & Skipper 1995;
Stahler et al. 1995). Without a control condition, authors
may have wrongly assigned a time effect to case manage-
ment, while other factors such as motivation, retention, and
client characteristics may have accounted for these positive
outcomes.

Other authors have suggested “spontaneous remission”
or “regression to the mean” to explain effects, since most
substance abusers start with case management at a very low
level in their functioning and a certain degree of improve-
ment may be part of the natural course of substance abuse
problems (Braucht et al. 1995; Lapham, Hall & Skipper
1995; Stahler et al. 1995). Both hypotheses have been re-
jected based on the observation that persons receiving less
intensive services show far less improvement.

According to Orwin and colleagues (1994), the lack
of evidence for the differential effectiveness of case man-
agement may have more to do with the way it is evaluated
than with the intervention itself. Treatment that has been
compared primarily with other viable treatment—not with
minimal or no treatment—may seem less effective since
the latter studies have usually found (more) significant dif-
ferences (Miller & Wilboume 2002). Generally, models of
case management have been compared with control condi-
tions that include standard treatment, another innovative
intervention or another model of case management, thus
reducing the chance of observing significant differential
effects. Also, other sources of bias may have obscured the
differential effectiveness of this intervention.

Journai of Psychoactive Drugs 91 Volume 3 9 (1), March 2007

Vanderplasscben et aL Models of Case Management

First, bias may occur due to lower attrition rates in the
case management group (Vaughn et al. 2002; Kilbride et
al. 2000; Drake et al. 1998). Due to the nature of the case
management process itself, case managers can track even the
most difficult cases that would normally be lost at follow-up
when receiving standard treatment (Orwin et al. 1994).

Second, partial or incomplete implementation and low
intensity of the intervention due to staffing problems, lack
of training and inexperience of case managers, and staff
turnover may account for limited or no effectiveness (Orwin
et al. 1994). Robustness of implementation can be optimized
by intensive initial training, regular supervision, administra-
tive support, application of protocols and manuals, treatment
planning and a team approach (Jerreli & Ridgely 1999).
Since McLellan and colleagues (1999) could only demon-
strate the effectiveness of a case management program 26
months after initial implementation, they further stressed the
importance of precontracting of services to ascertain their
availability and accessibility. Usually much shorter periods
are adhered to for piloting and fine-tuning new programs,
which may result in a lack of or underestimation of particular
effects (Lapham, Hall & Skipper 1995).

Third, differential effects between groups can hardly
be demonstrated if the comparison group receives more
services than planned or if other programs or the control
condition adopt principles of the innovative intervention
(Drake et al. 1998; Orwin et al. 1994). From an ethical and
practical point of view, it may be unwarranted to keep a
potentially effective intervention from individuals in need
of it (especially high-risk populations), and this might invite
other caregivers to provide similar services (Inciardi, Mar-
tin & Scarpitti 1994). The drift of one intervention toward
another can also happen in the opposite direction, when
experimental conditions begin to resemble the comparison
group as case managers settle into their jobs and lose their
initial enthusiasm (Ridgely & Willenbring 1992).

Finally, despite the fact that results from experimental
studies conceming case management have been biased to
a certain extent, it is unlikely that case management and its
particular models are significantly more effective than other
interventions for substance abusers. Perhaps this should not
be surprising, since this intervention was originally designed
to provide ongoing and supportive care to clients and to link
them with community resources and existing agencies (Rapp
et al. 1998; Birchmore-Timney & Graham 1989). Expect-
ing to also have significant and lasting effects on clients’
functioning has probably been too optimistic an objective.

Limitations ofthe Review
Despite numerous empirical studies that have evaluated

case management, no comprehensive review has yet been
published about the effectiveness of this intervention for
substance abusers. This review may contribute to present-
day knowledge about the effectiveness of this intervention
and to its further implementation, and can be the starting

point for a meta-analysis. However, some shortcomings should
be kept in mind conceming the methodology of this review.

First, this review was based on articles published in
peer-reviewed joumals, which may have caused a publica-
tion bias (cf. supra). Since we found various and inconsistent
effects and several studies that reported insignificant effects,
we assume that our review was not merely affected by such
a bias. It can also be that published articles only contain
the strongest findings of a study, while other insignificant
observations were not reported. Analysis of the original
research reports and data could address this problem, but
this information is usually difficult to access at the expense
of its comprehensiveness and quality.

Second, this review started from four different models
of case management that have been accepted by a consensus
panel of American specialists (SAMHSA 1998). Due to
contextual differences and lack of program fidelity, most of
the practical applications of case management only vaguely
resemble the pure version of each model (Vanderplasschen
et al. 2004; Jerreli, Hu & Ridgely 1994). Articles were
grouped according to the model applied, based on authors’
information about which case management model was
used. If insufficient details were given about the actual
intervention or no specialized model was mentioned, these
interventions may have been incorrectly classified as gen-
eralist case management. Indicators to measure program
fidelity and robustness of different models of case manage-
ment are needed, as well as an accurate description of the
implemented intervention (Godley et al. 2000;Teague, Bond
& Drake 1998).

Finally, contextual differences affect the imple-
mentation—and consequently the evaluation—of case
management to a large extent (SAMHSA 1998). Due to
the differing organization of social welfare and health care
systems in the United States and Europe, it can be questioned
whether the results from these predominantly American
studies can be easily transferred to the European situation
(Wolf, Mensink & Van der Lubbe 2002; Oliva et al. 2001).
Available findings from European studies suggest similar
outcomes, but further evaluation is needed to generalize
these results.

Recommendations for Further Research and Practice
Any firm conclusions about the effectiveness of case

management are premature and even unwarranted, given
the relative scarcity of randomized and controlled studies,
especially conceming some specific models of case manage-
ment (clinical, brokerage, and strengths-based). Additional
studies are needed, mainly outside the United States, that
apply a strong methodology among a sufficiently large
sample. Small samples have accounted for limited power
and reduce the chance of detecting small or medium effects
(Orwin et al. 1994).

The lack of longitudinal scope in most studies de-
bilitates any conclusion about the long-term effects of this

Journal of Psychoactive Drugs 92 Volume 39 (1), Mareh 2007

Vanderplasschen et al. Models of Case Management

intervention. Most of the selected studies have applied case
management interventions that do not last longer than six
to 12 months, and clients were usually not followed up for
more than six months after termination of the program.
Studies that have utilized case management over a 24- to
36-month period have demonstrated long-term positive ef-
fects and even cost-effectiveness (Oliva et al. 2001; Jerreli &
Ridgely 1999; Clark etal. 1998; Drake etal. 1998; Lanehart
et al. 1996; Levy, Strenski & Amick 1995). However, some
authors have shown that effects plateaued or even deterio-
rated after a while, particularly when the intervention was
discontinued (Sorensen et al. 2003; Zanis & Coviello 2001;
Conrad et al. 1998; Mercier & Racine 1993). Given the
chronic and relapsing nature of substance abuse problems,
application of a longitudinal approach to case management
is indicated. It is necessary to know if its value declines over
time and when, if ever, case management efforts should be
reduced or terminated (Clark et al. 1998). The combination
or alternation of intensive and less intensive interventions
from a chronic care perspective (including case manage-
ment) may yield the best results.

Evaluations of the effectiveness of case management
should include multiple outcome measures and process vari-
ables. Not only socially acceptable changes (e.g. drug use,
employment, criminal behavior) should be studied, but also
indicators conceming quality of life and clients’ subjective
perceptions, since such changes may be as important for
society (Sindelar et al. 2004). Up to now, little information
has been available about the crucial features of this interven-
tion: what specific aspects contribute to specific outcomes?
Since the identification of these elements has been defined
as the most important future research issue in the field of
mental health care, insights from this field should be closely
followed (Bums et al. 2001). A team approach, monitoring,
treatment planning, outreaching, and focusing on strengths
and good relationships with case managers have been as-
sociated with positive outcomes among substance abusers
(Vanderplasschen et al. 2004; Brun & Rapp 2001; Jerreli
& Ridgely 1999). In-depth qualitative research with clients
and case managers is required to further explore elements
that contribute to the effectiveness of case management. The
general nature ofthe elements identified in qualitative stud-
ies can then be tested in randomized and controlled trials.

CONCLUSION

Based on this review of published articles, the authors
conclude that at least some evidence Is available for the
effectiveness of some models of case management. These
effects are small or modest at best and do not differ signifi-
cantly from those of most other interventions in the field
of substance abuse treatment. As in the field of mental
health care, obvious positive effects include reduced use
of inpatient services and increased utilization of outpatient
and community-based services, prolonged treatment re-
tention, improved quality of life, high client satisfaction,
and stabilization or even improvement of the situations
of—often problematic—substance abusers. Retention in and
completion of case management programs have consistently
been associated with positive outcomes, but overall effects
conceming clients’ functioning are less consistent. Various
authors have found significant effects over time for several
drug-related outcomes, but often these did not differ from
outcomes among clients receiving less intensive or even
minimal interventions. Longitudinal outcomes are still
unclear, but at least some studies have shown long-term
effects if the intervention was sustained.

Several aspects of the effectiveness of this intervention
need to be studied further. The extent of the effects was
beyond the scope of this article, but should be included
in a meta-analysis concerning the effectiveness of case
management for substance abusers. Although some studies
have shown that this intervention works, it is still unclear
what exactly makes this intervention work and how long
its effects last. Given the increased acceptance of the idea
that substance abuse is a chronic and relapsing disorder,
the role of case management should be discussed from a
chronic care perspective. Ultimately, the effectiveness of
this intervention for affecting clients’ functioning should
not be overestimated; its effect primarily lies in supporting
clients in their daily lives and linking them to adequate
services. Providing direct services or psychotherapy as part
of case management may contribute more substantially to
the stabilization or improvement of clients’ situations, but
such support probably needs to be sustained over time to
produce long-term effects.

REFERENCES

Birchmore-Timney. C. & Graham. K.A. 1989. Survey of case management
practices m addictions programs. Alcoholism Treatment Quarterly
6 (3/4): 103-27.

Block, R.I.; Bates, M.E & Hall, J.A. 2003. Relation of premorbid cognitive
abilities to substance users’ problems at treatment intake and
improvements with substance abuse treatment and case management
American Journal of Drug and Alcohol Abuse 29 (3): 515-38.

Braucht, G.N.; Reichaidt, C.S.; Geissler, LJ.; Bormann, CA.; Kwaitkowski,
CF. & Kirby, M.W. 1995. Effective services for homeless substance
abusers. Journal of Addictive Diseases 14 (4): 87-109.

Brindis, CD. & Theidon, K.S. 1997. The role of case management in
substance abuse treatment services for women and their children.
Journal of Psychoactive Drugs 29 (1): 79-88.

Broekaert, E & Vanderplasschen, W. 2003. Towards an integrated treatment
system for substance abusers: Report on the second international
symposium on substance abuse treatment and special target groups.
Journal of Psychoactive Drugs 35 (2): 237-45.

Brun, C & Rapp, R.C 2001. Strengths-based case management:
Individuals’ perspectives on strengths and the case manager relations.
Soda/Wort 46 (3): 278-88.

Journal of Psychoactive Drugs 93 Volume 39(1), March 2007

Vanderplasschen et al. Models of Case Management

Burns, T ; Fioritti, A.; Holloway, F; Malm, U. & Rossler, W. 2001.
Case management and assertive community treatment in Europe.
Psychiatric Services 52 (5): 631-36.

Clark, R.E; Teague, G.B.; Ricketts, S.K.; Bush, P.W.; Xie, H.; McGuire,
T.G.; Drake, R.E; McHugo, G.J.; Keller, A.M. &Zubkoff, M. 1998.
Cost-effectiveness of assertive community treatment versus standard
case management for persons with co-occurring severe mental
illness and substance use disorders. Health Services Research 33
(5): 1285-1308.

Conrad, K.J.; Hultman, C.I.; Pope, A.R.; Lyons, J.S.; Baxter, W.C;
Daghestani, A.N.; Lisiecki, J.P.; Elbaum, PL.; McCarthy, M. &
Manheim, L.M. 1998. Case numaged residential care for homeless
addicted veterans: results of a true experiment. Medical Care 36:
40-53.

Cox, G.B.; Walker, R.D.; Freng, S.A.; Short, B.A.; Meijer, L &Gilchrist,
L 1998. Outcome of a controlled trial of the effectiveness of intensive
case management for chronic public inebriates. Jourruil of Studies
on Alcohol 59 (5): 523-32.

Cretzmeyer, M.; Sarrazin, M.V.; Huber, D.L; Block, R.I. & Hall, J.A. 2003.
Treatment of methamphetamine abuse: research findings and clinical
directions. Journal of Substance Abuse Treatment 24: ISl-Tl.

Drake, R.E; McHugo, G.; Clark, R.; Teague, G.B.; Xie, H.; Miles, K. &
Ackerson, T.H. 1998. Assertive community treatment for patients
with co-occurring severe mental illness and substance use disorder:A
clinical trial. American Journal of Orthopsychiatry 68 (2): 201-15.

Durell, J.; Lechtenberg, B.; Corse, S. & Frances, R.J. 1993. Intensive
case management of persons with chronic mental illness who abuse
substances. Hospital and Community Psychiatry 44 (5): 415-16,
428.

Eisen, M.; Keyser-Smith, J.; Dampeer, J. & Sambrano S. 2000. Evaluation
of substance use outcomes in demonstration projects for pregnant
and postpartum women and their infants: Fmdings from a quasi-
experimenL Addictive Behaviors 25 (1): 123-29

Evenson, R.C; Binner, PR.; Cho, D.W.; Schicht, W.W. & Topolski, J.M.
1998. An outcome study of Missouri’s CSTAR alcohol and drug abuse
programs. Journal of Substance Abuse Treatment 15: 143-50.

Falck, R.; Siegal, H.A. & Carlson, R.G. 1992. Case management to
enhance AIDS risk reduction for injection drug users and crack
users: Theoretical and practical considerations. In: R.S. Ashery
(Ed.) Progress and Issues in Case Management. NIDA Research
Monograph 127. Rockville, MD: National Institute on Drug Abuse.

Godley, M.D.; Godley, S.H.; Dennis, M.L; Funk, R. & Passetti, LL. 2002.
Preliminary outcomes from the assertive continuing care experiment
for adolescents discharged from residential treatment Journal of
Substance Abuse Treatment 23 (1): 21-32.

Godley, S.H.; Finch, M.; Dougan, L ; McDonnell, M.; McDermeit, M. &
Carey, A. 2000. Case management for dually diagnosed individuals
involved in the criminal justice system. Journal of Substance Abuse
Treatment 18 (2): 137^18.

Gossop, M.; Marsden, J.; Stewart, D. & Kidd, T. 2003. The National
Treatment Outcome Research Study (NTORS): 4-5 year follow-up
results. Addiction 98 (3): 291-303.

Griffith, J.D.; Rowan-Szal, G.A.; Roark, R.R. & Simpson, D.D. 2000.
Contingency management in outpatient methadone treatment: A meta-
analysis. Drug and Alcohol Dependence 58 (1-2): 55-66.

Hall, J.A.; Carswell, C ; Walsh, E ; Huber, D.L. & Jampoler, J.S. 2002.
Iowa case management: Innovative social casework. Social Work
47(2): 132-141.

Hser, Y.I.; Anglin, M.D.; Grella, C ; Longshore, D. & Prendergast, M.L
1997. Drug treatment careers: A conceptual framework and existing
research findings. Journal of Substance Abuse Treatment 14 (6):
543-58.

Huber, D.L.; Sarrazin, M.V.; Vaughn, T. & Hall, J.A. 2003. Evaluating
the impact of case management dosage. Nursing Research 52 (5):
276-88.

Inciardi, J.A.; Martin, S.S. & Scarpitti, ER. 1994. Appropriateness of
assertive case management for drug-involved prison releasees.
Journal of Case Management 3 (4): 145-49.

Jerrell, J.M. & Ridgely, M.S. 1999. Impact of robustness of program
implementation on outcomes of clients in dual diagnosis programs.
Psychiatric Services 50 (1): 109-12.

Jerrell, J.M. & Ridgely, M.S. 1995. Evaluating changes in symptoms and
functioning of dually diagnosed clients in specialized treatment.
Psychiatric Services 46 (3): 233-38.

Jerrell, J.M.; Hu,T. & Ridgely, M.S. 1994. Cost-effectiveness of substance
disorder interventions for people with severe mental illness. Journal
of Mental Health Administration 21 (3): 283-97.

Kanter, J. 1989. Clinical case management: Definition, principles,
components. Hospital and Community Psychiatry A/0 (4)\ 361-68.

Kilbride, H.; Castor, C ; Hoffman, E & Fuger, K.L 2000. Thirty-six month
outcome of prenatal cocaine exposure for term or near-term infants:
Impact of early case management Journal of Developmental and
Behavioral Pediatrics 1\ (1): 19-26.

Koski-J^nes A. 2005. On the problems of randomized clinical trials as a
means of advancing clinical practice. In: M.U. Pedersen; V. Segraeus
& M. Hellman (Eds.) Evidence Based Practice: Challenges in
Substance Abuse Treatment. Helsinki: Nordic Council for Alcohol
and Drug Research (NAD).

Laken, M.P. & Ager, J.W. 1996. Effects of case management on retention
in prenatal substance abuse treatment American Journal of Drug
and Alcohol Abuse 22 (3): 439-48.

Lanehart, R.E; Clark, H.B.; Rollings, J.P; Haradon, D.K. & Scrivner,
L. 1996. The impact of intensive case-managed intervention on
substance-using pregnant and postpartum women. Journal of
Substance Abuse Treatment 8 (4): 487-95.

Lapham, S.C; Hall, M. & Skipper, B.J. 1995. Homelessness and substance
use among alcohol abusers following participation in project H&ART.
Journal of Addictive Diseases 14(4): 41-55.

Levy, J.A.; Strenski, T. & Amick, D.J. 1995. Community-based case
management for active injecting drug users. Advances in Medical
Sociology 6: IS3-206.

Udz, V.; Bux, D.A.; Platt, J.J. & Iguchi, M.Y. 1992. Transitional case
management: A service model for AIDS outreach projects. In: R.S.
Ashery (Ed.) Progress and Issues in Case Management. NIDA
Research Monograph 127. Rockville, MD: National Institute on
Drug Abuse.

Lightfoot, L.; Rosenbaum, P; Ogurzsoff, S.; Laverty, G.; Kusiar, S.; Barry,
K. & Reynolds, W. 1982. Final Report ofthe Kingston Treatment
Programmed Development Research Project. Ottawa, Canada:
Department of Health and Welfare, Health Promotion Directorate.

Martin, S.S. & Scaipitti, F.R. 1993. An intensive case management approach
for paroled iv drug users. Journal of Drug Issues 23 (1): 43-59.

McLellan, A.T.; Hagan, T.A.; Levine, M.; Meyers, K.; Gould, F.;
Bencivengo, M.; Durell, J. & JaiTe, J. 1999. Does clinical case
management improve outpatient addiction treatment? Drug and
Alcohol Dependence 55: 91-103.

Mejta, C.L.; Bokos, PR.; Mickenberg, J.; Maslar, M. & Senay, E. 1997.
Improving substance abuse treatment access and retention using a
case management approach. Journal of Drug Issues 27 (2): 329-40.

Mercier, C. & Racine, G. 1993. A follow-up study of homeless women.
Journal of Social Distress and the Homeless 2 (3): 207-22.

Miller, W.R. & Wilboume, PL. 2002. Mesa Grande: a methodological
analysis of clinical trials of treatments for alcohol use disorders.
Addiction 97 (3): 265-77.

Miller, W.R. 1996. Motivational interviewing: research, practice, and
puzzles. Addictive Behaviors 21 (6): 835-42.

Nebelkopf, E & Penagos, M. 2005. Holistic Native Network: Integrated
HIV/AIDS, substance abuse, and mental health services for native
Americans in San Francisco. Journal of Psychoactive Drugs 37 (3):
257-64.

Okin, R.L; Boccellari, A.;Azocar, F; Shumway, M.; O’Brien, K.; Gelb, A.;
Kohn, M.; Harding, P & Wachsmuth, C. 2000. The effects of clinical
case management on hospital service use among ED frequent users.
American Journal of Emergency Medicine 18 (5): 603-08.

Oliva, H.; GBrgen, W.; Schlanstedt; G.; Schu, M. & Sommer, L. 2001. Case
Management in der Suchtkranken- undDrogenhilfe: Ergebnisse des
Kooperationsmodells nachgehende Sozialarbeit – Modellbestandteil
Case Management, Berichtszeitraum 1995-2000. KOln: FOGS,
Gesellschaft ftlr Forschung und Beratung in Gesundheits- und
Sozialbereich mbH.

Orwin, R.G.; Sonnefeld, L.J.; Garrison-Mogren, R. & Smith, N.G. 1994.
Pitfalls in evaluating the effectiveness of case management programs

Journal of Psychoactive Drugs 94 Volume 39(1), March 2007

Vanderplasschen et al. Models of Case Management

for homeless persons: Lessons from the NIAAA Community
Demonstration Program. Evaluation Review 18 (2): 153-207.

Pearlman, S. 1984. Early experiences with primary care. In: FB. Glaser;
H.M. Annis & H.A. Skinner (Eds.) A System of Health Care Delivery:
Volume II Primary Care Assessment. Toronto, Canada: Addiction
Research Foundation.

Rapp, R.C; Siegal, H.A.; Li, L. & Saha, P. 1998. Predicting post-primary
treatment services and drug use outcome: A multivariate analysis.
American Journal of Drug and Alcohol Abuse 24 (4): 603-15.

Rhodes, W. & Gross, M. 1997. Case Management Reduces Drug Use and
Criminality Among Drug-Involved Arrestees: An Experimental Study
of an HIV Prevention Intervention. NU Research Report. Washington,
D.C: National Institute of Justice.

Rich,J.D.;Holmes,L;Salas,C;Micalino,G.:DBvis,D.;I^cz£k,J.&Hanigan,T200l.
Successful linkage of medical care and community services for
HIV-positive offenders being released from prison. Journal of Urban
Health 78 (2): 279-89.

Ridgely, M.S. & Jerreli, J.M. 1996. Analysis of three interventions for
substance abuse treatment of severely mentally ill people. Community
Mental Health Journal 32 (6): 561-72.

Ridgely, M.S. & Willenbring, M. 1992. Application of case management
to drug abuse treatment: Overview of’ models and research issues.
In: R.S. Ashery (Ed.) Progress and Issues in Case Management.
NIDA Research Monograph 127. Rockville, MD: National Institute
on Drug Abuse.

Rosen, A. & Teesson, M. 2001. Does case management work? The evidence
and the abuse of evidence-based medicine. Australian and New
Zealand Journal of Psychiatry 35 (6): 731-46.

Saleh, S.S.; Vaughn, T ; Hall, J.A.; Levey, S.; Fuortes, L. & Uden-Holmen,
T. 2002. Effectiveness of case management in substance abuse
treatment. Care Management Journal 3 (4): 172-77.

Sarrazin, M.V.; Huber, D.L. & Hall, J.A. 2001. Impact of Iowa case
management on family functioning for substance abuse treatment
clients. Adolescent & Family Health 2 (3): 132-40.

Scott, CK.; Sherman, R.E; Foss, M.A.; Godley, M. & Hristova. L. 2002.
Impact of centralized intake on case management services. Journal
of Psychoactive Drugs 34 (1): 51-57.

Shwartz, M.; Baker, G.; Mulvey, K.P & Plough, A. 1997. Improving
publicly funded substance abuse treatment: The value of case
management. American Journal of Public Health 87: 1659-64.

Siegal, H.A.; Li, L. & Rapp, R.C. 2002. Case management as a therapeutic
enhancement: Impact on post-treatment criminality. Journal of
Addictive Diseases 2\ (4): 37-46.

Siegal, H.A.; Rapp, R.C.; U, L ; Saha, P. & Kirk, K. 1997. The role of
case management in retaining clients in substance abuse treatment:
an exploratory analysis. Journal of Drug Issues 27 (4): 821-31.

Siegal, H.A.; Fisher, J.H.; Rapp, R.C; Kelliher, C.W.; Wagner, J.H.;
O’Brien, W.F. & Cole, P.A. 1996. Enhancing substance abuse
treatment with case management: its impact on employment Journal
of Substance Abuse Treatment 13 (2): 93-8.

Siegal, H.A.; Rapp, R.C; Kelliher, C.W.; Fisher, J.H.; Wagner, J.H. &
Cole, P.A. 1995. The strengths perspective of case management: A
promising inpatient substance abuse treatment enhancement. Journal
of Psychoactive Drugs 27 (1): 67-72.

Simpson, D.D.; Joe, G.W.; Fletcher, B.W.; Hubbard, R.L. & Anglin,
M.D. 1999. A national evaluation of treatment outcomes for cocaine
dependence. Archives of General Psychiatry 56 (6): 507-14.

Sindelar, J.L.; Jofre-Bonet, M.; French, M.T. & McLellan, A.T. 2004. Cost-
effectiveness analysis of addiction treatment: paradoxes of multiple
outcomes. Drug and Alcohol Dependency 73 (1): 41-50.

Sindelar, J.L. & Fiellin, D.A. 2001. Innovations in treatment for drug
abuse: Solutions to a public health problem. Annual Review of Public
Health 22: 249-72.

Sorensen, J.L.; Dilley, J.; London, J.; Okin, R.L.; Delucchi, K.L. & Phibbs,
C.S. 2003. Case management for substance abusers with HIV/AIDS:
A randomized clinical trial. American Journal of Drug and Alcohol
Abuse 29 {\): 133-50.

Stahler, G.J.; Shipley,TF; Bartelt, D.; DuCette, J.P & Shandler I.W. 1995.
Evaluating alternative treatments for homeless substance-abusing
men: outcomes and predictors of success. Journal of Addictive
Diseases 14 (4): 151-67.

Stein, L.I. & Test, M.A. 1980. Alternative to mental hospital treatment:
Conceptual model, treatment program and clinical evaluation.
Archives of General Psychiatry 37 (4): 392-97.

Substance Abuse and Mental Health Administration (SAMHSA). 1998.
Comprehensive Case Management for Substance Abuse Trealment
(TIP Series 27). Rockville, MD: Department of Health and Human
Services, Public Health Service, Substance Abuse and Mental Health
Services Administration, Center for Substance Abuse Treatment.

Teague, G.B.; Bond, G.R. & Drake, R.E. 1998. Program fidelity in assertive
community treatment: Development and use of a measure. American
Journal of Orthopsychiatry 6S (2): 216-31.

Thomquist, L ; Biros, M.; Olander, R. & Sterner, S. 2002. Health care
utilization of chronic inebriates. Academic Emergency Medicine 9
(4): 300-08.

Vanderplasschen, W. & Wolf, J. 2005. Case management bij drugsverslaafden:
ABC voor implementatie en praktijk. Verslaving: Tijdschrift over
Verslavingsproblematiek 1: 66-78.

Vanderplasschen, W; Lievens, K. & Broekaert, E 2001. Implementatie van
een Methodiek van Case Management in de Drughutpverlening: Een
Proefproject in de Provincie Oost-Vlaanderen (Orthopedagogische
Reeks Gent Nummer 14). Gent, Belgium: UniversiteitGent, Vakgroep
Orthopedagogiek.

Vanderplasschen, W; Wolf, J.; Rapp, R.C. & Broekaert, E. 2005. Is case
management an effective and evidence-based intervention for helping
substance abusing populations? In: M.U. Pedersen; V. Segraeus & M.
Hellman (Eds.) Evidence Based Practice: Challenges in Substance
Abuse Treatment. Helsinki: Nordic Council for Alcohol and Drug
Research (NAD).

Vanderplasschen, W; Rapp, R.C; Wolf, J.R. & Broekaert, E. 2004. The
development and implementation of case management for substance
use disorders in North America and Europe. Psychiatric Services
55 (8): 913-22.

Van Stelle, K.R.; Mauser, E. & Moberg, D.P 1994. Recidivism to the
criminal Justice system of substance-abusing offenders diverted into
treatment. Crime and Delinquency 40 (2): 175-96.

Vaughan-Sarrazin, M.S.; Hall, J.A. & Rick, G.S. 2000. Impact of Iowa case
management on use of health services by rural clients in substance
abuse treatment Journal of Drug Issues 30 (2): 435-63.

Vaughn, T ; Sarrazin, M.V.; Saleh, S.S.; Huber, D.L. & Hall, J.A. 2002.
Participation and retention in drug abuse treatment services research.
Journal of Substance Abuse Treatment 23 (4): 387-97.

Volpicelli, J.R.; Markman, I.; Monterosso, J.; Filing, J. & O’Brien, CP.
2000. Psychosocially enhanced treatment for cocaine-dependent
mothers: evidence of efficacy. Journal Substance Abuse Treatment
18(1): 41-49.

Willenbring, M. 1996. Case management applications in substance use
disorders. In: H. Siegal & R.C. Rapp (Eds.) Case Management and
Substance Abuse Treatment: Practice and Experience. New York:
Springer Publishing Company.

Willenbring, M.L; Ridgely, M.S.; Stinchfield, R. & Rose, R. 1991.
Application of Case Management in Alcohol and Drug Dependence:
Matching Techniques and Populations. Rockville, MD: National
Institute on Alcohol Abuse and Alcoholism.

Witbeck. G.; Hornfeld, S. & Dalack. G.W. 2000. Emergency room
outreach to chronically addicted individuals: A pilot study. Journal
of Substance Abuse Treatment 19(1): 39-43.

Wolf, J.; Mensink, C & van der Lubbe, P 2002. Case Management
voor Langdurig Verslaafden met Meervoudige Problemen: een
Systematisch Overzicht van Interventie en Effect. Utrecht: Trimbos-
instituut, Ontwikkelcentrum Sociaal Verslavingsbeleid.

Woodside, M. & McClam, T. 2002. Generalist Case Management: A
Method of Human Service Delivery. Horence: Thomson Leaming.

Zanis, D.A. & Coviello, D. 2001. A case study of employment case
management with chronically unemployed methadone maintained
clients. Journal Psychoactive Drugs 33 (I): 67-73.

Ziguras, S.J. & Stuart, G.W. 2000. A meta-analysis of the effectiveness of
mental health case management over 20 years. Psychiatric Services
51:1410-21.

Journat of Psychoactive Drugs 95 Volume 39(1), March 2007

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

© 2008 The Author(s)

Journal compilation © 2009 Blackwell Publishing Ltd and the International Journal of Social Welfare.

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:

18

: 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

1

, Wouter Vanderplasschen

2

,
Jessica De Maeyer

2

1

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

2

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 perspective

Kolind 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: tk@crf.au.dk

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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271

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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273

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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277

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

Kolind et al.

© 2008 The Author(s)

278

Journal compilation © 2009 Blackwell Publishing Ltd and the International Journal of Social Welfare

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.

The case manager’s perspective

© 2008 The Author(s)
Journal compilation © 2009 Blackwell Publishing Ltd and the International Journal of Social Welfare

279

References

Asmussen V (2006). On whose terms? User participation in Danish
methadone maintenance treatment. In: Anker J, Asmussen V,
Kouvonen P, Tops D, eds.

Drug users and spaces for
legitimate action

. NAD no. 49. Helsinki, NAD-Publications.
Asmussen V, Kolind T (2005).

Udvidet psykosocial indsats i
metadonbehandling. Resultater fra en kvalitativ evaluering
af fire metadonforsøgsprojekter

[Enhanced psychosocial
support in methadone treatment. Results from a qualitative
evaluation of four methadone pilot projects]. Aarhus, Centre
for Alcohol and Drug Research, University of Aarhus.

Bacchus L, Marsden J, Griffiths P, Gossop M, Farrell M, Clarke
K, Strang J (1999). Client perceptions of inpatient treatment.
A qualitative account with implications for ser vice delivery.

Drugs: Education, Prevention and Policy

6: 87–97.
Boehm A, Staples LH (2002). The functions of the social worker

in empowering: The voices of consumers and professionals.

Social Work

47: 449– 460.
Brindis CD, Theidon KS (1997). The role of case management

in substance abuse treatment services for women and their
children.

Journal of Psychoactive Drugs

29: 79–88.
Broekaert E, Soyez V, Vanderplasschen W, Vandevelde D, Bradt

R, Morival M, Kaplan C (2001). The video addiction
challenge test: A new instrument for qualitative substance
abuse assessment, treatment planning and research in
therapeutic communities.

International Journal of Social
Welfare

10: 134– 141.
Brun C, Rapp R (2001). Strengths-based case management:

individuals’ perspectives on strengths and the case manager
relations.

Social Work

46: 278–288.
Coviello DM, Zanis DA, Wesnoski SA, Alterman AI (2006).

The effectiveness of outreach case management in re-
enrolling discharged methadone patients.

Drug and Alcohol
Dependence

85: 56 –65.
Cruikshank B (1999).

The will to empower. Democratic citizens
and other subjects

. London, Cornell University Press.
Godley S, Godley M, Pratt A, Wallace J (1994). Case

management services for adolescent substance abusers: A
program description.

Journal of Substance Abuse Treatment

11: 309–317.
Graham K, Birchmore-Timney C (1990). Case management in

addictions treatment.

Journal of Substance Abuse Treatment

7: 181–188.
Hall JA, Carswell C, Walsh E, Huber DL, Jampoler JS (2002).

Iowa case management: Innovative social casework.

Social
Work

47: 132–141.
Hesse M, Broekaert E, Fridell M, Rapp RC, Vanderplasschen W

(2007). Case management for persons with substance use
disorders.

Cochrane Database of Systematic Reviews

, Issue
4, article no. CD006265.

Hesse M, Pedersen MU (2008). Easy-access services in low-
threshold opiate agonist maintenance.

International Journal
of Mental Health and Addiction

6: 316–324.
Holloway F, Carson J (2001). Case management: an update.

International Journal of Social Psychiatry

47(3): 21–31.
Huber DL, Sarrazin MV, Vaughn T, Hall JA (2003). Evaluating

the impact of case management dosage.

Nursing Research

52: 276–288.
Hunt G, Rosenbaum M (1998). ‘Hustling’ within the clinic:

Consumer perspectives on methadone maintenance
treatment. In: Inciardi JA, Harrison LD, eds.

Heroin in the
age of crack-cocaine

. Thousand Oaks, Sage.
Jerrell JM, Ridgely MS (1999). Impact of robustness of program

implementation on outcomes of clients in dual diagnosis
programs.

Psychiatric Services

50: 109–112.
Kolind T (2007). Form or content. The application of user

perspectives in treatment research.

Drugs: Education,
Prevention and Policy

14: 261–275.
Kuhn S, Schu M, Vogt I, Schmid M, Simmedinger R,

Schlanstedt G

et al

. (2006). Das bundesdeutsche
modellprojekt zur heroingestützen behandlung opiatabhängiger
– eine multizentrische, randomisier te, kontrollierte
therapiestudie: Spezialstudie der binnenevaluation der
psychosozialen begleitung [The German heroin trial of opiate
addicted persons: a multi-centred, randomized and controlled
study: Specific evaluation of the psychosocial treatment].
Hamburg, Zentrum für Interdisziplinäre Suchtförschung der
Universität Hamburg.

Lambert MJ (2003). Psychotherapy outcome research:
Implications for integrative and eclectic therapists. In:
Norcross JC, Goldfried MR, eds.

Handbook of psychotherapy
integration

. Oxford, Oxford University Press.
Leonardsen D (2007). Empowerment in social work: an

individual vs. a relational perspective.

International Journal
of Social Welfare

16: 3–11.
Lilly R, Quirk A, Rhodes T, Stimson G (2000). Sociality in

methadone treatment: understanding methadone treatment
and service delivery as a social process.

Drugs: Education,
Prevention and Policy

7: 163–178.
Mahs BM (2002).

Jeg har planer, eller har jeg? – Sociale
handleplaner og praksis

[I have plans or do I? – Social
activity plans and practice]. Copenhagen, Fokus.

McLellan AT, Hagan TA, Levine M, Meyers K, Gould F,
Bencivengo M

et al

. (1999). Does clinical case management
improve outpatient addiction treatment?

Drug and Alcohol
Dependence

55: 91–103.
Morgenstern J, Blanchard KA, McCrady BS, McVeigh KH,

Morgan TJ, Pandina RJ (2006). Effectiveness of intensive
case management for substance-dependent women receiving
temporary assistance for needy families.

American Journal
of Public Health

96: 2016 –2023.
Morse GA, Calsyn RJ, Klinkenberg WD, Helminiak TW, Wollf

N, Drake RE

et al

. (2006). Treating homeless clients with
severe mental illness and substance use disorders: costs and
outcomes.

Community Mental Health Journal

42: 377– 404.
Moxley DP (1989).

The Practice of Case Management

. London,
Sage.

Neale J (1998). Drug users’ views of drug service providers.

Health and Social Care in the Community

6: 308–317.
Noel PE (2006). The impact of therapeutic case management

on participation in adolescent substance ab use treatment.

The American Journal of Drug and Alcohol Abuse

32: 311–
327.

Ontwikkelcentrum Sociaal Verslavingsbeleid (2003).

Handreiking
voor casemanagers in de sociale verslavingszorg

[Manual
for case managers in social addiction care ]. Utrecht,
Resultaten Scoren.

Pedersen MU (2005).

Heroin-afhængige i metadonbehandling.
Den medicinske og psykosociale indsats

[Heroin addicts and
methadone treatment. Medical and psychosocial ser vices].
Aarhus, Centre for Alcohol and Drug Research, University
of Aarhus.

Rapp RC (2006). Strengths-based case management: Enhancing
treatment for persons with substance abuse problems. In:

Saleebey D, ed.

The strengths perspective in social work
practice

, 4th edn., pp. 128–147. Boston, Allyn & Bacon.
Rapp RC, Siegal HA, Li L, Saha P (1998). Predicting post-

primary treatment services and drug use outcome: A
multivariate analysis.

American Journal of Drug and Alcohol
Abuse

24: 603–615.
Rapp RC, Otto AL, Lane DT, Redko C, McGatha S, Carlson

RC (2008). Improving linkage with substance abuse
treatment using brief case management and motivational
interviewing.

Drug and Alcohol Dependence

94: 172–182.
Ridgely MS (1996). Practical issues in the application of case

management to substance abuse treatment. In: Siegal H,
Rapp R, eds.

Case management and substance abuse
treatment: practice and experience

, pp. 1–20. New York,
Springer Publishing Company.

Kolind et al.

© 2008 The Author(s)

280

Journal compilation © 2009 Blackwell Publishing Ltd and the International Journal of Social Welfare

Ridgely MS, Willenbring M (1992). Application of case
management to drug abuse treatment: overview of models
and research issues. In: Ashery RS, ed.

Progress and issues
in case management

(NIDA Research Monograph 127)
pp. 12–33. Rockville, National Institute on Drug Abuse.

Roeg DP, Van de Goor IA, Garretsen HF (2005). Towards
quality indicators for assertive outreach programmes for
severely impaired substance abusers: concept mapping with
Dutch experts.

International Journal of Quality in Health
Care

17: 203–208.
Roeg DP, Van de Goor IA, Garretsen HF (2007). European

approach to assertive Outreach for substance users:
Assessment of program components.

Substance Use &
Misuse

42: 1705–1721.
Saleebey D (2006). Introduction: Power in the people. In:

Saleebey D, ed.

The strengths perspective in social work
practice

. Boston, Pearson Education.
Sargent P, Pickard S, Sheaff R, Boaden R (2007). Patient and

carer perceptions of case management for long-ter m condi-
tions.

Health & Social Care in the Community

15: 511–519.
Schu M, Schmid M, Görgen W, Vogt I, Oliva H (2002). Case

management mit integriertem Motivational Interviewing
im bundesdeutschen Modellprojekt zur heroingestützten
Behandlung Opiatabhängiger – eine multizentrische ,
randomisierte, kontrollierte Therapiestudie: Manual [Case
management with integrated Motivational Interviewing in the
German heroin trial of opiate addicted persons: a multi-
centred, randomized and controlled study: Manual]. Köln,
Heroinstudie.de.

Scott CK, Sherman RE, Foss MA, Godley M, Hristova L (2002).
Impact of centralized intake on case management services.

Journal of Psychoactive Drugs

34: 51–57.
Siegal HA, Rapp RC, Kelliher CW, Fisher JH, Wagner JH, Cole

PA (1995). The strengths perspective of case management: A
promising inpatient substance abuse treatment enhancement.

Journal of Psychoactive Drugs 27: 67–72.

Sorensen JL, Dilley J, London J, Okin RL, Delucchi KL, Phibbs
CS (2003). Case management for substance abusers with
HIV/AIDS: a randomized clinical trial. American Journal of
Drug and Alcohol Abuse 29: 133–150.

Substance Abuse and Mental Health Administration (SAMHSA)
(1998). Comprehensive case management for substance
abuse treatment (TIP Series 27). Rockville, US Department
of Health and Human Services, Public Health Service,
Substance Abuse and Mental Health Services Administration,
Center for Substance Abuse Treatment.

Van Ooijen-Houben M (1998). Het zorgplan: leidraad bij het
werken met zorgplannen in de ggz en verslavingszorg
[The treatment plan: guidelines for working with treatment
plans in mental health and addiction care] . Utrecht,
Trimbos-instituut.

Vanderplasschen W, De Bourdeaudhuij I, Van Oost P (2002).
Coordination and Continuity of Care in Substance Abuse
Treatment. European Addiction Research 8: 10 –21.

Vanderplasschen W, Rapp RC, Wolf J, Broekaert E (2004). The
development and implementation of case management for
substance use disorders in North America and Europe.
Psychiatric Services 55: 913–922.

Vanderplasschen W, De Maeyer J (2007). The practice of case
management for substance abusers: what’s in a name?
Adiktologie 7: 460 – 469.

Vanderplasschen W, Mostien B, Franssen A, Lievens K, De
Maeyer J, Broekaert E (2007a). Dealing with multiple and
frequent service utilisation in substance abuse treatment:
Experiences with coordination of care in residential
substance agencies in the region of Ghent, Belgium.
International Journal of Therapeutic Communities 28: 74–
89.

Vanderplasschen W, Wolf J, Rapp RC, Broekaert E (2007b).
Effectiveness of different models of case management for
substance-abusing populations. Journal of Psychoactive
Drugs 39: 81–93.