The Role of Case Management in Retaining Clients in Substance Abuse Treatment: An Exploratory Analysis

Article excerpt

The positive relationship between time spent in substance-abuse treatment and improved outcomes has led to a significant interest in interventions that encourage substance abusers to remain in treatment. Case management has been tested for its role in both encouraging continued participation and directly affecting desired outcomes. This article reports findings from an ongoing longitudinal study that randomly assigned over 600 substance abusers entering treatment to one of two groups, either: (1) usual primary and aftercare drug treatment services or (2) usual services and an enhancement of strengths-based case management. A cluster analytic technique was used to identify patterns of participation in post-primary treatment, i.e., aftercare and case management, among those substance abusers in the enhanced group. Three distinct clusters emerge that suggest a prominent role for this model of case management as either an adjunct or an alternative to conventional treatment.

Introduction

Because of the generally positive association between length-of-time in treatment and successful outcome, substance-abuse treatment programs have included interventions likely to keep clients from dropping out (Brownell et al. 1986; Catalano et al. 1988; DeLeon 1990; Hawkins and Catalano 1985; Ito and Donovan 1990; Stark and Campbell 1988; Walker et al. 1983). Case management, as one of such interventions, has been used not only to encourage treatment retention but also to directly promote goals such as drug abstinence, improved employment functioning, and reduced criminality (Ashery 1992; Martin and Inciardi 1993; Siegal et al. 1996; Willenbring et al. 1991).

When implemented as a distinct modality, case management adds an important array of activities to the treatment continuum. In keeping with its traditional role, case management helps substance abusers access resources and services that can support their recovery, frequently accomplishing this goal through active advocacy (Willenbring et al.1991). More recently, models of case management have offered drug-abuse treatment clients the opportunity to acquire and practice the social, psychological, and organizational skills useful in obtaining such needed resources as housing and employment even after formal contact with their case manager has ceased (Rapp et al. 1992; Sullivan et al. 1992). Whether through simple referral, advocacy, or skills training, it is argued that by helping clients acquire needed resources they will be more likely to attend treatment and, thereby, be less likely to relapse.

In a major longitudinal study funded by the National Institute on Drug Abuse (NIDA), strengths-based case management was included as an enhancement to a conventional, disease concept-oriented substance-abuse treatment program operated in a Veterans Affairs Medical Center. A sample of substance-abuse treatment patients were randomly assigned to participate in either: (1) the program's usual primary and aftercare drug treatment services or (2) usual services and an enhancement of strengths-based case management.

The overall study design and some initial comparisons between the randomly assigned groups have been examined elsewhere (Rapp et al. 1992; Siegal et al. 1993; Siegal et al.1996; Siegal et al. n.d.). This article presents data from the second group only-the one that received both usual aftercare and enhanced case management services. In selecting this group for analysis we were able to compare the patterns of participation in the two services and determine how differences in treatment participation may be related to demographic and background characteristics and, subsequently, to differences in post-treatment drug use, criminality, and employment.

Cluster analytic techniques are used to define patterns of attendance and retention in both aftercare treatment services and case management activities. The three clusters that emerge from this analysis are then explored in greater detail: first, for comparability of their pretreatment characteristics and second, for differences on selected outcome variables 6 months following treatment. …