Abstract
This paper will review the case management approaches used in substance abuse counseling. First, the case management setting, its features, and the substance abuse factors affecting it will be outlined. Next, the historical development of models from the Middle Ages to the present will be established in chronological order. After that, the Theoretical Foundations on which case management is based will be considered. The following section presents the research results and the approaches applied in the selected studies.
After analyzing all the methods, the best-practice models will be highlighted that offer advantages in the substance abuse counseling setting and demonstrate greater effectiveness. In this case, this method is group therapy, which, thanks to the mutual support of the participants, provides a longer-term result of counseling. Among the more than 15 models considered in this approach, cognitive behavioral therapy was chosen as the most effective.
Case Management Setting
The setting for this case will be substance abuse counseling. The issue selected for this work will be substance use disorder, in particular, alcoholism. In most cases, a person cannot altogether refuse to drink alcohol, which is a prerequisite for recovery on their own. Therefore, if alcoholism occurs, one needs to seek qualified drug treatment as soon as possible.
The doctor will make a simple diagnosis, determine whether there are disorders in the work of internal organs provoked by alcoholism, and draw up a therapy plan. After preparing for coding, the narcologist will conduct anti-alcohol therapy. This paper discusses her case management in detail.
At the same time, it is not alcoholism, namely alcohol abuse, that is responsible for most problems of physical and mental health, as well as social functioning. The situation is complicated by the fact that alcohol abusers often do not realize this or hide such a fact from medical professionals, fearing social condemnation or publicity (Boursier & Tsochatzis, 2021). The lack of clear criteria for abuse, as well as specific social and gender stereotypes of drinking alcohol, leads to the fact that harmful and dangerous alcohol consumption remains unrecognized (Leggio & Mellinger, 2023). There are also cases when it is not considered a deviation from healthy behavior.
According to formal signs, alcohol abuse is not a reason for drug treatment, so a significant number of patients do not come to the attention of doctors. Moreover, many medical professionals consider discussing alcohol consumption to be futile or time-consuming (Pouwels et al., 2022). Other obstacles to such counseling may include the doctor’s workload, limited time at the reception, lack of specialized training, and a lack of confidence in their competence.
There is strong evidence that even short structured counseling can be effective. It is especially productive when used systematically across different levels of medical care, including primary, specialized, outpatient, and inpatient (Purdue University, 2019). Any reason for contacting a medical institution can be used as an opportunity to diagnose and correct excessive alcohol consumption. Even a slight reduction in alcohol consumption can lead to significant health improvements.
For example, a decrease in the average daily consumption of pure alcohol from 45 to 35 grams is associated with a 50% reduction in the risk of oral cancer, a 15% reduction in the risk of hypertension in men, and a 65% reduction in the risk of hypertension in women (Leggio & Mellinger, 2023). Therefore, the problem of alcohol case management is significant and requires a review and analysis of existing models.
History of Models
The development of medical disciplines is evolutionary — from ignorance to knowledge, from medicine to healing. As new scientific facts accumulate, therapy strategies should evolve, becoming more effective and safer. This is precisely what happens in various fields of medicine, including in world narcology, that is, addictive medicine (Summers, 2016). However, there is still a very low effectiveness of case management of alcoholism due to the use of unscientific methods by doctors and the introduction of questionable measures to combat alcoholism.
Statistics on the most drinking countries are constantly changing and depend on who conducts the studies. However, one fact remains unchanged — there are alcoholics everywhere, they have to be treated, because it is almost impossible to overcome alcohol dependence of any kind on their own (Pouwels et al., 2022). Attempts were regularly made to restrict the production of alcohol globally, and so-called dry laws were issued. The most significant of them are the prohibition of 1865 in Sweden, 1915 in Iceland, and 1919 in the USA and Finland (Pouwels et al., 2022). However, a complete ban did not become effective in case management, as it led to an increase in the underground production of unsafe alcoholic beverages.
The history of alcoholism as a substance use disorder does not give precise dates. As the effects that occur during intoxication are revealed, scientists and doctors are increasingly convinced that, in large quantities, ethyl alcohol is perceived by the body as a poison (Boursier & Tsochatzis, 2021). This means that all reserves are being mobilized to neutralize and withdraw it. However, it was during the adoption of prohibition that not only the physical, but also the mental side of alcohol dependence was revealed (Summers, 2016). It was then that case management stopped focusing solely on the physical manifestations of alcoholism, but began to consider the patient as a patient, and not as a violator of the law.
In the Middle Ages, a state monopoly on the production and sale of vodka arose in many countries. In the first half of the 15th century, very harsh methods of combating drunkenness emerged, ranging from beating to imprisonment (Boursier & Tsochatzis, 2021). Sermons on the dangers of drunkenness were read in churches. In France, it was ordered that a 7 kg (Leggio & Mellinger, 2023) medal be issued. It was worn around a drunkard’s neck for a week. It could not be removed until the end of the term, so moral condemnation from others was added to the physical punishment.
Even half a century ago, the approach to alcohol case management was ineffective because it was not comprehensive. Even 30-40 years ago, a person who abused alcohol was first treated with medication in a hospital, then sent to a medical and labor dispensary or to a collective on bail (Pouwels et al., 2022). More often, under the psychological pressure of caregivers, a person returned to an old habit, and the cycle closed.
Theoretical Foundation
Alcoholism is a mental and physical dependence of a person on drinking drinks containing ethanol. They become necessary because they help to relieve mental stress or improve physical condition. At the same time, it worsened just because of the withdrawal or long-term non-consumption of alcohol. In case management, it is necessary, first of all, to focus on the primary causes of alcoholism (Leggio & Mellinger, 2023).
The hereditary factor affects the rate of damage to metabolic processes in the body. When fragments of genes involved in alcohol metabolism are disrupted, the body’s ability to compensate for damage and regulate other processes decreases (Pouwels et al., 2022). This increases the risk not only of developing alcoholism but also of diseases associated with this addiction, for example, cirrhosis of the liver.
The ethnological factor should also be included among the unfavorable factors leading to the formation of dependence. The metabolic rate of the indigenous peoples of Europe is much lower than that of the indigenous peoples of the small northern regions (Leggio & Mellinger, 2023). In this regard, the gene pool of the indigenous peoples of Asia and American Indians allows addictions to develop much faster (Pouwels et al., 2022).
Dependence is formed in relation to those substances that, in their chemical structure, resemble substances of the body itself or can take part in metabolic processes. The intake of such toxic substances disrupts the activity of natural enzymes, and after a break in alcohol intake, tension arises (Leggio & Mellinger, 2023). To relieve it, addicted people compensate for the lack of natural enzymes with another portion of alcohol. Therefore, in case management, it is necessary to base theoretical ideas on the psychology of addiction and its structure.
The development of alcoholism is influenced by various factors unrelated to genetics, which must be taken into account when choosing case management. These are household disorders, difficulties in the professional sphere and personal life, a dysfunctional drinking environment, as well as depression and other personality disorders (Boursier & Tsochatzis, 2021). The leading indicator for choosing case management in this case is the frequency of use adopted in a particular environment (Boursier & Tsochatzis, 2021). In general, alcohol abuse can provoke any psychogenic factor, both positive and negative.
Research Results
Among the case management models identified in the research, some primarily use personality development strategies. They can be divided into two groups: individual rational counseling and family counseling (Pouwels et al., 2022). These methods primarily address regulatory and compensatory processes and are characterized by the following. The patient is considered a subject of exposure, and the purpose of the exposure is to increase the individual’s capabilities. However, in this case, case management therapy is quite lengthy and time-consuming (Leggio & Mellinger, 2023). The results are achieved relatively slowly, but are pretty stable. The relationship between the consultant and the patient is based on partnership and cooperation.
Individual rational counseling is the primary traditional method of a consultant’s direct influence on a dependent patient. It should be personally oriented towards each of them. The tasks of individual consultation of patients with alcoholism are to convince the patient about the dangers of alcohol. In this case management, the goal is also to influence patients’ conscious and unconscious attitudes to foster criticism of their disease and a desire for a sober, healthy lifestyle (Leggio & Mellinger, 2023). Case management for the most part consists of teaching the patient how to de-actualize the pathological craving for alcohol in case of exacerbation during remission.
In family counseling, the object of influence is not so much the patient himself as the family of an alcoholic patient as a whole. Various options for family counseling are focused on the destruction of pathological stereotypes, improving social skills, and, first of all, on overcoming the phenomena of codependency (Pouwels et al., 2022). Case management in the form of family alcohol addiction counseling is based on the belief that the formation of alcoholism is a family problem (Boursier & Tsochatzis, 2021). From the point of view of systemic family counseling, the problem of a family with a dependent is understood as an incongruence in the organizational family hierarchy.
In such a family, the boundaries between generations are blurred, and dysfunctional vertical ties are preferred to marital relations. They are formed as a coalition of one of the spouses with their parents or children. As a result, a family member thrown to the periphery tries to restore their position with the help of alcohol, making their partner or other family members helpless in front of their problem and restoring equality (Summers, 2016). The solution to the problem and the primary goal of case management in this case is to establish a congruent hierarchy in the family (Pouwels et al., 2022). Moreover, the tasks of family counseling are to establish an adequate attitude of a married couple to the illness of one of the spouses.
Approaches Used
Among the approaches used, predominantly manipulative, suggestive directive strategies were revealed. These include hypnosis, trance techniques, and auto-training (Summers, 2016). As a rule, suggestive methods of influence are used in combination with elements of rational counseling (Pouwels et al., 2022). They also involve occupational therapy, behavioral psychotherapy techniques, and a range of assistive methods, such as bibliotherapy and art therapy. Coding is a modern development of suggestive approaches.
Hypnotherapy is a psychotherapeutic case management treatment that is based on the effect of suggestion in a state of hypnotic trance and is effectively applicable to alcohol addiction. Hypnosuggestive therapy uses suggestions aimed at prohibiting alcohol consumption (Leggio & Mellinger, 2023). It occurs with the consolidation of fear of possible unpleasant and even grave consequences for the patient if this prohibition is violated (Pouwels et al., 2022). During its duration, the patient is considered an object of influence.
The purpose of exposure is to change alcohol-dependent behavior. Therapy is usually short-lived, with results achieved relatively quickly but not always stable (Pouwels et al., 2022). The relationship between the patient and the consultant is based on paternalism on the part of the case manager and their assumption of responsibility for the positive result of treatment.
Coding is a session of anti–alcohol suggestion conducted in a state of alcoholic abstinence for several days or weeks. The essence of the method consists of hypnotic influence on a person with the suggestion of a certain period of sobriety and a set of prohibitive measures (Pouwels et al., 2022). They are aimed at developing the patient’s fear of imminent severe health disorders in the event of a return to drinking alcoholic beverages (Leggio & Mellinger, 2023). This is accompanied by the complete removal of cravings for alcohol for the entire duration of coding.
The main form of psychotherapy is emotional stress psychotherapy, the laying of a code in the subconscious mind prohibiting the use of alcohol. The listed symptomatic methods are limited in their effect on the patient over time, and disruptions often occur after the end of the treatment period (Summers, 2016).
Moreover, often, as a complication, certain manipulative procedures lead to the replacement of a symptom repressed in a patient with another, sometimes even more pronounced, than the one that was neutralized (Boursier& Tsochatzis, 2021). The main disadvantage of such techniques in comparison with deep types of psychotherapy is the implementation of direct effects on painful manifestations (Boursier & Tsochatzis, 2021). They are carried out without the active involvement of the patient’s personality in the treatment process.
Models Used
Based Clinical &Brokerage
In clinical psychotherapy, alcohol and substance abuse do not depend on psychological theory and concepts, but on the clinical picture of the mental disorder experienced by the addicted patient. The clinician-psychotherapist reads in the clinical picture the body’s struggle with external and internal, including hereditary harmfulness, which led to alcohol and substance use (Downey & Chang, 2024).
Next, they carry out therapeutic and protective-adaptive work to combat alcoholism. The brokerage model deals with the mental and emotional state of alcohol and substance abusers. In this model, it is essential to change how the patient’s behavior and way of thinking affect their addiction (Joly, 2024). It also affects the patient’s discipline and their willingness to get better.
Client-Centered & Clinical
The client-centered approach asserts that the alcohol or substance user can find a way to become the best version of themselves. They will be able to recover if they are accompanied by a professional in this process (Joly, 2024). At the same time, the therapist should take a non-directive position towards the alcohol substance abuser, that is, not try to give answers to questions or advice.
Specialists in the clinical model proceed from how a healthy psyche works and what happens to it when there are pathologies. Alcohol substance abuse is also considered a mental disorder (Downey & Chang, 2024). The clinical model studies how bodily somatic ailments are associated with changes in the psyche of alcohol substance abuser.
Comprehensive & Ecological
The complete model comprises psychological procedures, approaches, and theoretical frameworks (Joly, 2024). They try to change the cognitive processes, motives, emotional reactions, self-awareness, and behavior of alcohol and substance abusers to improve their mental and physical health. The ecological model is one type of psychological support that aims to improve the psycho-emotional state of alcohol and substance abusers through a connection with nature (Joly, 2024). For example, painting in nature improves mood and diverts attention away from unpleasant ideas, preparing the patient for mental balance.
Ecological Humanistic & Holistic
The ecological humanistic paradigm focuses on integrating alcohol and substance abusers into the ecosystem, empathic adjustment to their living environment, and the development of ecological consciousness and self-awareness (Downey & Chang, 2024). The holistic approach is a style of treatment that considers both psychological and physiological elements of alcohol and substance dependence (Downey & Chang, 2024). According to this concept, a psychotherapist deals with both the psyche and the body at the same time, because they are inextricably linked.
Integrative
The integrative model links various psychotherapy methods to the needs of therapeutic practice. This model uses the integration of comparable scientific disciplines such as medicine, sociology, psychology, pedagogy, philosophy, neurophysiology, and psycholinguistics to treat alcohol substance abuse (Joly, 2024). Synthesis of theoretical information of various psychotherapeutic orientations, taking into account the basic concept of alcohol substance abuser personality and its development, psychopathology and symptom formation.
Intensive & Psychodynamic
The intensive model is a method of treating mental disorders based on an intense interaction between an alcohol or substance abuser and a therapist. Unlike traditional psychotherapy, which can last for several months or even years, intensive psychotherapy is carried out for a limited time, usually several weeks or months (Joly, 2024). The psychodynamic model is developed on the basis of the psychoanalytic theory of Freud and his followers. Its approaches are based on the theory that the internal conflicts of alcohol and substance abusers, formed in childhood, determine their experiences and behavior in the future (Joly, 2024). The objectives of psychodynamic therapy are to uncover the hidden motives of alcohol and substance abusers and free them from repressed emotions and traumatic memories.
Strengths & Trauma
The strengths model is a harsh method of psychotherapy aimed at mobilizing the internal resources of alcohol and substance abusers at the expense of protest emotions (Downey & Chang, 2024). The trauma model is a work with a specific lesion of the central nervous system, which appears after severe stress, and leads to the appearance of alcohol or substance abuse (Joly, 2024). The manifestations of mental trauma are similar to the consequences of severe stress, the physical manifestation of which is also alcohol abuse.
Best Practice Models
In the setting of my choice which is substance abuse counseling the best practice model used for case management is counseling in alcoholics anonymous groups — specialized communities in which drinkers unite. The participants of such a micro-organization are trying to recover. They all have the same problem; therefore, it is easier for them to communicate with each other. Together they are trying to defeat alcoholism as substance abuse.
By joining the community of alcoholics, a patient can be relaxed about confidentiality issues. They do not need to tell anything about themselves — their name, occupation, and place of residence remain a secret (Summers, 2016). Due to this, drug addicts get a chance to talk about their problems and experiences without looking back at the critical society, without fear of condemnation and publicity (Summers, 2016). This is an advantage among other models and reduces the risk of relapse, increasing openness and incentive to combat substance abuse.
The emergence of group psychotherapy is associated with the observations of employees of private clinics in the United States. They noted that meetings in small groups have a much greater positive effect than ordinary individual communication and are generally effective in improving treatment outcomes. Group psychotherapy for alcoholism began to be used starting in the 30s, when addicts in the United States began to form mutual aid groups (Boursier & Tsochatzis, 2021). It is now known in different countries of the world as the alcoholic anonymous movement.
Today, methods of group psychotherapy are used in many drug treatment institutions and psychological care centers. It is generally believed that in the fight against alcoholism, the group method is preferable to simply treating alcoholism with a psychotherapist, since the group is more effective in resisting attempts by its members to justify drunkenness than the doctor (Summers, 2016). Moreover, the example of those who have already coped with their craving for alcohol gives hope for a cure to beginners, helping them to dispel doubts and strengthen faith in their own strength.
In the treatment of alcoholism as substance abuse, it is extremely important to overcome mental dependence on alcohol. Specifically for this purpose, complex therapy is used within the framework of case management, which also includes psychotherapy of alcohol dependence, and auto-training for alcoholism (Summers, 2016). This approach was developed based on the practical experience of patients who have already freed themselves from addiction.
Group therapy classes here are supervised by a qualified consultant. They usually involve meetings in the mornings and evenings. For psychological support, they use the author’s programs and the achievements of specialists who have already overcome the same problem. All this combined helps to consider the group therapy methodology one of the most effective case management models.
Preferred Model
Cognitive behavioral psychotherapy is used in the treatment of alcohol substance abuse and rehabilitation after it. The cognitive part involves correcting existing attitudes, conclusions, and beliefs. The behavioral part includes the development of control skills, behavior management, and actions performed (Sosin & Germer, 2024). Such therapy has proven effectiveness, simplifies alcohol withdrawal, and reduces the risk of breakdown (Sosin & Germer, 2024). When using cognitive-behavioral psychotherapy, patients work closely with support groups and relatives, which improves treatment outcomes (Sosin & Germer, 2024). Family sessions are an essential part of therapy because if any member of a family is sick with alcohol or substance abuse, the whole family system is affected.
References
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