1 Daisho

Counseling Case Study Sample For A Alcoholic

When one realizes that no matter how much they may know about theoretical drug problems and alcohol problems, it is still possible to be staring in the face of a full on alcoholic and not know it until after the fact. Alcoholism and drug problems, much like other chronic illnesses, are not things one can identify just by looking at someone’s face. However, if one pays attention there are probably warning signs that are indicative of a substance abuse problem. However subtle the signs may be, they are usually consistent. A story, with not so subtle signs, may be in order to properly illustrate the point:

George is a 30 year old junior marketing executive. He shares an apartment with his brother and is not in a relationship. George has a very active social life. Almost every night of the week, George can be found at some sort of festivity that is at a bar, club or restaurant. At all of these occasions, liquor is present. George often jokes about how he must look like an alcoholic because in most pictures he is holding a drink. In addition, the woman he has begun a flirtation with finds that every time she calls him he is drinking. She thinks nothing of it, since this man must just enjoy one or two social drinks. The fact that he drinks every night does not flag him as an alcoholic in her eyes. They have spoken on the phone scores of times, spent time together and been in constant communication for a two month period. In addition, he really is such a nice guy. He casually mentions that his mother has asked him to promise not to drink. They laugh about how parents often refuse to view their children as adults.

One night before George goes out with his new lady friend, he tells her a few stories. One included waking up one morning after a night of drinking with blood on his shirt. The caveat being he had no idea where the blood came from. On another occasion, upon being shoved by a young woman in a club after drinking for a while, George pushed her back and the woman went flying across the room. George admits that at this point, he realized he did not know what his alcohol limit was. He stated this in past tense; these events had happened about a year prior and since then, George had allegedly altered his drinking habits. This statement was made as George pulled out two small bottles of vodka. One was for himself one for his lady friend. When she declined the offer of drink he downed both bottles himself.

Two hours later at the club the couple had gone to George has drunk two beers and was ready for a shot of tequila. He at this point is holding his liquor well. However; once the shot of tequila comes into play George succeeds in alienating his new friend. He spills salt all over the bar then begins dancing sloppily and says more than a few insulting things to his date. By the end of the evening the young lady wants nothing more to do with him. George can’t understand why.

George is in a state of denial about his drinking problem. The main issues here include the following:

  1. An inability to stop drinking
  2. Inability to see conflicts arising subsequent to drinking
  3. Spending excessive money on drinking to the point of putting oneself in a financially precarious position
  4. Jeopardizing existing relationships
  5. Damaging potential future relationships
  6. Does not correlate his poor decisions with the outcomes they procure
  7. Not understanding the concern those around have for him and his poor behavior

George continues to drink excessively, regardless of the concern expressed by his family and friends. He holds that he does not have a problem and does not seek help. In the long term, George is never able to find a more secure job position or maintain a serious romantic relationship with any woman he meets. The issues here are many. George’s inability to stop drinking will also eventually erode his body functioning. This will result in a financial strain both on George, his family and society. The most common health risks for alcoholics include strain on the liver and kidneys.

Should George ever decide he wants to stop drinking, what he may not realize is detoxification from alcohol unsupervised can be life threatening. The purpose of writing down George’s story is his experience may be able to help someone you know. If you read this anecdote and see a bit of yourself in it, or someone you know please contact someone who can help you.

Rachel Hayon, MPH, RN

Case management applied to the treatment of alcohol dependence



Neliana Buzi FiglieI; Ronaldo LaranjeiraII

IAmbulatório de Dependência do Álcool da UNIAD (Unidade de Pesquisa em Álcool e Drogas) – Departamento de Psiquiatria – UNIFESP
IIUnidade de Pesquisa em Álcool e Drogas (UNIAD) – Departamento de Psiquiatria – UNIFESP





This article aims is to conceptualize and describe the main steps in case management applied to the treatment of alcohol dependence. It is important to note the case manager functions, the importance of the first appointment, check the motivation to the treatment, some goals and activities suggestions for adherence reinforcement.

Keywords: Alcoholic beverages. Treatment. Therapy. Counseling. Disease management.




Evidence suggests that case management has been a powerful intervention to assist people with psychosocial problems, including chronic mental diseases, old age and child emotional disturbances.1 2 3 More recently, this type of approach has been adapted for the work with chemical dependence.4 5

Generally, case management may be defined as a set of interventions aiming to facilitate the treatment outcome. Some of the relevant functions within this context are to: 1) identify the specific needs, determining strong and weak points, as well as the patient's needs; 2) plan, developing a specific proposal for each patient; 3) establish a connection with other services, be they in formal or informal health service network; 4) monitor and assess the case, visualizing the progress obtained; 5) facilitate the legal support if needed.6 7 8 Although widely accepted in health services, there is not yet an operational consensus about the definitions of these functions.9 They describe what case managers do, but not how they do, as we cannot rule out the influence of variables such as: service's goals, type of service, target population, socio-demographic characteristics, among others which would hamper the standardization of a consensus about 'how to do'.

Case management has become popular without a specific protocol, as it depends on the diversity of adaptations to the local and cultural circumstances. However, this article aims to discuss the practical challenges of implementing case management applied to the treatment of alcohol-dependent subjects.


Case management in the treatment of chemical dependence

Marshman 10 has described the functions of case management specifically in the context of chemical dependence:

1) Providing individualized support for patients and their family members;

2) Helping patients to solve problems;

3) Helping the patients' family and employability;

4) Facilitating the access between patients and treatment;

5) Facilitating the access of patients to consultation psychiatry for specific treatments if needed;

6) Keeping aware of the changes in the patients' needs and problems during the treatment;

7) Assuring patients that they could be reached and encouraged to return to the treatment in case of dropout;

8) Reinforcing and continuing the treatment process, in a less invasive way, proceeding the treatment in order to support the rehabilitation of patients in the community, early identifying future difficulties.

In the planning of case management it is important to take into account the duration, intensity, assessment and type of service, keeping in mind:

1) Target population: The characteristics of the target population may be determinant in the type of case management program. Characteristics such as gender, age, race, severity and chronicity of the problems are important considerations in the definition of the program. For example: when a high proportion of patients is part of an ethnic minority, an important consideration in the planning of case management is what the program may perform in ethical and cultural terms in order to enable the patients' rehabilitation.

2) Objectives: The program's objectives are important to prevent misunderstandings in the implementation. The objectives depend on the target population and on the problem's definition. For example: distinguishing a harmful alcohol consumption from alcohol dependence is fundamental to define the treatment's objectives which are pertinent to patients; the definition of the treatment's success is different for a homeless when compared to a middle-class patient.

There are determined fields which suffer a direct impact from the consequences of alcohol consumption. Among them stand out: alcohol consumption pattern, work, physical and emotional health, legal problems, dwelling stability and patients' satisfaction. When identifying which of these fields is the most problematic for patients, the professional establishes as the focus the solving of the problems in the specific field, besides the issue of alcohol consumption, aiming to succeed in the treatment.

3) Setting: The setting may be determinant for the treatment's outcome. Studies have shown11 that the effectiveness of case management is more related to the involvement of the service in the patient's environment than the case management per se. The higher the connections of the professional with other services, be they formal or informal, the higher will be the quality of the treatment.

4) Administrative model: There is a consensus that an interactive and multidisciplinary team is beneficial for case management, as it allows the exchange of different points of view to manage problems, increasing the creativeness and energy, preventing therefore isolated actions.

5) Case manager: the profile of a case manager includes academic formation, professional identity, commitment with the philosophy of the treatment setting, knowledge and experience on chemical dependence, readiness to research the several areas of the patients' lives, knowledge of the characteristics of the population, as well as the service's system.


Alcohol dependence

Although the treatment field for alcohol dependence syndrome has developed in the last years, it is undeniable that there is part of society that does not respond to treatment. This absence of response, combined with case management aimed at the social well-being and medical programs, have arisen questions about how it would be appropriate treating or facilitating the treatment for this demand. Among the characteristic of patients dependent on alcohol and other drugs, stand out: 9

1) Severest forms of chemical dependence;

2) Coexistence of medical and psychiatric conditions;

3) Severe incapacitation in several areas of life;

4) Socioeconomic challenge;

5) Lack of formal education;

6) Unemployment and poverty

7) Social stigma;

8) Extensive use of public services;

9) Problems present for long periods (chronicity);

Unfortunately the traditional treatments are not always conceived to deal with these problems. This type of patients needs continuous and intermittent professional support for months and/or years, and most of conventional treatments provide episodic interventions. The recent model and the implementation of specialized treatment programs for specific substance-related problems in sub-populations has currently improved the fragmentation of care. Structured programs impose barriers for the treatment such as admission criteria and procedures, distinct treatment model and lack of integration with other services. Case management arises as an alternative to circumvent these difficulties and the fragmentation of health services.11 Case management is aimed at problems of accessibility, efficacy, treatment continuity, its format and implementation. A clear conception of what will be performed in the case management is needed, by whom, with whom and which will be the aimed benefits. Below the main goals of case management in a particular setting are described.6

1) Increasing the treatment's continuity (fundamental): Cross-sectional (researching individual and comprehensive evidence of the treatment in a determined period of time) and longitudinal studies (with the continuing of the intervention, collecting evidence about the response to the intervention provided).

2) Increasing the accessibility: overcoming administrative barrier

3) Increasing the assessment: assign an effect point for the treatment's outcome whenever multiple services are involved to meet the patients' needs.

4) Increasing the effectiveness: rising the probability of patients receiving services adequate to their needs, decreasing the duplication of services. Cost analysis may or not be performed.

Summing up, the professional acts as an agent responsible for the coordination of the case as to enable the patient's individual needs, and the latter may keep receiving several other types of interventions in varied services. In this context, the professional or manager is not seen as a care provider, but as someone who visualizes, comprehensively, the patient's needs and acts as a facilitator to supply these needs.


What is needed in alcohol dependence treatments: Practical clues

1. Functions of the case manager

Professionals called case managers may be engaged in additional and alternative functions aiming at the treatment's success. This is a fundamental aspect for the applicability of case management with alcohol-dependent subjects, as much of the work, such as establishing connections with other services or coordinating any specific situation of the patient, may demand from professionals a whole adaptation in their professional life.

If the treatment proposal is developed in a team, it is important to verify which professional will be the case manager. The idea is that this professional would be the reference for the patient in the service, being very integrated to the team as he/she will act as an interlocutor between the treatment proposal and the patient's needs, in order to enable them. Not necessarily case managers should have finished college. Many times community agents, provided they have the adequate training, may be case managers. Most importantly, these professionals should be available and sensitive regarding patients and should keep in continuous contact with them.

2. The first contact: the clinical history

The collection of information to obtain the clinical history should be performed through the analysis of situations of use, risk of use, social and health consequences of chemical dependence, but also must*: 1) create a therapeutical alliance and favor the engagement of patients in the treatments; 2) understand the context in which the dependence has developed; 3) identify the factors which favored the installation of dependence; 4) identify the factors which maintain the dependence; 5) identify the factors which favor abstinence; 6) gather conditions to establish the diagnostic hypothesis.

Professionals have to be sensitive to verify at which point all information needed for the clinical history could be assessed in one or two sessions; if patients are not intoxicated up to the point of compromising the trueness of their answers; if, in that moment, it would be more productive to assure the therapeutical link and alliance as to make patients return in the next consultation; as well as the capability of performing a sympathetic listening and the capability of being in the relationship in order to help, and the concept of help should be established by the patients and not only by the professional or the treatment's requisitioner, assigning the self-efficacy to the patients as to prevent the arguing and break the resistance. But, more important than collecting information is to be with patients, being able to listen to them, situating oneself in the patients' place as to not judge, but understand their fears, desires, anguishes and attitudes to understand and receive them without being judgmental, aiming to assure the continuity of the treatment in the future.

3. Checking the motivation for treatment

In the treatment setting it is essential a careful assessment to identify the nature, problems, adequacy and possible objectives of the treatment. Similarly, the treatment process should identify the specific factors which will help or hamper the objectives to the reached. In this context, the motivation is useful to identify the different factors which may be appropriate for the different motivation stages, being an important orientation for the case manager. For example, patients in the pre-contemplation stage should be helped to recognize and develop awareness about their problems rather than being directly guided towards abstinence. Patients in the contemplation stage are open to interventions which increase the awareness (educational and self-monitoring methods), but are resistant to orientations directed towards action. In the action stage, patients need practical help with procedures for behavioral change12. Table 1 displays a definition of the stages of change, with suggestions of interventions for the case manager.13



Some scales may help in the identification of the patients' motivation. The University of Rhode Island Change Assessment Scale (URICA) investigates the stages of change: contemplation; pre-contemplation; action; maintenance.14 This scale has been translated and culturally adapted into Portuguese.15 Other scale used to measure the readiness to change the drinking behavior is the The Stages Readiness and Treatment Eagerness Scale (SOCRATES) 16, which has been also validated and adapted.**


Goals and activities to incentive compliance

Considering the objectives, target-population, the setting and the administrative model of the intervention, table 217 displays some of the specific goals, related activities and methods of verification aimed to increase the treatment's adherence and retention.



Final Considerations

Summing up, studies on mental health and substance dependence9 indicate that case management may be a useful tool especially in the treatment of patients with multiple problems, being fundamental the establishment of a point of responsibility for each patient. The case management program works with realistic and feasible goals, both for patients and the treatment, as to avoid false promises. The implementation of the program may require months until all the team be integrated into the proposal, as to the point of being acquainted with the target population and the specific community. In this procedure, many problems may arise and they may not always be predicted, but it is possible to act helping to solve problems and, for that, the communication between the case manager, the treatment program and the patients is essential.



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17. Perty NM, Bohn MJ. Fishbowls and Candy Bars: Using Low-Cost Incentives to increase treatment retention. Scien & Pract Perspect 2003;1(2):55-61.         [ Links ]



Correspondence to
Neliana Buzi Figlie
Unidade de Pesquisa em Álcool e Drogas (UNIAD), UNIFESP/EPM – Depto. de Psiquiatria
Rua Borges Lagoa, 564 - conj 44
Vl. Clementino - São Paulo - SP – Brazil - CEP 04038-001
Phone / Fax: 0 xx 11 5579-0640
E-mail : neliana@psiquiatria.epm.br



* Note: Figlie NB, Laranjeira R, Bordin S. Aconselhamento em Dependência Química. São Paulo: Roca (in press 2004).
** Note: Figlie, NB, Dunn J, Laranjeira, R. "Motivation for Change in Alcohol Dependent Outpatients from Brazil". Addictive Behaviors (in press 2004).

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