Hosted by: Center for Advocacy and Leadership Training A project of Time for Change Foundation

1. Hosted by: Center for Advocacy and Leadership TrainingA project of Time for Change Foundation Presented by Dr. Richard Rapp Strengths-Based Case Management June 12th & 13th , 2014

2. Richard C. Rapp, M.S.W., Ph.D. Wright State University Boonshoft School of Medicine

3. Objectives • Understand principles and practice activities important in Strengths-Based Case Management • Engage in practice scenarios & role plays • Discuss adaptation and implementation issues for your setting

4. Terms • Strengths-based Case Management (SBCM) • Treatment Linkage Case Management (TLCM) • Persons with substance abuse problems • ARTAS Linkage Case Management (ALCM) • Persons newly diagnosed with HIV • Emergency Department SBCM (ED-SBCM) • Opiod addicts being treated in emergency departments • “Linkage”; “Care Coordination”

5. Case Management & Substance Abuse • Prior to 1990 case management used almost exclusively with mental health populations • 1990 – four case management studies proposed as part of a National Institute on Drug Abuse initiative to improve treatment retention and outcomes

6. Case Management & Substance Abuse • Models adapted from mental health field • Strengths-based: Wright State University; University of Iowa • Assertive Community Treatment: University of Delaware • Generalist: UCLA • Since 1990, mostly generalist case management

7. Case Management

8. Barriers to Treatment • Personal • Practical • Transportation • Financial • Childcare • Lifestyle • Substance abuse & mental health • High risk behaviors • Homeless • Incarceration • Internal • Fear of discovery • Stigma • Denial • Fatalism • Lack of trust • Physical • Side effects Substance abuse treatment & medical care Persons who have substance abuse problems & are HIV positive • System • Location • Rural providers • Affordability • Eligibility criteria • Inflexible hours • Admission process • Cultural competence • Impersonal • Intimidating • Staff skills • Waiting lists

9. Case Management Functions • Assesses – Identifies service(s) the client needs • Arranges – Makes plans to get service(s) • Coordinates – Makes sure that service(s) are received • Monitors – Follows the progress of client – service(s) interactions

10. Case Management Functions • Evaluates – Makes sure that client gets services as intended • Advocates – Intervenes to assure that client gets the services they needed

11. Duration of Case Management • On-going support of clients over a protracted period of time; long-term support of mental health clients reintegrated into community AND/OR • Support in achieving specific, short-term goals; assisting clients to link with services

12. Strengths Perspective

13. Barriers to Treatment • Personal • Practical • Transportation • Financial • Childcare • Lifestyle • Substance abuse & mental health • High risk behaviors • Homeless • Incarceration • Internal • Fear of discovery • Stigma • Denial • Fatalism • Embarrassment • Lack of trust Persons who have substance abuse problems & are HIV positive Substance abuse treatment & medical care • System • Location • Rural providers • Affordability • Eligibility criteria • Inflexible hours • Admission process • Cultural competence • Impersonal • Intimidating • Staff skills • Waiting lists CASE MANAGEMENT STRENGTHS PERSPECTIVE

14. Principle I: Focus on Client Strengths • Emphasize client strengths, positives, assets, skills, abilities, etc. • De-emphasize client recounting of what they’ve done wrong • Recognize motivation and personal efforts • Base goal-setting on past assets

15. Principle II: Client Driven • Establish client as responsible for identifying own goals and path to accomplish those goals • Increase client investment in goals • Promote self-determination • Reduces resistance and denial

16. Principle III: Case Manager as Primary Relationship • Development of working alliance, relationship is critical • Provides the short-term foundation for client taking risks • Primary, but not exclusive relationship

17. Principle IV: Community as a Resource • Selective use of formal, informal, and created resources • Formal – specialized, entitlements • Informal – day to day functioning and community involvement • Created – Expand personal interests, skills

18. Principle V: Assertive Outreach • Encourages understanding of client’s life • Helps case manager to help client formulate plans • Promotes relationship between client and case manager

19. Combining Case Management & Strengths Perspective

20. Case Management Assessment Planning Linking Coordinating Advocacy Strengths Perspective Focus on strengths Client driven Primary relationship Assertive outreach Creative use of resources C • Center for Interventions ITAR • Treatment & Addictions • Research Case Management + Strengths Focus

21. STRENGTHS-BASED CASE MANAGEMENT Tangible Support Transportation Childcare Planning Advocacy Assessment Planning Linking Monitoring Advocacy Linkage with Care Retention in Care Improved Functioning Focus on Client Strengths Client Driven Emphasize Relationship Assertive Outreach Use of Informal Resources Emotional Support Increase Hopefulness Increase Self-Efficacy Decreased Resistance

22. Strengths-Based Case Management • A value-added intervention in that: • Case management provides concrete support in getting resources • Strengths perspective provides emotional support in identifying abilities

23. Strengths Perspective Basic position is to find strengths, assets, and abilities Diagnosis and labeling is avoided Full discussion of client’s story is encouraged Medical/Disease Model Basic position is to find sickness, problems, disease & pathology Diagnosis is required; labeling is frequent Client/patient usually seen as less capable, needs to be helped/fixed Strengths Perspective and Medical Model

24. Strengths Perspective Individual is asked about needs Individual seen as “able” and necessary participant in addressing needs Active involvement encouraged Goals are (almost) always supported Medical/Disease Model Worker supports “party line” and agency role Client/patient goes to services Solutions usually involve formal resources Doctor-patient relationship Strengths Perspective and Medical Model

25. Activity #1 • Scenario A & Scenario B

26. Outcomes Linkage & Retention

27. Percent linkage by intervention and modality

28. Substance abusers’ linkage by number of CM contacts

29. Path Model of Significant Factors on Post-Treatment Contact and Drug Severity • (Baseline) • .251 • .122 • .165 • .129 • .136 • .399 • Unemployed • Fewer Arrests • Less Depression • Lower Drug Severity • (Six Months) • Less Drug Use • Less Use of Crack Cocaine • .113 .120 • Fewer Treatments • More Weeks in Aftercare Treatment • Case Manager

30. Path Model of Significant Factors on Post-Treatment Contact and Legal Severity • (Baseline) • .251 • .242 • .104 • .425 • Unemployed • Lower Legal Severity • Readiness for Treatment • Lower Legal Severity • (Twelve Months) • Case Manager • .092 .089 • .112 • More Weeks in Aftercare Treatment

31. Practice of SBCM

32. A Word About Motivational Interviewing • Some of basic skills of MI can be very useful as part of SBCM • Reflective comments vs. open and closed questions • Recognizing stage of change • Rolling with resistance; empathy • Using discrepancy

33. Strengths-Based Case Management • Preparation – Getting ready • Engagement – First impressions are everything • Strengths Assessment – Changing the discussion • Case Management Planning – Following the client • Disengagement – Letting go

34. Preparation (System) • Learn about & make a directory of both formal and informal resources • Examine structure of own agency, what interferes with linkage • Visit all resources where you might refer clients • Shadow program staff; Be the client • Establish informal relationships with staff • Encourage your agency to develop MOUs with other programs

35. Preparation (Clients) • Have a strengths “attitude” • Have knowledge necessary to assist clients • Understand situation of your potential clients • Interview clients who have been successful • Have basic support/counseling skills • Stay open to learning new ways of helping people

36. Note on Preparation • If you aren’t prepared, you put clients’ ability to be successful at risk • Especially true when it comes to: • “Strengths attitude” • Fully knowing the resources where you refer clients

37. Engagement • Find out about client; Talk, don’t interview • Ask about their reaction to their situation • Don’t worry about apparent motivation • Recognize and state strengths as soon as possible • Provide a summary of what you can and can’t do for client • Be cautious about self-disclosure too early

38. Example ofStrengths-Related Assessment Tools

39. Strengths Assessment • Benefits • Help client identify strengths, abilities, assets, skills, dreams, interests • Provide improved sense of self-efficacy and hopefulness • Use strengths, etc. in planning • Develop relationship • Reduce client resistance

40. Strengths Assessment • Provides constructive challenge • Can’t do “autopilot” on reciting pathology • Encourages thoughts about, and practice of, strengths (rather than practicing pathology) • Inoculates case manager against hopelessness and skepticism

41. Strengths Assessment • Initially may be difficult for both worker and client • Usually unstructured; may have a list of strengths to prompt client’s thinking • Always dynamic and interactive • On-going throughout the relationship

42. Strengths Assessment • Summarize and write strengths down, give to clients • Help client take credit for things going well • Continually connect client strengths and current challenges they face

43. Strengths Assessment Questions • What are your strengths/positives/good points/abilities? • When have you faced challenges successfully? • When were things going well and what were you doing to make them go well?

44. Strengths Assessment - Relationships • Who do you trust? What is it about them? • What has been the most successful relationship you’ve had, successful for both parties? What made it successful? • When have you been able to just give to others without expecting anything in return?

45. Strengths Assessment -Internal Resources • What was an example of your solving a problem effectively? • When did you successfully identify and complete a goal? What helped you complete that goal? • When did you feel most in control of your own life? What were you doing to make that happen?

46. Strengths Assessment - Recovery • When was a time that you stayed sober? What were you doing that helped you stay sober? • When was a time that you controlled your drug use? What were you doing that helped you stay in control? • What have you done to try and deal with your drug use?

47. Non-Strengths Information • Suicidal ideation or attempts • Risk to do harm to others • Physical problems associated with drug use, HIV status, general health concerns • Intrinsic limitations such as learning difficulties, not reading well

48. Activity #2 • Conducting strengths-based assessments

49. Example of a Goal-Setting Tool

50. Goal Setting/Treatment Planning • Benefits • When client identifies own goals (objectives, strategies) they are more likely to accomplish them • Places responsibility for action on client • Enhances client investment in own care • Teaches a process that can be used in the future