Dilemmas when working with substance abusers with multiple and complex problems: the case manager's perspective

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.