Clinical Case Management for People with Mental Illness

A Biopsychosocial Vulnerability-Stress Model

Daniel Fu Keung Wong

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317824985
• Edition: 1
• Topic: Medicina
• Subtopic: Teoría, práctica y referencia médicas

A unique—and effective—approach to mental health practice Clinical Case Management for People with Mental Illness combines theory, practice, and plenty of clinical examples to introduce a unique approach to case management that's based on a biopsychosocial vulnerability-stress model. This practice-oriented handbook stresses the dynamic interplay among biological, psychological, social, and environmental factors that influences the development—and severity—of a person's mental illness. Filled with case examples to illustrate the assessment and intervention process, the book is an essential resource for working with people who suffer from depression, anxiety disorders, schizophrenia, and personality disorders. Author Daniel Fu Keung Wong draws on his experiences as an educator, cognitive therapist, mental health worker, and case manager working in Asia and Australia to explore the concepts and contexts of clinical case management for individuals suffering from mild and chronic mental illness. He guides you through the creative use of various therapeutic approaches that emphasize different aspects of a person's condition that can influence the cause and course of mental illness. Clinical Case Management for People with Mental Illness examines a range of important topics, including the roles and functions of mental health workers, relapse prevention, assessment and clinical intervention, psychiatric crisis management, and working with families. In addition, the book includes checklists, worksheets, activity charts, and three helpful appendices. Clinical Case Management for People with Mental Illness examines:

• models of assessment
  
• microskills in assessment
  
• areas of assessment and intervention
  
• understanding the roles and psychological reactions of family members
  
• assessing and working with individuals with suicidal risk or aggressive behaviors
  
• and much more!

Clinical Case Management for People with Mental Illness is an essential resource for mental health professionals, including psychologists, occupational therapists, mental health social workers, nurses, counselors, and family social workers.

Chapter 1

Clinical Case Management: An Overview

INTRODUCTION

Mental health workers function within certain political, social, and economic contexts in a society. This chapter introduces these contexts by giving an account of the development of mental health services in Hong Kong, a critique of the mental health services, and an explanation of the difficulties faced by mental health workers when delivering services to their clients in Hong Kong. The second part of this chapter is devoted to discussing the concept of clinical case management and how this concept has been developed to work with two broadly differentiated groups of people with mental illness: individuals with mild mental illness and individuals with chronic mental illness. Differences exist in the nature and skills of clinical case management for people suffering from mild mental illness and those suffering from chronic mental illness. Generally speaking, whereas the emphasis for working with people with chronic mental illness (e.g., schizophrenia) centers on rehabilitation and supportive counseling, the focus of intervention for people suffering from mild mental illness (e.g., anxiety disorders) revolves around cure and in-depth, therapeutic counseling.

MENTAL HEALTH SERVICES IN HONG KONG: A CRITICAL REVIEW

Development of Community-Based Mental Health Services in Hong Kong

At least three driving forces led to the development of community care in Hong Kong. These forces were quite similar to those found in other developed countries, and included: (1) adverse effects of insti-tutionalization, (2) advent of psychotropic medications, and (3) benefits of community living.

Adverse Effects of Institutionalization

The effects of institutionalization were strongly criticized in the 1960s and 1970s. In a classic movie, One Flew Over the Cuckoo’s Nest (1975), patients had to conform to strict rules and regulations in an oppressive psychiatric hospital. In the movie, patients were confined to a locked-up environment without any programs for rehabilitation. Some patients escaped into their illnesses in order to survive the institutional oppression. Others were apathetic and showed no interest in their living environment. The movie was said to reflect a certain reality of psychiatric hospitals at the time, and understandably, this and many other incidents aroused the public attention toward improving the lives of people with mental illness. Consequently, a movement toward deinstitutionalization of mental patients began.

Advent of Psychotropic Medications

It would not be possible for some chronically mentally ill patients with severe psychotic symptoms to live in the community without the support of psychotropic medications. Indeed, these medications were, and still are, able to help control clients’symptoms. With the intake of medications, many chronically ill patients are able to function adequately in the community. The earliest publicly used psychotropic medication was chlorpromazine (Torrey, 1988). Therefore, the advent of psychotropic medications could be seen as a positive driving force toward deinstitutionalization and community care for people with chronic mental illness.

Benefits of Community Living

Since the 1960s, some countries, such as the United States and Great Britain, have begun to experiment with different types of community-based mental health programs for persons with mental illness. These programs have been introduced with the understanding that in-vivo training in community living is a better treatment modality for persons with mental illness than hospital care (Test & Stein, 2000). Moreover, it may foster a sense of community spirit among citizens. Thus, community-based mental health programs such as assertive outreach, psychiatric crisis assessment and treatment team, halfway houses, small group homes, and sheltered employment have been established (Test & Stein, 2000). Many of these programs underwent evaluations and were found to bring beneficial effects such as reduced hospital stay, fewer hospitalizations, better social functioning, and better quality of life for persons with chronic mental illness (Test & Stein, 2000). In Hong Kong, studies have been carried out to examine the effectiveness of some currently run community mental health services, such as the community psychiatric team services (Chiu, Poon, Fong, & Tsoh, 2000) and long-term care homes (Cheung, 2001). However, no comprehensive review or policy evaluation of mental health services has yet been done in Hong Kong.

Time Line of Development of Mental Health Services in Hong Kong

The Early Days: Custodial Care

Prior to World War II, no community-based psychiatric service was available for people with mental illness in Hong Kong. These individuals were put into asylums run by charitable organizations, such as Tung Wah services. Some of them might also be sent to Fong Chuen Hospital in Guangzhou, China. Services were custodial in nature and the Hong Kong government did not take an active role in financing and providing services for people with mental illness (Yip, 1998).

The 1960s and 1970s: The Introduction of an Infrastructure of Mental Health Services

The establishment of the infrastructure of inpatient and outpatient mental health services began after World War II (Yip, 1998). The Castle Peak Hospital, one of the largest psychiatric hospitals in Hong Kong, was opened in 1961. Community-based facilities, such as halfway houses and sheltered workshops for mentally ill persons, were also established during this period. In addition, the Mental Health Ordinance was enacted at around the same time as well. However, although hospital-based psychiatric services were still largely custodial in nature, community-based psychiatric rehabilitation services were far and few (Yip, 1998). For example, very few halfway house placements were available for persons with mental illness before 1982. Moreover, these houses were managed on a twenty-four-hour basis, seven days a week, by one social work diploma holder and two nontrained welfare workers. In the case of vocational rehabilitation services, with the exception of a few sheltered workshops, little vocational training and employment-assisted programs, such as supported employment and day training centers for persons with mental illness, were available. Indeed, community-based psychiatric rehabilitation services did not take shape until the early 1980s. During these early days of the development of mental health services, the basic skeleton of medical, social, and vocational rehabilitation services had begun to form. However, the movement to deinstitutionalize mentally ill persons had not been fully recognized by the government.

The Consolidation of Mental Health Services

In 1982, an acutely psychotic person went into a kindergarten in Kowloon, Hong Kong, killing and injuring a number of children. This incident created a scare in the community. As a consequence, the government formed a task force and subsequently made several recommendations for improving community-based psychiatric services in Hong Kong. For example, community psychiatric nursing services were introduced and halfway houses for persons with mental illness were greatly expanded, with a new staffing structure that included social workers, psychiatric nurses, welfare workers, and minor staff. Other services, such as day training centers, aftercare services, long-stay care homes, and carer support groups, were gradually introduced to the community psychiatric rehabilitation service structure in Hong Kong. To further protect the interest of the public as well as the right of persons with mental illness, the Mental Health Ordinance was also revised. During this period the government took more responsibility in financing social and vocational rehabilitation services in Hong Kong. However, residential services were still institutional in nature, with each halfway house and long-stay care home taking forty and two hundred residents respectively. Yet, with the rapid expansion of community-based psychiatric services in Hong Kong, psychiatric stigma surfaced as an important issue of grave concern (Hong Kong Council of Social Services & MHAHK, 1996). The public was found to hold very negative and even hostile attitudes toward persons with mental illness. Indeed, many community psychiatric services had to be built in remote areas or with front entrances put in locations that were not easily accessible to the public.

It was during this period that the call for the establishment of a case management system was raised among professionals in the mental health field. This included a number of issues. First, with the rapid and extensive expansion of community-based rehabilitation services, the lack of coordination between the inpatient hospital services and the community-based psychiatric services, and between different types of community-based services was criticized. Complaints about the delay in accessing services, the rigid criteria for admission to services, and the inadequate services in the community were heard. Second, since clients may receive a multitude of services from different mental health professionals, it would be sensible to identify a key worker who would oversee the coordination of services for the clients. However, mental health workers, family members, and clients had difficulty choosing the key workers. It was not clear to them who should be responsible for coordinating services for the clients. A system to designate the key person accountable to the welfare of the client needed to be created. Third, since many clients were rather chronic and passive, the clients had difficulty asserting their rights and negotiating their needs with the health care professionals in the mental health system. Professionals were needed to help these individuals advocate their rights. In spite of these needs, the government has not yet formally adopted a case management approach as part of the mental health care system, even to this date. In contrast, in the United States, case management has been included as one of the key components in the service delivery system in mental health care (Levine & Fleming, 1984).

The 1990s to Present: The Experimentations of New Mental Health Services

Since the establishment of the Hospital Authority (HA) in Hong Kong in the early 1990s, psychiatric inpatient and community rehabilitation services have undergone many changes. A number of specialized, community-based psychiatric services have been established. These include such initiatives as community psychiatric treatment (CPT) teams for crisis assessment and management services, psychogeriatric assessment and treatment services, and early assessment service for young people with psychosis (EASY). Indeed, under the governance of HA in Hong Kong, a trend toward developing inpa-tients and community-based specialized psychiatric services (e.g., for the elderly, youth, and children with special needs) has begun. Mental health professionals have begun to experiment with new medical and psychosocial intervention approaches in helping their clients. For example, different intervention programs and psychotherapies, such as cognitive therapists and social skills training, have been used to help people with different mental health problems.

Under the Social Welfare Department (SWD), attempts have also been made to shorten the waiting list for different types of community-based rehabilitation services by building more halfway houses and long-stay care homes. In vocational rehabilitation, supported employment as a new initiative was launched in the mid-1990s. A new service called mental health link was also introduced in the mental health care system in early 2000.

Issues and Problems of Mental Health Services in Hong Kong

Several issues and problems confront the mental health care system in Hong Kong. These are explained in the following sections.

Lack of Direction and Coordination of Service

In Hong Kong, the Health, Welfare and Foods Bureau is designated to be in charge of the overall coordination of health care related services, including mental health services. Three parties are involved in the provision of mental health services in Hong Kong: The HA, SWD, and the Department of Health. The HA provides inpatient and medically related community-based rehabilitation services, and the SWD renders mainly community-based social, residential, and vocational rehabilitation services to persons with mental illness. The Department of Health provides prevention services such as public education for the general population (Health and Welfare Bureau, 1999). Under this structure, several questions may be raised. On the policy level, although it is encouraging to find that various parties have deployed resources to develop different mental health programs, no clear, overall policy direction guides the development of mental health services in Hong Kong. For example, what is the best mix for hospital and community-based rehabilitation services in Hong Kong? In some parts of the world, resources resulting from the closure of psychiatric hospitals have been devoted to developing community-based psychiatric rehabilitation services (Australian Health Ministers, 1992). In Hong Kong, a larger proportion of the health care resources for psychiatric services are still put into supporting hospital services (Health and Welfare Bureau, 1999). Whereas various political, social, and cultural conditions may have shaped the development and setting of different priorities in different countries, the Hong Kong SAR (Special Administrative Region) government still has not established an overall mental health policy to guide the development of mental health services in Hong Kong, even though various mental health acts have been legally endorsed in such countries as the United States, the United Kingdom, and Canada.

Other important questions that need to be asked are What is the best possible model of community rehabilitation services for Hong Kong? and What specific types of community-based services should be further developed? Lawson (1995), invited by the government to examine the mental health services in Hong Kong, proposed a cluster-based model of mental health service. According to the model, each cluster consists of psychiatric beds located in general hospitals, an outpatient clinic, a CPT team, vocational rehabilitation services, and residential services. This type of cluster-based service model has been successful in other countries. Unfortunately, his idea had not been fully adopted by the Hong Kong government.

On the practice level, mental health professionals from the HA and the SWD have complained about the delay in service provision due to rigid admission procedures and criteria (Yip, 1997). For example, some hospital staff commented about the long delay in processing and formally admitting a client into halfway houses. Other staff found that the CPT teams are unable to respond quickly to their request for assisting clients in crisis. Central to these complaints is a difference in judgment among different service personnel regarding the severity and urgency of the conditions and the needs of clients.

Confusion exists as well regarding the admission criteria set by different units offering similar services. For example, staff commented that different CPT teams have different sets of service criteria. Some teams manage only cases that were discharged from their own hospitals and do not reach out and assess potential outside cases. Another example is complaints that the staff of some halfway houses interpret their admission criteria more stringently than others, thus refusing to admit certain clients who would otherwise be accepted in a different house.

Inadequate Delivery of Mental Health Services

Experiences in the United States and Britain have suggested that assertive outreach is an essential characteristic of a good community support system for persons with mental illness, particularly those with chronic mental illness. Services should also be continuous with no definite time frame. In Hong Kong, except for community psychiatric nurses (CPNs) and CPT teams, the dominant service delivery mode is still largely office-based, with a nine-to-five working schedule. Very few services operate on the weekends and after office hours. Clients with chronic mental illness who are passive and/or resistant to treatment may not be able to receive timely interventions when needed. Indeed, evidence has shown that delays in seeking psychiatric treatment are a common and serious issue needing the attention of the mental health professionals (Chiu et al., 2000). Mental health services that bear an assertive outreach component and operate after office hours may be able to address the issues of the delay in treatment and prevent hospitalization.

Continuous support, particularly by an identifiable person in a trusting relationship, is crucial for persons with chronic mental illness. Current practices of mental health services such as medical social services and halfway houses have a definite time frame, and no single, identifiable person assists the client throughout his or her rehabilitation process. This servic...