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INTRODUCTION
The period from the mid-1970s to the present has seen the emergence of case management as a viable modality for the rehabilitation and treatment of the seriously mentally ill. A plethora of publications have described the tasks of mental health case managers (Rose, 1992; Harrod, 1986; Rapp and Chamberlain, 1985; Morin and Seidman, 1986; Goldstrom and Manderscheid, 1983); the effectiveness of the approach (Bond et al., 1988; Deitchman, 1980; Goering et al., 1988); and the refinement of the model to clinical case management (Surber, 1994; Lamb, 1980; Kanter, 1988; Harris and Bachrach, 1988). The same period has witnessed the growth of literature devoted to examining the impact of culture and ethnicity on service utilization (Snowden and Cheung, 1990; Cheung and Snowden, 1990; Scheffler and Miller, 1989); the development of cross-cultural approaches to counseling and psychotherapy (Jones and Korchin, 1982; Gibbs and Huang, 1989; Acosta, Yamamoto, and Evans, 1982; Wilkinson, 1986; Pederson and Pederson, 1989; Comas-Diaz and Griffith, 1988); and cross-cultural considerations in psychiatric diagnoses (Loring and Powell, 1988; Adebimpe, 1984; Westermeyer, 1985; Fabrega, 1987). The contributions to these parallel literature streams have been multidisciplinary in nature, with the fields of psychiatry, social work, psychology, sociology, and anthropology being abundantly represented. While covering the same time span, however, the trends in the literature have tended to speak to the topic of cross-cultural work or of case management with the seriously mentally ill. These two separate and distinct literature streams rarely, if ever, refer to each other. To some degree, this represents the bifurcated thinking of mental health planners and others who have been charged with identifying “priority populations,” in the face of vastly inadequate resources. Funding for both research and treatment has tended to be earmarked for either the seriously mentally ill, or for ethnic minorities of color. There is evidence, however, that there is considerable overlap among these two groups (Snowden and Cheung, 1990). While the former group is defined by the severity of their symptoms and the duration of their illness, the latter is characterized by chronic exposure to serious environmental stressors that often result in acute symptom syndromes somewhat different from those manifested by majority culture members (Draguns, 1980). Both groups tend to suffer from catastrophic stressors such as unemployment, homelessness, poverty, and domestic violence, but the latter group also often suffers from the effects of translocation, racism, and even torture. Indeed, there is also ample evidence that ethnic minorities of color comprise a growing percentage of the users of public mental health services (Cheung and Snowden, 1990). The time has come for a more comprehensive definition of what constitutes “at risk” populations, variously defined as at risk for psychiatric hospitalization, criminal incarceration, the development of serious medical illness complicated by stress, or other manifestations of severe life stressors.
The person-in-environment approach of clinical case management allows us to view the client and his or her needs holistically. Therapeutic interventions can be targeted toward the client, a variety of points in the client's environment, or both. The realization that the client's environment is composed of agencies, professionals, and informal support systems, each with their own distinct subculture, allows us to integrate the two previously mentioned bodies of literature. In addition to their other tasks, each case manager must act as a cultural bridge between the client, his or her own culture, and the various subcultures the client must deal with in the mental health environment. This chapter synthesizes existing thinking on case management and cross-cultural practice and provides a framework that will underpin the culturally competent practice of clinical case management in public mental health settings. It proposes a role for case managers as “culture brokers,” that will make some of the work on ethnic culture more useful to them. Some contributions from the fields of linguistics and medical anthropology are included and the resultant fresh approach to case management is illustrated with case vignettes.
THE EMERGENCE OF CASE MANAGEMENT
The group of clients usually targeted for case management services is that designated as the seriously mentally ill. Most mental health systems include in this group persons suffering from psychoses and major affective disorders on Axis I of the DSM-III-R. With the limited resources available, people with Axis II disorders generally do not qualify for services. Diagnostic criteria alone, however, do not give us a very clear picture of the range of people who are recipients of public mental health services. The past decade has seen a drastic increase in the number of homeless people in the United States, and the mentally ill are generally thought to comprise between 28 and 40 percent of this population (Koegel, Burnham, and Farr, 1990). The ranks of the chronically mentally ill have been swollen by the addition of a whole new generation of young adult patients who, while generally socially disenfranchised and suffering from multiple problems, have not spent long periods of time in state mental hospitals (McCreath, 1984; Bender, 1986). Added to this are the ever-increasing number of “dually diagnosed” mentally ill individuals who also have substance abuse problems, and the large numbers of immigrants and refugees (Lee and Lu, 1989) who often suffer from the effects of war, racism, and even torture. From this we can get a picture of the current need for community-based mental health services, whose resources, in constant dollars, have been shrinking annually for more than a decade (Elpers, 1989). Meanwhile, the individuals needing such services are more ethnically diverse than at any time in the past (Sands, 1991, p. 155), and ethnic minorities of color comprise a growing percentage of the users of mental health services (Cheung and Snowden, 1990).
Three factors affect the appropriate service package for a given client. The first, of course, is availability. Community mental health services have never been funded at levels adequate to replace services that “deinstitutionalized” clients needed. A variety of factors, including the cessation of direct federal participation in community mental health care, local “taxpayer revolts,” and ongoing indifference, if not hostility, toward the mentally disabled have resulted in treatment systems that have seen declining support for several years. Very few communities in this country have the comprehensive service networks needed to sustain seriously mentally ill individuals outside of the hospital with a reasonable quality of life (Gerhart, 1990, p. 11). The second factor is that services must also be accessible to clients. This means geographically, physically, linguistically, and culturally. Changing demographic trends among the users of public mental health services require concurrent changes in services if these services are to be culturally accessible. Finally, the services that do exist need to be carefully coordinated for the client. Perhaps this latter requirement has contributed most to the rising popularity of case management.
Given the diverse forces behind deinstitutionalization, researchers have looked at the need for case management from a variety of perspectives. Inherent in the nature of deinstitutionalization was the mandate to attempt to keep clients out of the hospital. This was reinforced by increasing cost consciousness and by the fact that inpatient services have invariably been the most expensive. One of the primary justifications for the case management approach, therefore, has been that it reduces “recidivism” (Morin and Seidman, 1986; Harris and Bergman, 1988). Increasing evidence supports that indeed it does (Bond et al., 1988; Goering et al., 1988). Others saw a need to reduce duplications of service and general inefficiencies in the delivery system (Deitchman, 1980). Recent thinking, however, has come back to the realization that treating serious mental illness is a long-term process and that relapses requiring brief hospitalizations can be expected to occur periodically in some patients. This wisdom seems to free us from the ongoing paradox of identifying the sole goal of one service (case management) as the reduced utilization of another service (hospital recidivism). Contemporary conceptualizations of the practice of case management, however, see it as a process that should be driven by the needs of the client (Anthony et al., 1988; Kanter, 1991). Such notions have focused upon the needs of the client within the context of functional limitations imposed by long-term mental illness. We should add to these considerations the dimension of the client's ethnic culture. The ethnic culture of the clients blends with their “socialized” culture as mental patients to form complex and often confusing identity amalgams that profoundly affect their attitudes, beliefs, and behavior.
CHARACTERISTICS OF CASE MANAGEMENT
While a variety of definitions of case management have emerged in the literature, they tend to be descriptions of case management tasks that lack a common conceptual base (Goldstrom and Manderscheid, 1983; Spitz and Abramson, 1987). These descriptions have looked at the activities of case managers in public, for-profit, and non-profit settings. Consistent with the two-tiered system of mental health care represented by the public and private sectors respectively, each of these sectors has developed separate models of case management. Public sector case management, the focus of this volume, attempts to secure needed services for an individual from a patchwork of poorly coordinated and underfunded services either operated by, or on contract to, public entities. Private case management is exemplified by the “managed care” field and often takes the form of regulating access to insurance benefits and pre-authorization of service utilization. The practice of case management, nevertheless, is commonly acknowledged to be part of social work's person-in-environment tradition (Leukefeld, 1990). A controversy, however, has arisen over the relative weighting of personal and environmental interventions. This is understandable given the triple historical mandates of maintaining clients out of the hospital, improving their quality of life, and coordinating inadequate and fragmented community services. The emphasis on referral, advocacy, linkage, and service coordination (Turner and TenHoor, 1978; Leavitt, 1983; Johnson and Rubin, 1983) has come to be known as the service brokerage model. Critics have variously called this model too bureaucratic and pathology/deficit-focused. In addition, it has been seen as contributing to a trend to de-professionalize the practice of case management. A modification of the brokerage model is the developmental-acquisition model (Rapp and Chamberlain, 1985; Modrcin, Rapp, and Poertner, 1988). This model emphasizes the development of the client's potential (utilizing his/her strengths) and the acquisition of community resources. The most recent thinking, and that embraced by many of the contributors to this volume, encompasses all of the above, and emphasizes, moreover, the importance of the therapeutic relationship between client and case manager. It adds periodic psychotherapy to the list of tasks performed by case managers, and has come to be known as clinical case management (Lamb, 1980; Kanter, 1988; Surber, 1994).
All in all, clinical case management for the seriously mentally ill is “fundamentally a putting into practice of the concept of continuity of care” (Harris and Bachrach, 1988, p. 1). Perhaps the simplest way to conceive of the clinical component of case management is that it involves the conscious use of self by the case manager. Concepts of transference and counter transference arise and often must be interpreted in the context of serious mental illness (Kanter, 1989). Nevertheless, two other levels of relationships must be examined in the practice of clinical case management. While, of course, transference and counter transference classically refer to the relationship between the therapist and client, two other important relationships-that of the client and the environment, here understood as the network of agencies, professionals, and significant others in the client's life, and that of clinical case manager and this environment.
We thus get a picture of a triangular relationship between client, clinical case manager, and the environment.
Each side of the triangle consists of a diadic relationship between two of the entities and is a possible target for therapeutic intervention. Consequently, the case manager must make ongoing assessments of both the client's level of functioning and the environment's responsiveness to the client's needs in order to arrive at a systematic and informed judgment about an appropriate point of intervention. This is the main difference between clinical case management and traditional office-based psychotherapy. The central thesis of this volume is that each side of this triangle represents a relationship between either the client and case manager, client and environment, or case manager and environment; that each of these entities has its own complex culture; and that effective clinical case management demands that these three key relationships reflect appropriate cultural bridging between the three entities.
THE ROLE OF CULTURE
Culture can be defined as the vehicle through which one generation passes on to the next its ways of seeing, experiencing, interpreting, and being. It serves the purpose of teaching the new generation ways of coping and surviving in the world as the previous generation understood it. Indeed, as D'Andrade (1984, p. 116) explains, it consists of
learned systems of meaning, communicated by means of natural language and other symbol systems having representational, directive, and affective functions, and capable of creating cultural entities and particular senses of reality. Through these systems of meaning, groups of people adapt to their environment and structure interpersonal activities.
Consequently, culture shapes the basic characteristics of human beings, such as beliefs, emotions, sense of self, and even, as some have claimed, the diseases to which one is susceptible. While such a broad definition of culture allows us to interpret behavioral data from a variety of perspectives, and indeed, allows us to practice cultural relativism (Fabrega, 1989a) in public mental health, care must be taken not to overly attribute physical and mental phenomena to cultural influences. Overgeneralization can result in cultural reification, harmful stereotyping, and loss of the individuality that is so important in effective treatment and case management. In fact, intracultural differences may exceed intercultural differences in some cases (Sue, 1981). As Roll, Milien, and Martinez (1980, p. 165) illustrate, “there are some ways in which any particular Chicano is like all other Chicanos and there are some ways in which a particular Chicano is like some other Chicanos, and there are ways in which a particular Chicano is like no other Chicano.”
A slightly divergent trend among anthropologists has focused on culture as a set of coherent subsystems or domains of shared knowledge (D'rade, 1981), behavioral domains (Roberts, 1964), or semantic domains that feature ways of classifying and talking about phenomena (Romney, Weiler, and Batchelder, 1986). This framework allows us to conceive of the professional and bureaucratic environments our clients encounter as having their own cultural characteristics. These environments, for each client, comprise agencies, professionals, formal and informal support networks, and other systems, with each...
