Working Creatively in Mental Health Case Management

As mentioned in a previous post, I have been working in the area of case management for the past 6 months, with some therapy with a handful of clients- for example with a caseload of 50-60 client I may do more regular therapy with 5-10 of them.

There is a movement to adopt “recovery” oriented language and outlook but to date I have seen only glimpses of it in case management, but when things get tough (hospitalizations, etc) this language of looking at someone’s strengths, good reasons for their actions and own abilities gets thrown out the window in lieu of mechanisms of control.

In times of crisis and challenge it seems more common to start the see the client as problematic in our conversations together as professionals. For example very often people are described in the following ways: “she is very dependent”. “she is non-compliant” “requires redirection frequently”. This paternalistic lingo evolves in part by being a “manager”, rather than a therapist or a supporter.

It has become rarer now since becoming a case manager that I share with my colleagues with amazement of accomplishments that my clients have made or the amazing insight that they arrived at in session that day. Even if they are doing well it may also be attributed to the role of medication, which may be true in part, but also denies the client the victory of their own self-accomplishment.

As a case manager I spend so much time on medication refills and psychiatrist appointments that it seems like a big switch of gears to put on a therapeutic lens in each conversation. Many other professionals try to assure me that this is too much to expectof myself. However, I yearn to give the same attention and curious wonder to my clients I only see half an hour per month (or more frequently when medication changes are being made or person is unwell) as those I see every two weeks for therapy.

Part of this is beginning to think creatively, more visually and outside the box. I would like to dream to find new ways to engage their strengths and goals. This involves taking the time in each conversation to wonder out loud with someone about the future, about the ideas, about what is going well in their lives.

I have tried to have the lenten practice praying for my clients as I see them. I would also like to take time, even 15 minutes a day to think openly and creatively about one of my clients and think and plan a way forward. A therapist I used to work with used to set aside a day a month to plan and think about the work she was doing with her clients. In my work a blank calendar would definitely not go unnoticed, so a little bit integrated in would be the best strategy.

I’m curious to here about strategies of working creatively with long-term and chronic clients that you have used as a fellow therapist or ideas you may have from those outside the field. For those in mental health and case management how have you managed to refocus on recovery and strengths. Please share!!!

From therapy to case management

In my new job I’ve switched from doing therapy with people 100% of the time do now doing 80% case management and about 20% therapy in my new role working with adults with chronic mental illnesses mostly those with psychosis of some sort, and also those with bipolar or longstanding and complex mental illness of varying sorts.

Some would call it a fall from grace other people would call it a chance to directly impact people’s lives.

The work I do now puts me squarely in the medical model as I work closely with the psychiatrists monitoring medication adherence and tolerance, as well as working together with the client on a movement to recovery in their mental illness. 

One positive aspect of my job is now working more closely with Occupational Therapists at our centre who do a wonderful job of connecting people with activities, socialization and even housing.  The job of the OT and case manager overlaps at times as I may be actively working on some areas that OT’s may also help with (housing for example).  The OT’s run groups at some of the community mental health clubhouses and by doing this they introduce the clients to a new community support network.

Because of the short-term nature of my previous job doing therapy I did not usually refer my clients to these resources as they were not appropriate supports, or the person was independent enough to connect individually.

I miss doing therapy greatly.  I have a number of clients I have offered to do therapy.  For example, one client with schizophrenia (now under control with meds) and OCD.  We will be working on the OCD together in therapy.  This will be a new challenge for me as I have not worked with someone on OCD before and because of his also having a diagnosis of schizophrenia. 

Working in therapy on this team is generally harder for a couple of reasons.  Firstly my caseload is at least double and almost triple what it was before- so I am caring for more people with the same amount of time in a week- so in this model I cannot do therapy with everyone but with somewhere between 5-12 people at a time.

People come to our team because they have had a mental illness for some time; this can make therapy harder as they and those around them have accepted that this is how life is for them.  Therapy can feel threatening as if to challenge the equilibrium they may have found.  Most people have had case management for a long time (usually meeting once a month for a 1/2 hour) that they are accustomed to the care they have. 

Other people benefit so much from medications and are well-supported by family and involved  in their community (many of my clients are christians who go to church regularly) that the focus is much different; on relapse-prevention planning and re-enforcing and maintaining good support.

 What I have noticed is that in some people with psychotic disorders there is  a strong anxiety component.  For example, a cleint may  have had hallucinations and delusions in the past but they are now managed by medication but still they have significant fear and worry in their lives, and have difficulty handling difficult emotions, like shame or embarrassment.

These are the folks that I would like to do some basic therapy for anxiety.  However, given their chronic nature and how negatively their mental illness has impacted their ability to function in basic areas of their life they may have a harder time engaging in traditional CBT therapy- some of them are just not interested as well. 

This is the challenge ahead.  I hope there will be some encouragement in undertaking this work with those who are ready and providing support to all of my clients in meeting their goals and needs wherever they are on their road towards greater wellness.