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!!!

The Hazards and Joys of work in Mental Health

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One of the riskiest and most challenging aspects of working in mental health is that of suicide.  For those who are depressed, bipolar, and psychotic that risk is very high.  We do everything in our power to prevent such tragedies.

In the last two weeks at work I have witnessed two contrasting stories on the topic.  Firstly, a client committed suicide that was on the caseload of one of the case manager.  This client’s life was very hard, she suffered from extreme highs and lows and she had numerous previous attempts where she had escaped death. The case manager noted that on the weekend that it happened there was a hang-up message from that client.  So close to asking for help.  This was very hard for the case manager and for all those who had worked with the client over the many years.

The second story is one of miraculous grace.  A client of a different case manager told me that one of her clients told her that over the week-end her client had prepared to commit suicide and was ready to do it and at that very moment her phone rang and the client picked it up.  It was his daughter who he had not heard from in 10 years calling to say that she wanted to come and visit him shortly.  This stopped the man in his tracks and he sought out help.

I have never experienced the loss a client by suicide, but I understand that most people who work in mental health do so at some point in their career.  I know that likely I would struggle emotionally and feel guilt and wonder what I could have done.  I know it would be an incredibly painful experience.  Trusting in God, as a loving father, I know he loves that deeply wounded and through the second story see that he does miraculously use us weak human beings for his means of grace in this world.

I was interviewing and listening to a new client the other day as she told me her story of death of all of those close to her, parents who were not available or in jail, and chronic physical problems. I  also read the chart to see also that she had experienced abuse in foster case.  It is so easy to understand how people become so hopeless when they experience life as unhappy and without joy as this woman described.  I just wanted this client to experience the love of Jesus.  The story of the phone call reminds me that God moves in mysterious ways gently and unexpectedly through each person’s life.

My lenten discipline for this season is to endeavour to pray for each client before seeing them and ask that God would give me openness, patience, love and grace.

Challenging therapy clients : Psychosis

When most people think of challenging clients in therapy they immediately think of a few different labels: one of which is borderline personality clients- few think of those with schizophrenia.

Today I’m weighing on a challenging client group: those with psychosis/schizophrenia.  I find these clients tricky to figure out if and how to do therapy. 

Historically in the psychoanalytic schools of thought some people thought it was inadvisable to do therapy with those with psychosis, as classical psychoanalysis (going back to childhood) can be indeed in some cases cause more harm than benefit for someone with psychosis.  (However- this is not to say that it is never helpful- please see Elyn Saks’ book- The Centre Cannot Hold a story of a woman with schizophrenia who found medications and psychoanalysis helpful). Jung however, formed his theories by observing those with psychotic illnesses and worked directly with them.  Currently there are numerous articles on CBT for psychosis, some of which I’m trying to wade into.

Here are the challenges:

1) For  psychotic illnesses the first line of treatment is medication management with antipsychotics.  For many when this is accomplished they have nearly eliminated positive symptoms of hallucinations and voices- although some have residual symptoms. For those folks for whom medications are working therapy seems unnecessary however even those successfully on medication relapse sometimes due to stress and other times because they go off their medications.   Do you do CBT for psychosis for those in remission?  Or just educate about warning signs?  Mostly we just check that people are sleeping well and not getting too stressed out. 

2) Those with residual symptoms of paranoia, voices, and delusions can be hardest to engage personally due to fixation on ideas, or fear of their voices.  Some with delusional ideas it seems that their connection to the ideas are so strong that it can be hard to find a window of uncertainty to introduce doubts are hypothesis testing around their beliefs.

I’m struggling to offer my clients some therapy but end up offering a conversation here and there and am uncertain how to and when engage these clients.

I’ve been reading a lot about psychosis these days to help and finding various models in addition to the purely biological vulnerability model that is espoused that help me think of windows to address psychotic illnesses.  I think for clear-cut cases of schizophrenia with an average onset age and classical symptoms that there is likely a strong biological component.  However, there have been numerous other studies that have linked mood disorders, anxiety, and experiences of trauma with psychosis.

If you are a therapist what have you found works in therapeutically working with those with symptoms of psychosis?

If you have experienced psychosis yourself and attended therapy or had psychiatric treatment, what helped and what didn’t help?

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.

Trauma and Psychosis

I just attended an interesting seminar on trauma and psychosis and CBT. 

Psychosis is almost exclusively explained as a biological vulnerability.  Trauma is often assumed to be linked to depression and anxiety but causality is not openly as linked to psychosis.

One researcher and psychiatrist Dr. Bill MacEwan, found that among those in the Downtown Eastside of Vancouver in a population that is highly addicted to substances there is a higher comorbidity of psychosis and childhood trauma than anxiety and childhood trauma.  One explanation is that drug use mediates/masks the anxiety symptoms that trauma can produce and that increased drug use can trigger or exacerbate psychotic symptoms.

Notably Tony Morrison of the UK reported a study that found that in one study institutional care was especially significantly associated with paranoia and rape was associated with audio-visual hallucinations.  Physical abuse alone was significantly linked to both paranoia and audio-visual hallucinations.  Numerous other studies found the same link between psychosis and traumatic events, especially those in early childhood.  Also: people can experience psychosis itself as traumatic and may go on to develop PTSD after having PTSD from the psychosis or institutional care.

This is particularly significant because it means a couple of things.

1) Preventing abuse of children could diminish those who experience psychosis

2) Understanding this link can help someone gain insight into their illness  and through addressing trauma.

3) Our care should acknowledge this and seek to diminish further trauma and increased sense of safety.

For me going starting into a field working with people with psychosis and also with a huge passion for helping people with trauma this brought a new meaning to my work with those with psychotic illnesses and more perspective and ideas on how to understand those of my neighbors in the DTES with psychosis.

One week

After one week immersed full-time in the world of mental health therapy I am in love and energized.  The day I arrived I had a dozen cases already assigned to me, including both initial assessments and clients who were already long-time clients of the woman I was filling in for.  

The experience of being with someone suffering from anxiety or depression and literally seeing relief and reduction of symptoms as the session went on was satisfying.  I really got to use my whole self in the process and be genuine. What an experience.  And on top of that to try and understand the complexity of people’s lives, thoughts and beliefs and how and when they manifest into “symptoms”.  

I have a fantastic supervisor who herself absolutely loves working with people and doing therapy and who has spend time with me to introduce me to clients and give feedback on the direction of my cases.

I feel as if it is an answer to a prayer I was almost too tentative to pray.  

 

 

What is this blog about?

This blog is an attempt to synthesize all the thoughts that I’ve been collecting in my head around social work, faith, therapy, psychology, and the like.

I’m at the tail end of a masters in social work in Canada.  I have had two placements in the area of mental health and addictions.  I also live in a poor neighborhood in our city, and am part of a network of Christians who are wanting to support people around here, creating a new kind of family, and a renewed expression of church.