“Aggressive” and “problem-focused” models of case management for the severely mentally ill

Community Mental Health Journal, Vol. 29, No. 5, October 1993

CLINICAL CARE UPDATE

"Aggressive" and "Problem-Focused" Models of Case Management for the Severely Mentally Ill

Patrick W. Corrigan, Psy.D. Donna Kayton-Weinberg, MS

ABSTRACT: In this paper, the relative merits and limitations of two models of case management (CM) are compared: "aggressive" and ~problem-focused". Although aggressive CM has a well-established history of improving the community tenure of deinstitu- tionalized patients, individuals participating in this treatment are likely to become dependent on health care providers and hence require indeterminate assistance. Problem-focused CM teaches patients how to identify and resolve community-based predicaments thereby making them relatively more independent of the mental health system. Patients receiving problem-focused CM, however, need reasonably competent cognitive functions thereby ruling out participation of the most severely disabled individuals. An interaction of the two approaches is proposed in which aggressive and problem-focused CM is selected depending on the patient's current needs, cognitive deficit, and level of social support.

As more and more severely mentally ill patients have been released from long term psychiatric hospitals, clinical investigators have searched for and developed treatment strategies that meet patients' multi-faceted needs. After two decades of work, it now seems apparent that competent community support programs (CSPs) that include long

Patrick W. Corrigan is Director of the University of Chicago Center for Psychiatric Rehabilita- tion. Donna Kayton-Weinberg is affiliated with the Illinois School of Professional Psychology.

Address correspondence to Patrick W. Corrigan, Psy. D., University of Chicago Center for Psychiatric Rehabilitation, 7230 Arbor Drive, Tinley Park, IL 60430.

4 4 9 �9 1993 Human Sciences Press, l~c.

450 Community Mental Health Journal

term case management (CM) provide a better quality of life than contin- ued inpatient care. Traditionally, CM has been viewed as an "aggressive" endeavor in which case managers assume responsibility for the comprehensive treatment needs of their patients. However, aggressive CM that occurs over the long term is very expensive, especially with other, equally costly, interventions. With severe restrictions on mental health budgets common in most states, t reatment strategies are needed that augment aggressive CM and produce a more efficient and cost- effective intervention. In this paper, the pros and cons of problem- focused CM are reviewed for this purpose. Before discussing the com- parative strengths and weaknesses of these two forms of CM, however, the community needs of severely mentally ill patients are discussed.

THE NEED FOR COMMUNITY CARE

With the convergence of several independent movements in the early sixties, (e.g., wide spread use of neuroleptic medication, the institution of Aid to the Disabled (now Supplemental Security Income), and pas- sage of the Community Mental Heal th Centers Act of 1963), large numbers of institutionalized psychiatric patients were released from the hospital (Bachrach, 1981; Goldman, Gatozzi, & Taube, 1981; Lamb, 1982; Mechanic & Rochefort, 1990). Although the quality and organiza- tion of community care in the years immediately after deinstitutionalization have been widely regarded as lacking (General Accounting Office, 1978; Intagliata, 1982; Mechanic & Aiken, 1989), CSPs for a subsample of patients emerged where the quality of care was satisfactory. Several studies have shown that patients treated in well- administered CSPs for a discrete period of time have better outcomes than patients who remain in the hospital during the same period of time and then are released. Specifically, patients in CSPs report more satisfaction with treatment and greater a t ta inment of personal goals than inpatient comparison groups (Test & Stein, 1978). Despite the decrease in institutional structure, CSP patients dem(~nstrate less symptomatology (Herz, Endicott, Spitzer, & Mesnikoff, 1971; Stein & Test, 1978; Mosher & Menn, 1978) and fewer relapses (Mosher & Menn, 1978; Mueller & Hopp, 1983) than patients treated at inpatient settings and then released.

Other studies have indicated that quality of community care and improvement in mental status vary with the intensity of the CSP

Patrick W. Corrigan, Psy.D. and Donna Kayton-Weinberg, MS 451

(Modrcin, Rapp, & Poertner, 1988). Anthony and Blanch (1989) identi- fied twelve need domains including outreach, rehabilitation, health care, crisis intervention, housing, income support, family care, and advocacy. Programs that address more areas of community need yield greater outcomes. CM plays a central role in coordinating services for these domains and assuring that quality and continuity of care remains.

HOW TO CASE MANAGE." A G G R E S S I V E A N D PROBLEM- FOCUSED A P P R O A C H E S

Depending on the way in which CM is construed overall, specific duties may include discharge planning from the inpatient setting, estab- lishing linkages with community programs, networking with these programs to confirm that linkages have occurred, assurance that quality community care is proffered, and advocacy when sufficient quality is not provided (Kanter, 1989). Two models have developed that provide a framework for carrying out these duties: ~aggressive" CM (Johnson & Rubin, 1983; Schwartz, Goldman, & Churgin, 1982) and problem- focused (or ~'clinical") CM (Bachrach, 1989; Kanter, 1989; Lamb, 1980). As we will show in this paper, these two CM models do not entail mutually exclusive interventions nor pose independent goals. Rather, an interaction of the two strategies over the course of the disorder may provide the most effective CM for severely mentally ill adults.

In aggressive CM, case managers assume the role of responsible caretakers. Their goal is to actively assist patients in at taining service goals such as housing, financial aid, and vocational rehabilitation. For example, the aggressive case manager for Ed, a patient who has lost his Medicaid benefits, will call the Public Aid worker, obtain all necessary documentation to substantiate Ed's claims, travel with the patient to the Medicaid office, and follow-up with Ed to assure that Medicaid is eventually received. Sometimes extraordinary efforts may be needed to help accomplish these goals (e.g., work evening hours, travel across town for appointments, venture into dangerous neighborhoods), efforts tha t are assumed to be part of the aggressive case manager's standard duties. Proponents of aggressive CM assume that case managers are more skillful than patients in navigating the various services and agencies. As a result, patients often are relegated to passive roles with relatively little opportunity for learning new skills. For example, Ed


might not say much, instead deferring to his case manager who would iron out the problem.

Good aggressive CM has been described as longitudinal, cross sectional, and accessible (Baker & Intagliata, 1992; Caragonne, 1981; Intagliata, 1982; Test & Stein, 1978). Such CM is ongoing, beginning at discharge and continuing with patients as they move through various community services. Longitudinal CM does not end if the patient suf- fers a relapse and is rehospitalized. Instead, a spot remains vacant in the case load for the patient's eventual return to the community. Cross sectional CM implies that the case manager addresses all of the patient's need domains. Hence, case managers must have a broad network of service ~contacts" available to meet the changing spectrum of patient needs. By being accessible, case managers reach out to patients to serve them at their home, work place, or day treatment program rather than wait for them to meet at the office.

Rather than viewing the fulfillment of community needs as the ulti- mate goal of CM, '~clinical" case managers envision the work towards fulfillment as a therapeutic opportunity in which individuals with chronic mental illness may learn to cope with their disorder better. As a result, patients become more self-reliant and less dependent on the mental health system. In this light, the practice of CM is more akin to a therapeutic experience in which the mental health professional is reluc- tant to assume total responsibility for the patients' problems. Clinical case managers play an active role in helping patients to cope with community difficulties.

Problem solving provides a useful paradigm for clinical case managers. Seven steps in problem solving are reviewed in Table 1. The manner in which a case manager might adopt this strategy to resolve, for example, Ed's problem with Public Aid is also outlined in this table. Problem solving affords a stepwise clinical outline with which patients learn to resolve their community needs. Problem-focused case managers first teach the i r patients the steps of problem solving and then encourage them to independently resolve future community dilemmas, perhaps prompting patients when they are stuck at one of the steps or serving as a resource in generating solutions to esoteric community predicaments. Research on problem solving in inpatient settings has shown that severely mentally ill patients can learn this stepwise method and competently apply it to meet life problems (Hansen, St. Lawrence, & Christoff, 1985; Liberman, Mueser, & Wallace, 1986; Siegel & Spivack, 1976a,b; Wallace & Liberman, 1985).

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LIMITATIONS OF AGGRESSIVE AND PROBLEM-FOCUSED CM

Both aggressive and problem-focused CM have limitations in their effectiveness which suggest that an interaction of the two approaches serves CM and the patient best. Because the case manager is responsible for most service goals in aggressive CM, the patient is likely to become dependent on the professional such that CM services occur in never ending fashion. This form of CM is very expensive. Recent aware- ness about dwindling mental health budgets has driven legislators and mental health administrators alike to search for more cost efficient t reatment strategies. Still, some might argue tha t services like aggressive CM need to be ongoing to address the waxing and waning course of the severely mentally ill patient (Test & Stein, 1978). Is such lengthy and costly CM justified?

Research is mixed regarding the necessity for longitudinal case management. Bond (1984) showed that the length of time in CSP treatment was positively correlated with the rate of patient self-sufficiency. How- ever, others have argued that the need for specific CM services such as linkage planning diminishes soon after community reentry (Harris & Bergman, 1988; Surles & McGurrin, 1987). As patients adjust to other community care programs, CM can be curtailed. Aggressive CM that includes problem solving may help these patients become more independent and decrease the need for longitudinal care.

What limitations exist to the problem solving approach? Bellack, Morrison, and Mueser (1990) have criticized the stepwise approach of problem solving as not being representative of the actual process by which people confront day to day problems. Rather than being strategic in their approach towards common problems, individuals tend to draw on responses automatically with little cognitive mediation. People address novel problems in which they lack well-rehearsed responses intu- itively rather than using means-end logical analysis (Kitchener, 1983).

Whether problem solving is a stepwise process in normal individuals has not been resolved empirically. However, as a technique, the seven steps provide a useful prosthesis for guiding socially disordered patients in resolving interpersonal difficulties. This prosthesis may not totally approximate normative problem solving; artificial limbs do not always look exactly like arms and legs. However, the clearly specified steps of problem solving assist cognitively limited patients in better understanding their problems and in figuring out solutions. Still there are some patients with sufficiently severe cognitive and intellectual impairments who are unable to readily learn these skills (Corrigan et


al., 1991; Massel et al., 1991). As a result, the cognitive requirements of problem-focused CM may preclude a segment of the severely disturbed population from benefiting from this approach.

Problem-focused CM differs from aggressive CM in another signifi- cant way. Where aggressive CM requires extraordinary efforts to assure that community goals are accomplished, practitioners of problem- focused CM view errors in the at ta inment of community goals as oppor- tunities to learn to fine tune problem solving skills. Hence, problem- focused case managers are more likely to permit their patients to fumble with at taining community needs and to make mistakes. As a result, patient goals are not likely to be as quickly resolved as peers par taking in aggressive interventions. Given the immediacy and necessity of some patients' goals, this approach may have grave implications. For example, the homeless patient in the middle of winter needs to find emergency shelter at once. In this situation, a more aggressive approach is indicated. Alternately, the case manager may decide to inter- vene aggressively in situations where the problem-focused approach causes patients to become discouraged with frequent wrong decisions.

The immediacy and necessity of patients' goals is moderated by their support network. Individuals with a large and satisfactory network of family and friends are better able to address needs tha t occur in their lives (Sarason & Sarason, 1986; Sarason, Sarason, & Shearin, 1986). The support network of many patients with severe mental illness is smaller and less intimate than their peers (Tolsdorf, 1976). Neverthe- less, case managers may adopt problem-focused strategies for highly demanding life needs if the patient has family or friends that can lend support.

INTEGRATING A GGRESSIVE AND PROBLEM-FOCUSED CM

Kanter (1989) has called for development of a CM system in which the intensity of work with an individual patient is t i trated with that person's changing needs; the lability of patients' state and needs is especially marked in light of recent advances in psychopharmacology. Im- plicit in Kanter's recommendation is that individual differences exist in patients' need for various CM services. For example, research suggests that the course of severe mental illness within a patient may vary widely from a progressively worsening downhill trend at one extreme to total remission and performance of relatively "normal" social goals at the other (Harding, 1988). Hence, case managers need to use strategies


representing the aggressive or problem-focused models, depending on the patients' state. An empirical model outlining patient variables that should be monitored to guide selection of case management approaches is reviewed in Figure 1.

The severely mentally ill patient with more severe presentation (rep- resented in the center column of the figure) will have greater cognitive dysfunctions thereby reducing their ability to actively participate in resolving various living needs. They are also likely to have a smaller support network available to help at tain community goals; family and friends are less likely to be involved in a patient's life when they are more severely symptomatic. These factors combined suggest that patients will be better served by aggressive CM in the acute phase of the disorder. Outcome measures should subsequently show that in the relatively short term after receiving aggressive services from a competent case manager in a service system with sufficient resources, many

FIGURE 1 The Relationship Between Patient Variables and

Aggressive Versus Problem-Focused Case Management

SEVERE PRESENTATION

RELATIVE REMISSION

P~IENT VARIABLES

TYPE OF CASE MANAGEMENT

OUTCOME

HIGH THOUGHT DISORDER POOR SUPPORT NETWORK

HIGH PRIORITY NEEDS

LOW THOUGHT DISORDER GOOD SUPPORT NETWORK

LOW PRIORITY NEEDS

l 1 AGGRESSIVE CASE

MANAGEMENT I PROBLEM-FOCUSED

CASE MANAGEMENT

1 l MOST GOALS MET SHORT TERM GOALS AT SHORT TERM NOT WELL MET

LONG TERM GOALS STILL REQUIRE CASE MANAGER

LONG TERM GOALS |NDEPENDENTLY

ATTAINED


of the patient's needs will be met. However, problem-focused strategies should be introduced as patients improve.

Patients are better able to participate in CM planning and are more likely to learn the components of problem solving when they are in a relatively stable stage of their illness where cognitive deficits are di- minished. Case managers should introduce problem-focused strategies slowly by demonstrating the process around a specific, low priority problem with which the patient is struggling. In the beginning, the case manager assumes responsibility for guiding the patient through the seven problem solving steps. As the patient masters these steps, the case manager plays a less essential role so that eventually, the input of the professional is not needed to resolve some life difficulties.

When starting the problem-focused approach, specific problems are not likely to be quickly resolved. As a result, the priority of presenting problems and needs should be regularly assessed. The case manager may decide to include more aggressive approaches for some life problems. A dynamic mix of aggressive and problem-focused approaches will help patients learn how to better meet their life demands and become less dependent on the mental health system.

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Documents

“Aggressive” and “problem-focused” models of case management for the severely mentally ill