Mental Health Consumers as Case Management Aides

Hosp Community Psychiatry. 1991 May;42(5):494-8.

Paul S. Sherman, Ph.D.
Russell Porter, M.A.

Dr. Sherman is deputy director for mental health for the Harris County (Tex.) Mental Health and Mental Retardation Administration. He formerly was director of policy development and training for the Colorado Division of Mental Health in Denver. Mr. Porter is director of the Regional Assessment and Training Center, 3520 West Oxford Avenue, Denver, Colorado 80236.

Mental health consumers with chronic mental illness were trained for employment as case management aides in a psychiatric rehabilitation project in Denver. The project incorporated cooperative arrangements between the mental health system and vocational rehabilitation and occupational education agencies. The process used to recruit, select, train, and employ the consumer case management aides is described. Eighteen of the 25 trainees who began the training completed the program, and 17 moved on to employment as case management aides. At two-year follow-up, the 15 trainees who were still employed as case management aides had required a total of only two bed-days of psychiatric hospitalization since the training ended.

In the spring of 1986 the Colorado Division of Mental Health began a pilot project to train and employ individuals with chronic mental illness to provide case management services to other mental health consumers. The project's goal was to have the four community mental health centers in Denver employ 20 consumers who would share ten full-time jobs with the title of consumer case management aide. Job-sharing would provide employers with a way to ensure coverage if a case management aide decompensated and would also allow case management aides to have flexible work schedules.

The Division of Mental Health recognized that people with extended experience as consumers in the mental health and social services systems have acquired usable expertise. The organizers of the project believed that consumers would be able to establish rapport more quickly with other consumers, especially those who are reluctant to accept traditional mental health services. In addition, over the last decade, new developments and refinements in psychiatric rehabilitation have brought about improved outcomes for persons with chronic mental illness.

This paper describes the development of the consumer case management aide program, including funding arrangements, design of the training program, and recruitment, selection and placement of trainees. Program participants' employment rates and rates of psychiatric hospitalization at two-year follow-up are reported.

Project development

The Regional Assessment and Training Center, a Denver-based non-profit organization created to bridge the boundaries between the traditional mental health system and the vocational rehabilitation system, received a contract from the Colorado Division of Mental Health to direct the project and train consumers to be case management aides.

Training center staff built a support network for the project by recruiting employment and training agencies that would provide a wide range of services to trainees. The activities of participating agencies included supplying training materials, paying clients' wages during on-the-job training, and providing compensation for instructors. The network was seen as contributing to the success of the project by ensuring that a full range of interdisciplinary services would be available to the project's clients.

Full participation of these agencies was considered more likely if they committed their own funds to the project and were involved in monitoring whether their own requirements, standards, and outcomes were being met. To encourage agency participation, training center staff began a brokerage process by describing to other agencies the Division of Mental Health's funding commitment to the project and offering them the opportunity to further some of their own programmatic goals by participating in the project. The brokerage process minimized the cost for any single participating agency while simultaneously ensuring the availability of services needed and fundable according to each agency's defined mission and desired outcomes.

The participating agencies (and their funding contributions) were the Colorado Community Colleges and Occupational Education System ($28,205), the Community College of Denver ($9,205), the Denver Employment and Training Agency ($8,210), the Colorado Division of Rehabilitation ($15,082), the Regional Assessment and Training Center ($11,459), and the Colorado Division of Mental Health ($25,173). The total project cost was $97,334.

The project used a competency-based approach for curriculum design and training. The skills and knowledge required by case management aides were identified, curriculum was developed to facilitate attainment of those skills, and instruction continued until trainees demonstrated competency. Training center staff interviewed staff from the Division of Mental Health and from an independent case management agency, described recently by Sherman (1), to identify potential job tasks for the consumer case management aides.Based on the interview results, the following roles and tasks were proposed: outreach, communications between agencies, advocacy with entitlement and service agencies, counseling and support, and teaching communication and coping skills.

From this list, training center staff negotiated specific job tasks with prospective employers of the case management aides. The tasks were translated into skill sets that would form the basis of the training program curriculum. Position descriptions were written, and recruitment of trainees began. Simultaneously, training center staff negotiated salaries for the consumer case management aides, secured funding from the Division of Mental Health to cover salaries, and finalized the roles and responsibilities of the employing agencies and immediate supervisors. Last, project staff established training timelines and the project's reporting requirements.

Recruitment. The project's training and employment opportunities were publicized through the newsletter of the Colorado Alliance for the Mentally Ill. Training center staff also made presentations to consumers and clinical and administrative staff of the Denver community mental health centers. Presentations about the project were made to the state legislature, to members of the state's mental health planning advisory council, and to staff from the Robert Wood Johnson Foundation Demonstration Program for the Chronically Mentally Ill in Denver.

Assessment and selection of applicants.  Applicants were selected from a pool of candidates that met the Colorado Division of Mental Health's criteria for chronic mental illness. Staff informed applicants during the first screening interview that the selection process would incorporate extensive assessments of their functioning.  These assessments would guide other vocational endeavors if the applicants were not chosen for the case management aide project.

The assessment had two parts.  The first part measured academic skills such as reading, mathematic ability, general aptitude, written and oral communication, and learning styles. The second part consisted of interviews that elicited information about applicants' perceptions of themselves as students, their ability to make decisions, and their use of judgment in situations typically faced by a case manager.  Applicants were rank-ordered based on the combined scores for both parts with each part weighed equally.  The 25 applicants with the highest scores were invited to begin the program.  The average age of these applicants was 34.2 years.  Other demographic characteristics of the trainees are shown in Table 1.

Table 1

Demographic characteristics of trainees in the consumer case management aide program (N=25)

Characteristic                                               N

Sex

            Male                                                   10

            Female                                              15

Race 

            Hispanic                                            5

            Black                                                  3

            White                                                  17

Physical disability               

            Yes                                                     3

            No                                                       22

Employment status at

start of project

            Employed                                          6

            Unemployed            

                        Less than three months      3

                        Three to six months             3

                        Six to nine months               2

                        Nine to 12 months               2

                        More than a year                 9

Last job

            Service                                              11

            Entry-level industrial          

            or agricultural                                   7

            Clerical                                              3

            Sales                                                  1

            Skilled craft                                       3

            Professional or technical               1

Benefits

            Medicaid                                           7

            Medicare                                           4

            Both                                                    3

            Neither                                               11

DSM-III-R diagnosis

            Affective disorder                             17

            Schizophrenia                                  5

            Personality disorder                        3

The training program

Curriculum planning. Project staff created individualized educational plans that reflected each trainee's strengths and skill deficits. The plans included both generic skills, such as interviewing, communication, and crisis intervention skills, that would be needed by all case management aides and supplemental or remedial education components needed by individual trainees.

Classroom training.  Classroom training focused on acquiring skills common to all of the prospective work environments.  Direct-skills training began with 45 hours of instruction in survival skills, including stress management and study skills, and cognitive training, which included an analysis of affective circumstances that distort or reinforce learning. The next part of the training consisted of 45 hours of instruction in interviewing, acquiring benefits, identifying deficits in independent living skills, and transportation logistics. The final part, a 30-hour course on case management and crisis intervention, included assertiveness training and instruction in identifying crises and analyzing problems, communicating with team members, and supporting peers.

Remedial and compensatory skills were also taught in arithmetic (30 hours) and reading and writing (45 hours). Each trainee also completed at least 50 lab hours and 300 hours of on-the-job training. During the lab hours, trainees practiced work skills with each other in the classroom. The Community College of Denver granted 21 hours of college credit to trainees who completed all phases of the training.

An instructor-coordinator employed by the training center gave the formal training in interviewing, identifying problems, and survival skills. A variety of guest speakers presented technical information on enrolling clients in benefit programs, responding to a crisis, and understanding and identifying common psychiatric disorders. The coordinator prepared students for sessions with guest speakers by reviewing related background materials and presenting an overview of the subject. After the guest speakers' presentations, the coordinator usually led a discussion about the material presented. Role-playing was used to help show how the information presented could be applied to the job of case manager.

The formal classroom training lasted six weeks. Students attended classes Monday through Friday from 8:30 a.m. through 4 p.m. during the first two weeks. After the first two weeks, the schedule was changed to end classroom sessions earlier on Tuesday and Thursday afternoons to allow more time for students to assimilate material and conduct their business as clients of the mental health system. A two-week practicum in job-seeking skills, designed to prepare students for their on-the-job-training, followed classroom instruction.

Matching clients to job sites. Project staff matched trainees to sites where on-the-job training and eventual permanent employment would occur. Several factors were considered in placing consumer case management aides. First, interning aides could not be employed at an agency where they received treatment. This separation provided clearer differentiation of roles for case management aides, as well as for treatment and supervisory staff. Second, the agency staff's level of acceptance of the project and the case management aides was considered. Highly assertive trainees went to sites where staff resistance was initially high.

Third, case management aides' level of mastery of specific skills was matched to the tasks given high priority by the employing agency. These tasks included outreach, acquiring benefits, and assisting peers in obtaining residential and transportation support.  Fourth, personal characteristics of the agency staff responsible for supervision were considered. These characteristics included the supervisor's availability, reliability, ability to provide training, philosophical commitment to the project, and supervisory style.

On-the-job training. The employing agency's staff was responsible for supplying site-specific training and evaluation. The instructor-coordinator from the training center was responsible for creating and orchestrating whatever support the students needed and for supplying additional training, as needed, to enhance performance of specific tasks required in each of the 20 job placements. On-the-job training lasted 14 weeks.

Support systems. A wide variety of practical and therapeutic supports were required to respond to common and individual student needs. The importance of such support in enhancing client functioning is well documented in the rehabilitation literature (2-4). Generally, support was provided to students when they needed it, and students could choose when to stop or to replace one support, or combination of supports, with others.

A weekly support group for trainees was staffed by one counselor from the training center, one counselor from the Colorado Division of Rehabilitation, and the consumer case management aide project manager. The group met throughout the training period and continued for three months after the case management aides had permanent job placements. The group provided the opportunity for students to ventilate frustrations; to solve personal, learning, and work problems; and to encourage each other. Students often had knowledge and experiences that enabled them to act as resources for each other. This peer support endured throughout the training and is still ongoing.

Project staff assumed that the nature of support should change as the trainees progressed. At the beginning of classroom training, students' anxiety levels were high. Four of the five students who dropped out of training did so during the first two weeks of the classroom phase. The task of acquiring new skills often resulted in a need for additional support. Support group members helped each other master technical information such as procedures for obtaining benefits and transportation logistics.

Students also needed support when they began to apply new skills in the classroom and in practicum settings. During this period, students' behavior vacillated between responses they had learned as clients, responses more closely associated with their role as students, and attempts to identify themselves with a staff role. Saturated with a new perspective and new knowledge about mental illness, students first had to internalize this information before they could apply it in their new role in a constructive and significant way. Supportive counseling was needed when the content of classroom curriculum provided new insights into students' own experience, triggering intense emotional reactions. Some students needed variable levels and intensities of insight-oriented counseling, provided by the CMHCs to deal with these reactions.

When students began on-the-job training, the weekly support group meeting provided a forum for resolving early conflicts between trainees and their supervisors. Gradually, supervisors and coworkers became the primary sources of support, and trainees began to rely less on training center staff for counseling.

After students graduated and began permanent employment, the student case management aide network, coupled with the natural support system in the work environment, became the sustaining source for personal support and help in solving problems and validating work roles. Case management aides' reliance on these support systems led to the natural demise of the original, formal support group.

Effects of the program

Training and employment. Of the 25 candidates chosen to be trained from a pool of 49 nominees, 19 (76 percent) successfully finished the classroom training. Eighteen (72 percent) completed on-the-job training and graduated. Seventeen (68 percent) successfully moved on to employment as consumer case management aides in July 1986. Two of the 17 left for employment in other fields; one has since returned as a case management aide. One other graduate was hired into the mental health system as a staff member in a residential facility and is also attending nursing school. These two clients could also be considered as employment successes. Two case management aides resigned in the spring of 1987.

Fifteen case management aides (60 percent) had been continuously employed for 26 months as of August 1988. Furthermore, six increased their work hours to full time in July 1988. Nine continue to work part time for an average of 24 hours per week. The cohort of 15 consumer case management aides required a total of two bed-days of psychiatric hospitalization between July 1986 and August 1988.

Training center staff and independent others conducted formal and informal verbal surveys with both the aides and their supervisors several months after employment began. The written survey included items on productivity, similarity between expected and actual job duties, problems encountered, and recommendations for changes in the training process. The results indicated generally that both supervisors and the aides were highly satisfied with the program. Aides were performing duties they had been trained to do, such as helping clients acquire entitlements and locate housing and move in, teaching daily living skills, and providing transportation for clients. Exceptions to the general pattern of satisfaction occurred in situations in which the employer unilaterally changed the job functions to more menial tasks.

The lack of objective data about the productivity of nonconsumers in jobs with similar responsibilities precluded empirical comparison of the productivity of consumer case management aides. The satisfaction levels of the aides and their supervisors and the amount of support provided to the aides was greater in agencies that were committed to serving individuals with chronic mental illness by using aggressive outreach approaches than in agencies with more traditional approaches.

System effects. The success of the consumer case management aide project had a pronounced effect on the attitudes of staff and consumers in the mental health system in Colorado. The professional mental health community has been forced to reconsider its pessimistic prognosis about the potential abilities of clients who have chronic mental illness. Some professionals have reduced dissonance by changing their prognoses, others by considering the successful outcomes to be an artifact of misdiagnosis. The public mental health system, initially resistant to the project, has embraced the success of the consumer case management aides and now helps to identify other provider roles that consumers with chronic mental illness can fill. The Regional Assessment and Training Center subsequently completed a training program for consumers who are now employed as core staff in a single-room-occupancy residential program. Other projects and training curricula are being developed. Since 1986, five additional groups of consumers in Denver and one group in Houston have been trained to be case management aides.

Another systemic result of the program has been an increased willingness of agencies involved in vocational rehabilitation and occupational education to work with mental health clients. It is likely that this change is largely a result of the training center's brokering activities and the positive outcomes that occurred for all participating agencies.

The success of the consumer case management aides has also had a positive effect on the consumer empowerment movement and on the self-esteem of consumers nationally who have learned about the accomplishments of their peers.

Discussion and conclusions

The employment rate for this project exceeds that found in follow-up studies of other projects involving individuals with severe psychiatric disabilities (3,5,6). This difference may be related to the amount and type of support available to the consumer case management aides. Because the aides work in the mental health system, they have supervisors who understand mental illness and who constitute a potentially unparalleled support system. However, it should not be assumed that employment in a traditional mental health agency will ensure a positive, supportive environment. Unfortunately, many staff harbor stronger negative prejudices than the general public about the capabilities of individuals who suffer from severe mental illnesses.

The intrinsic rewards of the work done by case management aides may also have contributed to better employment outcomes. One case management aide wrote, "It is both rewarding and frustrating working with people with problems of mental illness. Some of the most gratifying aspects of this job are when the (professional) case managers come to us to ask us how we see things from our own perspectives, and seeing some of our clients really get a handle on their lives."

The high employment rate may also have been due to the aides' recognition that they were in the vanguard, creating opportunities for other consumers. Although this notoriety could have created increased stress levels that might have been deleterious to success, the outcomes for project participants suggest that the ability of individuals with severe and persistent mental illness to handle stress may be underestimated. The consumer case management aides encountered many events, such as being first on the scene after a client tried to commit suicide with a machete that would qualify as major stressors for anyone.

Mental health agencies committed to addressing the living, learning, social, and work needs of consumers will require help from other systems, including education, rehabilitation, and employment and training agencies. Most frequently, this help is sought after the primary mental health treatment is finished or is nearing completion. Often, this sequential approach is warranted, but in many cases, joint or multiagency remediation processes such as the one described in this paper could speed consumer recovery and enhance the outcome of habilitation and rehabilitation efforts.

The strategy of publicizing the consumer case management aide project with the state legislature and other influential organizations before the program began supplied the glue that held the project together when it surely would have otherwise shattered. Endorsements of the project from these powerful sources and funding commitments from agencies that participated in the project inexorably bound the system together through a common need to succeed. These forces unquestionably influenced the system's willingness to follow through with commitments made at first with great reluctance. High visibility is risky because it may magnify failures, but it is also a powerful strategy for overcoming resistance to, and dissipating heat encountered in, cutting-edge projects.

Writing in a newsletter for patients and their families, one of the consumer case management aides expressed the hope that their "work can help reduce the stigma of mental illness by proving to other clients, to providers, and to the general public that, with the right type and amounts of support, persons who have experienced severe mental illness can become productive, contributing members of their communities." There is every indication to date that this hope is quite realistic.

Acknowledgments

The authors thank Ed Cotageorge, M.S., and Dan Bradley, M.A., of the Regional Assessment and Training Center, and the supervisors of the consumer case management aides.  The character, courage, and strength of the consumer case management aide trainees who persevered through the program to gain employment in mental health agencies (and managed to help sustain us along the way) merit special recognition.

References

1. Sherman PS: A micro-based decision support system for managing aggressive case management programs for treatment resistant clients, in Stare Management Information Systems in the West: Trends and Developments. Edited by Greenhalgh J. Boulder, Colo, Western Interstate Commission for Higher Education, 1988

2. Anthony WA: The Principles of Psychiatric Rehabilitation. Austin, Tex, Pro-Ed, 1980

3. Anthony WA, Liberman RP: The practice of psychiatric rehabilitation: historical, conceptual, and research base. Schizophrenia Bulletin 12:542-559,1986

4. Harding CM, Strauss JS, Hafez H, et al: Work and mental illness. Journal of Nervous and Mental Disease 6:317-326, 1987

5. Anthony WA, Cohen MR, Vitalo R: The measurement of rehabilitation outcome. Schizophrenia Bulletin 4:365-383, 1978

6. Dion GL, Tohen M, Anthony WA, et al: Symptoms and functioning of patients with bipolar disorder six months after hospitalization. Hospital and Community Psychiatry 39:652-658,1988