The Cross-Cultural Practice of Clinical Case Management in Mental Health, edited by P. Manoleas, MSW, New York: Haworth Press, 1996, 246 pages.
As editor, Peter Manoleas notes: "Persons with major psychiatric disorders and ethnic minorities of color have been targeted and funded as separate priority populations by federal and state agencies, despite many overlapping interests. I would add that in the large literature on culture and mental illness, there are very few examples of culturally-competent services for persons with severe and persistent psychiatric disabilities, despite their high priority needs1. Since national statistics show disproportionately high hospital admission rates for some ethnic minority groups (primarily African-Americans and American Indians) and disparately long inpatient stays for others (primarily Hispanics and Asians), 2 cultural aspects of case management are of intrinsic interest to mental health administrators, as well as to clients and their families.
Among the numerous models of case management, the brokerage function of linking clients with resources needed for survival seems to be basic. In addition to rehabilitative care and medication management, all clients must be able to access resources to insure an adequate quality of life. In the authors’ model, clinical case management combines classical casework and psychotherapy. Functionally, clinical case managers "are at times caseworkers, advisors, therapist, friends, teachers, and advocates" (p. 27). The definition of "therapist" is unclear and may be of some concern to administrators concerned with credentialling, pay scales, and staff-client ratios. One solution has been to redefine "psychotherapy" and, as is increasingly the case, integrate supportive peer counseling with consumer case management.
Clinical case managers work collaboratively with clients’ families, communities, and larger systems. Since most urban mental health facilities treat ethnically diverse clienteles, the premise of this book is that in order to be optimally useful, case managers should be culturally and linguistically adept. They should know how to use "cultural reframing" to enable clinicians to understand behavior and do appropriate treatment planning. They should be able to deal with cultural barriers to effective treatment, to identify adaptive resources, and to utilize community and family support systems.
Specific chapters deal with case management issues germane to African American, Native American, Hispanic/Latino, and Southeast Asian populations, but happily, the editor’s definition of culture also encompasses social role groups. One chapter is devoted to the "culture of homelessness." Another chapter deals with gender, focusing on the subculture of women with major psychiatric disorders, and still another deals with culturally competent case management for emotionally troubled children and youth.
Within the United States, any discussion of cross-cultural practice inevitably involves the blurred boundaries and distinctions between traditional beliefs and practice, minority status, socioeconomic status, and migration history, to name just a few factors interactive with race and ethnicity. There are some useful materials on these issues. The chapter on Asians deals with service delivery strategies for refugees, a subpopulation whose experiences of flight, translocation, and loss transcend ethnic lines. The chapter on Native Americans deals with demoralization as a sociohistorical factor in case management strategies. The chapter on African-Americans deals with Africentric perspective, the matrix of family and community support, the dynamics of biculturalism, and the role of religion in case management. Some chapters present a global perspective, while others, such as Hodge and Kipnis’s chapter on Native Americans, present useful empirical research data on a salient cultural phenomenon.
Specific treatment and management strategies are also discussed. One chapter on Latinos deals with crisis intervention, another with the integration of clinical case management and cognitive-behavioral therapy with depressed Latino clients. There are many extremely helpful case vignettes that demonstrate how specific types of cultural knowledge may be used both to redirect inappropriate clinical thinking or to facilitate acceptance of treatment directives by clients and families.
Competent administration involves effective utilization of staff’s time and efforts, and this book is quite useful for staff working with different sociocultural and racial/ethnic groups. Although there are now numerous books on ethnicity and mental health, the focus on case management and culture brokerage with larger systems make this book particularly useful. For administrators, the chapter on the Family Mosaic Project with children and youth may be even more helpful, since it deals with setting up a coordinated case management system, measuring success, and flexible funding. Overall, the discussion of the parameters of clinical case management, and examples of culturally competent applications, make this a useful book and may even enable some administrators to rethink current services.
Harriet P. Lefley, Ph.D., Professor
Department of Psychiatry and Behavioral Sciences
University of Miami School of Medicine
The Effectiveness of Social Intervention for Homeless Substance Abusers. Edited by G.J. Stahler and B. Stimmel. New York: Hawthorne Medical Press, 1995, 208 pages.
This volume delivers on its title: it presents outcome, process, and treatment matching data derived from ten different experimental studies, each of which targeted homeless substance abusers. Studies meet a common standard of scientific rigor: each study randomized a sizeable number of clients to conditions, used a core set of outcome measures, and successfully followed a high percentage of clients for minimum of 6 months following the intervention (s). The policy-maker, program developer, or administrator who reads this volume will appreciate the common core of design elements for the ease it lends to comparisons across studies.
While shared features are a clear strength, the diversity of populations and geographic locations studied is commendable. Studies were implemented in such disparate urban areas as New Haven, Albuquerque, Birmingham, and Los Angeles. Study populations were equally wide-ranging. In St. Louis, for example, the population was 100% female, 97% African-American, and 83% cocaine abusers. By contrast, the Tucson study recruited 89% males, 40% Caucasians, and 60% alcohol abusers. The Los Angeles sample was entirely comprised of those with comorbid substance use and major psychiatric disorders. Latinos and Native Americans were most strongly represented in the Albuquerque study (31% and 18%, respectively). Diversity of samples and locales imparts generalizability, a factor of clear importance to those seeking to apply empirical findings locally.
This volume is well-written, the studies fairly and even-handedly presented. The interventions themselves are well-described, a feature of value to the book’s target audience. While not all figures and tables are clear, the results, if not the statistical analyses, are reasonably accessible. Gerald J. Stahler, Guest Editor, provides necessary background in an extremely helpful opening essay. Included studies were jointly funded by the National Institute of Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) under the Cooperative Agreements for Research Demonstration Projects on Alcohol and Other Drug Abuse Treatment for Homeless Persons. Stahler’s essay includes a series of conclusions which are admirably succinct but would be more appropriately placed in a brief closing essay. Effective Interventions… ends with a guide to topic-relevant literature review resources. While potentially helpful, the respective reference lists of this volume’s studies allow more direct access to pertinent literature. Notably missing from the guide are World Wide Web addresses of specific home pages or search engines such as LYCOS and ALTA VISTA.
Despite the care taken in the design of these studies, it is strikingly clear that there is a tremendous amount yet to learn about treating the plethora of interwoven problems the homeless substance abuser presents. A striking finding across studies was that the putative "control" condition showed significant improvement on substance use and housing variables. Improvement frequently rivaled that seen in the generally more intensive experimental conditions. Equally clear is the difficulty of this type of research. Across studies, formidable problems were encountered with randomization to treatment condition and attrition from treatment. The respective authors are admirably even-handed in their treatment of these problems. Limitations acknowledged, the value of this research to anyone in a position to make decisions about treatment services remains intact: few have the resources or time to engage in this type of research.
In conclusion, Effectiveness of Social Interventions for Homeless Substance Abusers is to be commended for its empirical approach to identifying effective interventions for homeless substance abusers, for the comparability across its studies and the generalizability of its results. Any policy-maker or administrator seeking to positively impact the complex problems of this population would be well advised to thoroughly digest the contents of this volume!
Jefferson D. Parker, Ph.D.
VA Medical Center
Jackson, Mississippi
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