Unit 3.1 DB: Client PreferenceUnit 3.1 DB: Client Preference

For each section of the chapter, we explore issues and challenges that case managers are likely to encounter. Focus your reading and study on the following objectives:

Confidentiality

· List reasons why the issue of confidentiality is so difficult.

· Define ways in which managed care and technology have affected confidentiality.

· Describe guidelines for discussing confidentiality with clients.

· Identify guidelines for confidentiality and working with minors.

· Describe guidelines for confidentiality and working with interpreters.

· Identify the ways that technology affects client confidentiality.

Family Disagreements

· Describe what happens when family members disagree about the care of a family member.

· List guidelines to follow to encourage positive participation by families.

Working with Potentially Violent Clients

· Describe why violence is becoming more prevalent in modern society.

· Apply the steps in addressing issues of violence in the workplace to a specific case management situation.

Working in the Managed Care Environment

· Identify two difficult dilemmas case managers encounter working with managed care organizations.

· List three ways that case managers might respond to these situations.

Duty to Warn

· Define the duty to warn.

· Demonstrate how the case manager works with a team on issues involving the duty to warn.

Autonomy

· Describe the difficulties that arise with regard to granting client preferences.

· Explain how guidelines can help a case manager who faces issues of autonomy.

· Describe how case managers can support autonomous end-of-life decisions.

· List the sources of rules and regulations.

· Determine when and how to advocate rather than break a rule.

Legal Responsibilities

· Define standards of care and standards of case management practice.

· Explain the term malpractice.

· Describe case management issues of liability.

4-1 Introduction

Before we discuss each of these issues in more detail, let us read what case managers have to say about their work related to ethical and legal issues.

Most of our clients do not want us to share their information with anyone else. For kids, adults, especially adolescents, it is the first question they ask. “You won’t tell my parents, will you?” There are some things we can keep confidential, but there is lots of information we need to share or report.

—Case manager and counselor, family services, Bronx, NY

What is most difficult for me is giving the client room to make mistakes or to refuse service. I see all of the ways a client’s life could improve “if only.” But if the client doesn’t want to help herself, then we are powerless. Every once in a while I want to push the client harder than I should.

—Case manager, intensive case management, Los Angeles, CA

There are some things that my clients need—services, help—that I am not supposed to do or provide. One day I was visiting a young boy and his mother. He was absent from school. His mother had been beating him before I arrived and she opened the door with a strap in her hand. I told his mom I needed to take him to school. Legally, I am not supposed to transport clients.

—Case manager, school-based intervention services, New York, NY

—Case manager and counselor, family services and addiction treatment, Knoxville, TN

These quotations reflect some of the tensions that case managers face. The case manager at family services describes the conflicts that arise related to confidentiality. Sometimes client confidentiality can be maintained. But there are other times that the case manager must break confidentiality, especially when suspicion of harm to self or others is involved.

The case manager from an intensive case management experience speaks of a different type of dilemma involving the mandate to grant clients autonomy whenever possible. Case managers may see clients choosing alternatives that are not in their best interests. Sometimes it is very difficult to let clients make these choices. The case manager from school-based intervention services talks about the difficulties involved in providing services according to legal or ethical guidelines. Clients often violate rules just so they can maintain their stability and have their needs met. Sometimes professionals violate or think about violating policies. Professionals always have to assess what they think and how they will behave in these situations.

Working with families is often integrated into the case management process. Sometimes families can enrich and support the helping process; sometimes they can cause difficulties. The case manager from family services and addiction treatment describes one of the times when family pressure threatened implementation of the case management plan and how the agency uses client participation in groups to help clients expand beyond the family’s influence.

We now explore various ethical and legal dimensions of case management work. We begin by considering the obligations that case managers have to maintain the confidentiality of their clients.

4-1aConfidentiality

4. The case manager must testify in court regarding information about the client, unless the case manager is protected by the state. This legal privilege of communication is usually reserved for patient–therapist communication.

5. The case manager must ask for the client’s permission to release information.

Figure 4.1Considerations for Confidentiality

There are exceptions to a case manager’s maintaining confidentiality, such as when the case manager is entering data into an electronic system, talking with colleagues either during staffing or consultation, or working under supervision. If case managers intend to share client information in any of these settings or during the course of performing job responsibilities, then they should let clients know.

Another consideration for the case manager is collecting information under the guidelines of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) (Department of Health and Human Services, 2015; Remley & Herlihy, 2015). The purpose of this legislation is to protect the confidentiality of client health records by allowing patients access to their medical records, requiring health professionals to explain how they will use patient information on health records, limiting the personal information a health professional may share with others, and allowing patients to request confidential communications. The act went into effect in April 2003. Compliance with this act may be integrated into the standard practice of case management. For example, if the case manager is seeing a client for the first time, then the case manager may explain the HIPPA regulations to the client. Each client must sign a statement indicating that he or she understands how HIPPA regulations are followed in that agency or organization.

The Family Educational Rights and Privacy Act (FERPA) protects the educational records of children (U.S. Department of Education, 2015). This act allows parents and children to view their educational records, to request copies, and to amend these records. It also requires the school to gain permission from parents to release the records. Schools may provide records without parental consent in connection with specific circumstances such as school audits, accreditation, health and safety issues, and, if allowed by the state, use by the juvenile justice system.

Having sensitive information about clients often causes dilemmas for case managers. To avoid problems, some decide to limit what information they seek to gather about a client, because the less information case managers have, the fewer confidentiality problems they will encounter. Certainly, case managers must carefully choose what information to seek, but strict limits on information gathering are not always recommended. A complete history of the client enables the case manager to develop a treatment plan that will meet the needs of that client. Relevant information must be gathered, which helps the case manager understand how to work with family members and friends. Because the case manager is also coordinating care and monitoring progress, abundant information helps him or her give better guidance to other professionals on the team.

The case manager should address certain matters before collecting any information to anticipate any confidentiality problems.

1. What does the case manager need to know to do the job, and why?

2. What should become part of the permanent record?

3. What understanding should exist between the case manager and client about why the information is being sought, how it will be used, and the client’s right to refuse to answer?

4. Under what circumstances should information be shared with third parties?

Sometimes the case manager needs information about the client from other agencies or institutions. It is important for the case manager to obtain written consent from the client to receive this information. The client may also have to provide a written consent to release the information to the agency or institution holding the information. To obtain client consent, the case manager discusses the need for the information with the client and helps the client with the appropriate paperwork. At this time, it is appropriate for the case manager to talk with the client about security of records, including those acquired from another agency.

Another dilemma is how much information to put in the permanent record. The case manager must record all information that documents the work with the client and describes his or her history. Not everything the client reveals needs to be recorded. At times clients talk about issues unrelated to the presenting problem. Unfortunately, the confidentiality of written information is not always secure, regardless of whether the record is on paper or computerized.

Once the case manager has decided what information to gather and what to record, he or she explains why each piece of information is important. Then, he or she decides what parts of the information will be shared with family, friends, and other professionals; this is discussed with the client. However, professionals and family members are bound to ask questions beyond what the client and case manager have agreed on. The client and the case manager negotiate about each such piece of information, and the client must give permission for disclosure. He or she also has a right to refuse to answer any question; if the information is necessary for determining eligibility, then the case manager explains this. He or she can ask the client whether there is another way to obtain the necessary information.

Even with these guidelines articulated, dilemmas concerning confidentiality often arise. Consider the following situations.

An 18-year-old has just found out that she is pregnant. There is no legal obligation to inform the parents of the young woman or the father of the child, but the care coordinator always encourages clients to disclose this information. This young woman refuses. The discussion is closed and the matter remains confidential, even though the young woman’s mother requests the information.

Take a minute and consider this first situation. Can you describe the ethical dilemma in this case? Describe the various points of view held by each individual. What are your thoughts about how the situation was resolved?

An elderly man is furious with his social services coordinator because she told his daughter that he was dying of pancreatic cancer. The service provider knew that the daughter’s husband had just asked for a divorce. The daughter was devastated because she had been counting on the father’s support.

Take a minute and consider this second situation. Can you describe the ethical dilemma in this case? Describe the various points of view held by each individual. What are your thoughts about how the situation was resolved?

A counselor has been asked by his minister for information about a client who is a member of their congregation.

Even following the guidelines presented, the case manager is bound to face issues that warrant further consideration. Three examples are the short cases presented previously. Let us consider how these situations might be resolved. In the first case, the care coordinator gathers confidential information about the 18-year-old’s pregnancy. The information remains confidential unless the agency has a policy mandating disclosure to parents or to the father of the child. If this is so, then the coordinator should have informed the young woman at the time of intake. The care coordinator’s obligation to inform supersedes the confidentiality guarantee. Such a policy is less likely to apply here because the young woman is of legal age. The situation becomes complicated if the young woman’s mental competence is in question or if her health or that of the fetus is threatened in any way. If there is no legal or policy mandate, then the coordinator must not inform the mother of the young woman’s pregnancy, even though she is the potential grandmother.

In the second situation, the social services coordinator is torn between her allegiance to the dying father and her responsibility to his daughter. The difficulty here hinges on the coordinator’s definition of who the client is. She has chosen to behave counter to the wishes of the father by breaking confidentiality with regard to his physical condition. Before doing so, she should ask herself the following questions: Is the father competent to request that his daughter not be told? Did he give the coordinator other information indicating that the daughter should be told, despite of his reaction after the fact? Does she believe that it is in the father’s best interest for the daughter to have this information? Does the coordinator see the daughter as the primary client? If so, why? The coordinator should not violate the father’s request for confidentiality unless the answers to these questions provide sufficient justification.

In the third case, the counselor is asked for information by a professional who is not involved with the client’s case, at least within the established service delivery system. The counselor is under no obligation to give the information unless there is an established need to know and the counselor gains the client’s consent to share the information. It would be a different matter if the counselor had reason to believe that the client might harm himself or others. There would then arise a duty to warn, changing the counselor’s obligation from confidentiality to a duty to share information. Before discussing the duty to warn in more detail, let us look at the client confidentiality issues that have developed in the past decade relative to technology.

Confidentiality and Working with Minors

For the case manager, confidentiality while working with minors includes many issues and challenges. First, in most situations, it is the parents who consent to a minors’ treatment. Except in special circumstances, minors may not consent to their treatment, although they provide assent. There are some legal exceptions that allow minors to consent to treatment linked to indications of a minor’s maturity and ability to make his or her own decisions. For instance, this might occur when the minor has been in the armed services or otherwise demonstrated an ability to care for one’s self (Behnke & Warner, 2002). There have been recent court rulings that grant a minor’s right to confidentiality, especially when mental health services are concerned. In Daniel versus Daniel O. H., the court ruled that confidentiality was not always mandatory, especially if the professional believed that sharing information with parents could be harmful to the minor. The jeopardy could be either placing the minor at odds with parents or damaging the helping relationship (Younggren & Harris, 2008). In addition, many states, such as Ohio and California, allow minors to participate in mental health treatment (for help with previous sexual abuse or substance abuse issues) on an outpatient basis (Levy & Siquiera, 2014).

In practice, confidentiality between parents and minors presents opportunities for dialogue at the beginning of the case management process. We encourage case managers to articulate the importance of confidentiality in treatment, with an emphasis on the times when confidentiality must be broken such as expression of the desire to harm self or others or disclosure of past or current physical, psychological, or sexual abuse. Confidentiality may be breached if the client (minor in this case) consents or if the information is court-ordered. Legal and ethical guidelines related to confidentiality and minors are important to note. These guidelines include considering the age of the child, the developmental age and competency of the child, and, of course, the best interest of the child (Mitchell, Disque, & Robertson, 2002). We present the following case in which the case manager struggles with decisions about confidentiality and the child with whom she works.

Ms. Roe conducts intake and assessment and coordinates treatment at a local hospital emergency department. She is working in the evening shift, 7  pm to 7  am. A social worker is also on-call this evening. Rose is 14. She arrives at the emergency department with her parents. She has cuts all over her arms. Her parents just saw the cuts tonight when her mother came into the bathroom while she was taking a shower. Her parents, shocked to see the open wounds, made her get dressed and drove her to the emergency department. Hospital staff placed Rose in a small room with her parents. Ms. Roe entered the room, introduced herself, and asked to talk with the parents outside the small room. Then, she asked the parents to remain in the room. She indicated to them that she wanted to talk with Rose alone.

Ms. Roe told Rose about her role in the hospital and explained the limits of confidentiality. Ms. Roe indicated to Rose that if Rose discussed hurting herself or others, then she and Rose would discuss what to tell her parents and who should deliver the information to them. Ms. Roe was clear with Rose that she would be assessing Rose’s potential to harm herself or others as well as any neglect or abuse by parents or others. Ms. Roe also emphasized the partnership she hoped to have with Rose to help find her the services that she needed.

During the intake and assessment, Rose shared her cutting activities with Ms. Roe. According to Rose, she first participated in cutting during what her friends call a “cutting group.” They cut in school and after school. Their favorite places were the school bathroom and some woods behind the school. She felt such relief at the cutting that she started cutting at home, too. Because it was less messy and she loved feeling water rushing over her while she was cutting, the shower became her favorite place to cut. Later in the interview, she disclosed smoking marijuana during the afternoons on her way home from school. Several times when her parents were away, she got her father’s rifle to see how she would kill herself. She could not figure out how to put the rifle in her mouth and pull the trigger.

· Decision Type 1: Keep full confidentiality.

· Decision Type 2: The client makes the disclosure; the case manager encourages this disclosure with family or others.

· Decision Type 3: The case manager makes the disclosure; the client is fully aware of the case managers disclosure to the parents.

· Decision Type 4: The case manager makes the disclosure to the parents; the client is fully aware of the disclosure; the client does not consent to the disclosure.

· Decision Type 5: The case manager makes the disclosure to the parents; the client is not aware of the disclosure and, hence, does not consent to the disclosure.

In addition, Duncan et al. (2015) reported the specific considerations that psychologists use to determine their decisions related to confidentiality with adolescent clients. These include: immediate risk of harm; best interests of clients; future risk of harm; duty of care (ethical responsibility); likely parental reaction; relationship between client and parent; age; impact on the therapeutic relationship; mandatory reporting guidelines; maturity of client; and client consent for release of information (p. 209). Using one or more of these considerations may help case managers make decisions related to confidentiality and their client of minority age.

Class Discussion

Working with Issues of Confidentiality

Working through issues of confidentiality can be difficult for a case manager. As a class, in small groups, or as an individual, think about how you as a case manager would handle the issue of confidentiality between Ms. Roe and Rose. Choose at least two of the five decision types that you would consider. Explain why you would consider each (factors that you deem important in making your decision).

When you have completed this exercise, share this information with your classmates.

Confidentiality and Technology

As case managers increase their use of technology to communicate, store, and retrieve information and care for clients, considerable concern is developing about client confidentiality. Remley and Herlihy (2015) outlined the following issues related to technology:

· Electronic storage of records

· Rendering of counseling or supervision services via electronic correspondence (i.e., telephone, Skype, two-way video, or e-mail)

· Helping professionals communicating with clients or other professionals via e-mail, text, or other electronic means

· Storage and transmission of recordings of client interviews

· Electronic signatures on documents

· Technology related to federal and state statutes and regulations; licensure and certification board rules; and agency operating procedures

All but one of these aspects of delivering social services involve confidentiality. For example, many case managers today are using e-mail and social media (e.g., Facebook and Twitter) to communicate with other professional colleagues, to contact case management team members, and to explore referral services. With regard to recording and accessing client records, case managers are able to enter and retrieve information from online databases by using the management databases established by human service agencies and organizations at the national, state, and local levels. This means that while working online, case managers have access to comprehensive, up-to-date information about their clients. Case managers are also using organizational and community computer networks to facilitate the sharing of information. As use of the technology expands, as indicated by Remley and Herlihy (2015), there are three areas of security and confidentiality to address: security of the data; use of e-mail and social media; and securing the communication site.

The computer and other electronic devices have already become an integral part of the case manager’s day-to-day work. As the use of technology continues to expand, case managers use guidelines to address the concern for and protection of client confidentiality. Several measures address security issues. Organizations can use systems with special encryption programs that scramble data and protect the data en route. They can install firewall systems for data stored on the Internet to prevent casual users and hackers from retrieving this information. To ensure the legitimacy of remote users, they can use special devices to authenticate the individuals who are using the system. With the advent of off-site storage (The Cloud), it is easier to share data with other agencies and other professionals. Complicating this ease of access is the “guarantee” of privacy and confidentiality.

There are two other considerations about confidentiality for case managers to consider. The first focuses on the use of e-mail and social media (e.g., Facebook, Twitter) in service delivery. Because e-mail and social media have become such popular media of communication, many clients are beginning to communicate with their case managers online and through social media sites. Sometimes clients are following-up on a referral or on their treatment, just checking in, or requesting their own records. In many instances, access to e-mail and social media has increased the efficiency of communication between the case manager and the client. For clients who live in isolated, remote, rural areas, who live alone, or who are homebound, e-mail and social media allow a new type of access to services. However, if a case manager decides to use e-mail or social media as a method of communication, then some decisions must be made that address issues of confidentiality.

MORPC Social Media Guidelines

MORPC does not seek to control, through this policy or otherwise, the purely personal online content posted by MORPC staff members, when that content is posted during nonworking time, when it is posted using the staff member’s own equipment, when it is unrelated to and does not identify MORPC or … staff member’s position with MORPC, and when it is not … disruptive to MORPC’s mission. However, the following rules apply to any online post by a MORPC staff member that:

· (a)

occurs during working hours;

· (b)

is posted using MORPC equipment; or

· (c)

identifies MORPC, links to information about MORPC, or identifies the staff member’s position ….

Rules

1. Online activity during working hours or using MORPC equipment must be primarily business-related.

2. Respect the audience.

3. Do not use religious, racial, or ethnic slurs, personal insults, or obscenity.

4. Show proper consideration for others’ privacy and for topics considered objectionable or inflammatory.

5. Do not participate in any political activity or communication during work hours.

6. MORPC staff members are personally responsible for the digital content they publish.

7. Protect your privacy. Determine what personal information you are comfortable sharing.

8. Identify yourself. Anonymous postings are rarely beneficial to anyone.

1. If you are speaking for yourself, use the following: “The views in this post are my own and don’t necessarily represent my employer’s positions, strategies or opinions.”

2. If you identify yourself as a MORPC staff member, ensure your profile and related content are consistent with how you wish to present yourself.

3. The lines between public and private and personal and professional are blurred in online and mobile interactions.

9. Respect copyright, fair use, and public records laws.

10. Protect confidential and proprietary information. Social media blurs many of the traditional boundaries between internal and external communications.

11. Prior to MORPC events, acquire:

1. Written agreements from speakers disclosing that all event materials are available to the public.

12. Do not pick fights. Be the first to correct your own mistakes.

13. Consider the purpose of the social media use. Online communications must not negatively impact achievement of … assigned tasks.

14. The availability of personal information on social media sites (both for the professional and the client) provides public self-disclosure that is unprecedented.

SOURCE: From The Mid-Ohio Regional Planning Commission.

Working Through Issues of Confidentiality and Technology

Working through issues of confidentiality and technology, especially the use of social media, can be difficult for a case manager. As a class, in small groups, or as an individual, think about how you as a case manager would handle the issue of confidentiality and social media described in the three scenarios. Explain how you, as a case manager, would respond. What are the factors you considered? What would you do? Share your thinking and decision-making with the class.

When you have completed this exercise, share this information with your classmates.

My Story

Sharon Bello, Entry 4.1

Confidentiality is a concern that I had when I entered the case management process. My concern was about how my involvement with social services might influence my training and job seeking, and I wanted to protect my family. Honestly, I did share my involvement with vocational rehabilitation with my friends and family, but I didn’t necessarily want them to know all about the details of the help that I was receiving. I must have asked my case managers questions each time that I met with them about where they kept their records, what they would communicate with my doctor, how our communication through e-mail was recorded, where their messages go, and how I was supposed to save the messages. I also asked Tom and Susan if they talked about their cases on Facebook, what they shared with their supervisors, and how they let their supervisors know what was happening with our case. Did they talk to them? Did they e-mail them? I am still not sure I understand where all of the information goes, and I will keep asking until I feel like I understand the agency information system.

Finally, all interpreters are guided by codes of ethics that provide guidance regarding professional behavior that helps ensure quality of service. In Virginia, for example, the Code of Professional Responsibility for Interpreters Serving Virginia Courts (2004) reads as follows:

· CANON 5: Interpreters shall protect the confidentiality of all privileged and other confidential information.

This brief but significant statement requires interpreters in court settings to uphold the attorney–client privilege and not repeat any confidential information obtained in the course of employment. If the interpreter becomes aware of information that suggests harm to an individual or relates to a crime being committed, then that information must be disclosed to an appropriate authority in the judiciary. With this exception, violating confidentiality in this setting or any other setting is unprofessional, unethical, and, in some cases, illegal (Davis, 2005). It may also be grounds for revoking professional interpreting certification.

The National Council on Interpreting in Health Care (NCIHC) establishes standards of care for interpreters (2005). Many of the standards within this code of ethics are applicable for interpreters working across the social services. The standards of practice encompass accuracy, confidentiality, impartiality, respect, cultural awareness, role boundaries, professionalism, professional development, and advocacy. Specific to confidentiality, the NCIHC suggests that the interpreter objective regarding confidentiality is to “honor the private and personal nature of the health care interaction and maintain trust among all parties” (p. 6).

Here are several scenarios that highlight the difficulties of interpreters maintaining confidentiality during case management work.

Adam, a case manager, is performing an intake with a Butanese refugee named Khawae. She is a senior woman applying for help from the BRIDGE program in her community. Khawae has been in the county for a few months. She is part of a resettlement program and she joins approximately 20 other Butanese refugees. The BRIDGE program has limited access to interpreters. The interpreter available is Khawae’s nephew. Adam sees issues with using a member of the client’s family as an interpreter.

Luis is a seasoned interpreter for the Department of Human Services. The case manager, Shirley, has third-hand knowledge from other colleagues that Luis is being investigated by the Department of Human Services in a neighboring county where he lives for suspected neglect and abuse of his oldest child. Shirley heard that Luis wants to ask clients for whom he interprets to serve as references for him.

Misha is an interpreter for the Hmong. She learned their dialect while being raised by her missionary parents in Southeast Asia. She works at eight different sites, so her family car is also her office. Her supervisor worries about her ability to keep information about her work confidential.

Working Through Issues of Confidentiality and the Use of Interpreters

These three vignettes provide only a few examples of confidentiality issues regarding the use of interpreters. For each of scenarios, what do you see as the issue related to confidentiality? How do you think that the issues might influence the case management and helping process? How might you begin to address the issues?

When you have completed this exercise as a class, in small groups, or as an individual, share this information with your classmates.

4-1bFamily Disagreements

Working with clients and their families is an important part of case management. Often, families can provide support to clients that will help them meet their goals. The American Counseling Association supports the idea that counselors should work with families of the clients they serve (American Counseling Association, 2014).

End-of-life care is one of the most difficult ethical areas for the case manager. One such issue occurs when there are family disagreements over the care of an incompetent client. The following example illustrates the difficulties faced by the family and the professionals involved in the case.

The client, Mrs. X, was a 50-year-old woman with a history of severe depression. She had been cared for by her 20-year-old daughter and placed in a hospital when the daughter could no longer care for her. The mother lost the ability to live independently, was unable to work, and had lost the majority of her social support. When the mother attempted suicide, she suffered brain damage. The daughter recommended that her should mother be given comfort care or medical attention so that she was comfortable and out of pain. There was no written directive from the mother, so the request went to the hospital ethics board. The board concurred with the request. The daughter was sure that this measure coincided with her mother’s wishes.

A second case is one example of the complex decision making that must occur when the wishes of the client, the family, and helping professionals are not in agreement.

Complications arose when the mother’s son (the daughter’s brother), who had not seen his mother in 7 years, arrived in town. The son demanded that his mother receive aggressive medical intervention. He was furious with his sister and told the medical staff that he knew what was best for his mother. He told them that he knew she could be saved and then could return home. During the next few treatment team meetings, he did not allow his sister to speak, and he refused to listen to the other professionals. He then left town abruptly.

The treatment team then again asked for a recommendation from the daughter. She again asked for her mother to be taken off medical intervention and to be made comfortable and pain-free. The mother died 2 weeks later, and the son did not return.

· Have you ever heard your “family member” share the wishes he or she has about what the end-of-life care should look like?

· Did you ever hear your “family member” reflect on the treatment of other members of the family or friends were receiving (e.g., “I don’t want to live the last months of my life like that”).

· What do you think that your “family member” thought was most important in life? What were some of this “family member’s” goals or ideas that he or she lived by?

A situation becomes more complicated when the goals of the organization or the ethical standards of the professionals are also being challenged (Pecchioni & Sparks, 2007). Here is a suggested hierarchy of decision making to help professionals proceed when the patient is incompetent and the family cannot agree on the treatment (Lang & Quill, 2004). Other sources to consult regarding how to make the decision might be state law or agency/organizational policy.

1. The patient’s wishes are followed if there is an advance directive.

2. When patient does not have a directive, then the family makes the decision. If there is disagreement in the family, then the spouse is consulted first.

3. At times, the medical staff must ask the court to intervene if there are irreconcilable family differences.

4. When the patient cannot speak for himself or herself and there is no one else to consult, the medical staff makes the decision.

Interdisciplinary teams need strategies for working with difficult families, especially when the client is incompetent. Here are some guidelines suggested by Sparks (n.d.):

· Ask all family members to attend a meeting with the case management team.

· At the meeting, provide a summary of the client’s status. Use language that all members of the family can understand.

· Identify the issue(s).

· Outline the decisions that need to be made and the options available.

· Be clear about the challenge or issue. Ask members of the family to talk over the issue and choose an option. Work with the family to achieve consensus.

· The family can appoint a member to attend treatment team meetings.

· If the family cannot reach consensus, then ask only one member of the family to choose an option. The spouse is the first person to ask.

· Continue to re-evaluate the decision. Situations are likely to be dynamic.

There are other situations in which case managers are working with families, especially when the client’s skills are limited, but the client is not incompetent. Examples are clients who are young, have limited mental capacity, are homeless, and/or are mentally ill. In working with each population, the case manager must maintain a delicate balance between advocating for the client, engaging the support of the family, and assessing what is in the client’s interest. Many times, families have invested years of effort and care in assisting the client. They may feel they deserve to have a primary role in making decisions.

Reid has been homeless for 15 years. Now 35 years of age, he continues to struggle to meet his basic needs each day. In the past, his parents and younger sister begged him to live at home. He used to come home for 1 or 2 days, create chaos, and then leave. Today, Reid and his case manager have broached with the family the possibility of his living with them. The family’s reaction was one of shock and anger. They refused to even discuss the issue.

Working Through Issues of Family Disagreements

Working through issues of family disagreements can be difficult for a case manager. As a class, in small groups, or as an individual, think about why working with families who disagree is challenging (e.g., reflect on prior family difficulties, resurfacing old tensions, unpleasant and/unproductive dynamics). Discuss what skills a case manager needs to address family disagreements.

When you have completed this exercise, share this information with your classmates.

Family Disagreements and Working with Minors

Working with minors and their parents or guardians often presents challenging issues. For example, an issue may arise related to a child (what the state determines the legal definition of child to be) living in a home with both of his or her parents. The parents may disagree about the status of the child, the goals for treatment, the treatment itself, or the process of case management. In this case, the difficulty with these issues reflects factors that may be at odds with one another. For instance, if the child and the parents belong to the same treatment team with other social service professionals, then each has a say in determining the course of case management. If the case manager meets with the child and works with the child one-on-one, then possible breaking of confidentiality between the case manager and the child may be at stake. If either parents wants control of the process and one “knows best” and ignores the second parent’s view, then difficulties can arise. The following case illustrates all three of these challenges.

Henry is a 16-year old in the tenth grade. His extreme learning disability related to his very aggressive behavior has kept him rotating between a regular high school experience, in-school suspension, and residential placement. His parents have participated in an Individualized Educational Program (IEP) since the third grade. When Henry was in the sixth grade, he attended the IEP meetings. The school social worker and the school psychologist recommended that Henry should be part of the team and the discussion to give him an investment in the decision-making process. They also thought he would be able to see the large number of individuals who wanted him to succeed.

As part of its program, the local school district hires a behavioral case manager to coordinate the care and oversee the IEP-directed services for high school students. The case manager is a coordinator of services and an advocate for the students. As such, Ms. Chen has worked with Henry for the past year and a half. Once every month, she meets with Henry and then with his parents to monitor Henry’s participation in school-related activities. She also meets with the family once every month. Right now, Henry, the school, and the family are involved in a fight over Henry’s future. Henry wants to participate in a technical training program that will allow him to work part-time during his junior and senior years. Henry’s father wants Henry to go to college; hence, he wants Henry to enroll in college preparatory courses. Henry’s mother is adamant that Henry should be allowed to choose his own route to graduation. Henry has told Ms. Chen that he will drop out of school if he does not get to study in the technical school. Ms. Chen wonders what will happen at the next IEP meeting.

· Help the team members agree on ground rules for positive communication (e.g., allowing each person a turn, not interrupting, showing respect, sharing multiple perspectives).

· Clarify that the purpose of the meeting is to work for the best interest of the child (minor).

· Establish a process to facilitate communication (e.g., agenda, clear goals for the meeting).

· Welcome multiple perspectives and see each person on the team as a partner.

· Recognize emotions and content or rationales.

· Maintain the belief that each member of the team wants what is best for the child or youth.

· Make sure that the child or youth has a voice in the process.

· Consider each option and process, and consider whether the option will result in success or will need to be revised in some way.

· Work toward consensus.

Following these guidelines does not predict the outcome of any team meeting, and that includes Henry’s IEP meeting. However, good communication and an understanding of the process encourage open discussion during the decision making.

4-1cWorking with Potentially Violent Clients

Violence is an issue on our society. Stresses are exacerbated by personal pressures, including divorce, illness, feelings of hopelessness, and lack of skills for coping with difficulties. In addition, the policies of deinstitutionalization and treatment within the least restrictive environment have released into the community many individuals who do not have resources to care for themselves. The problem is compounded by a lack of social support for many individuals, changing values, easy access to weapons, and a tendency in our culture to condone violence.

Some human services settings are more susceptible to violence than others. The most vulnerable seem to be psychiatric settings, nursing homes, emergency departments, and outpatient settings. In these settings, there is often insufficient support for staff who work with potentially violent clients.

Many agencies do not recognize the potential for violence in their clients. Service providers are not educated about this potential, and protocols for working with violent clients are seldom established. Many agencies just expect their clients to be violent. It is “part of their culture,” and staff members are simply expected to deal with it. Some agencies reward staff for keeping things quiet, putting the emphasis on controlling clients rather than working with them in a therapeutic way. In such an environment, professionals may hesitate to report any signs of violence, fearing that they will be accused of not doing their jobs. Administrative factors like understaffing and insufficient supervision may also contribute to poor management of violent clients (OSHA, 2009).

The case manager can support the work of the team by acknowledging the potential for violence and preparing for it. What exactly can the case manager do to address the issue of violence? The following steps can be used as guidelines.

1. Members of the team need to identify potentially violent clients and vulnerable situations. To do this, they need to understand and be able to conduct a violence risk assessment on each client.

2. Members of the team need to understand several triggers of violence, such as lack of control.

3. Members of the team should receive training to de-escalate a potentially violent situation.

4. The team needs to know how to write a report related to violent incidents in the workplace.

5. The agency needs policies and procedures that protect clients, employees, and family members from violent acts.

My Story

Alma Grady, Sharon Bello’s Case Manager, Entry 4.2

In recent years, my thoughts have changed about the possibility of violence in our rehabilitation building and offices. Although I have never been touched by a violent work place, the existence of terrorist acts, active shooters, and violent clients seems more of a possibility than ever before. In fact, our agency now has training about how to handle violent clients, how to lock-down the facility when there is a violent shooter, and how to protect ourselves if, in the rare times, we are visiting our clients in their place of employment or in their homes. The training, and I am glad for it, is sobering for me. I am a Quaker, and both my parents and one set of grandparents are Quakers. I grew up in a home of peace and nonviolence. Violence is not part of my world, but in reality it is. The way I approach the notion of violence in the workplace is two-fold: I learn ways to keep my clients safe and I take the training that my agency provides seriously. I have rearranged my office so I have a place in my office where I can step beyond the door and am not in range of shooting. I also have a small speech that I give my clients about the agency being committed to client safety and nonviolence. And I am on a safety task force here at the agency. Approximately 2 years ago, I decided that I would do my part to keep our clients and staff safe.

· Factors such as the unrestricted movement of the public in clinics and hospitals, and long waits in emergency or clinic areas that lead to client frustration over an inability to obtain needed services promptly

· The increasing presence of gang members, drug or alcohol abusers, trauma patients, or distraught family members

· Low staffing levels during times of increased activity such as meal times, visiting times, and when staff are transporting patients

· Isolated work with clients during examinations or treatment

· Solo work, often in remote locations with no backup or way to get assistance with communication devices or alarm systems (this is particularly true in high-crime settings)

· Lack of staff training for recognizing and managing escalating hostile and assaultive behavior

· Poorly lit parking areas

Administrative and Work Practice Controls to Minimize Risk

Administrative and work practice controls affect the way staff perform jobs or tasks. Changes in work practices and administrative procedures can help prevent violent incidents. Some options for employers are the following:

· State clearly to patients, clients, and employees that violence is not permitted or tolerated.

· Establish liaison with local police and state prosecutors. Report all incidents of violence. Give police physical layouts of facilities to expedite investigations.

· Require employees to report all assaults or threats to a supervisor or manager (e.g., through a confidential interview). Keep logbooks and reports of such incidents to help determine any necessary actions to prevent recurrences.

· Advise employees of company procedures for requesting police assistance or filing charges when assaulted and help them do so, if necessary.

· Provide management support during emergencies. Respond promptly to all complaints.

· Set up a trained response team to respond to emergencies.

· Use properly trained security officers to deal with aggressive behavior.

· Follow written security procedures.

· Ensure that adequate and properly trained staff are available to restrain patients or clients, if necessary.

· Provide sensitive and timely information to people waiting in line or in waiting rooms. Adopt measures to decrease waiting time.

· Ensure that adequate and qualified staff are available at all times. The times of greatest risk are during patient transfers, emergency responses, meal times, and at night. Areas with the greatest risk include admission units and crisis or acute care units.

· Institute a sign-in procedure with passes for visitors, especially in a newborn nursery or pediatric department. Enforce visitor hours and procedures.

· Establish a list of “restricted visitors” for patients with a history of violence or gang activity. Make copies available at security checkpoints, nurses’ stations, and visitor sign-in areas.

· Review and revise visitor check systems, when necessary. Limit information given to outsiders about hospitalized victims of violence.

· Supervise the movement of psychiatric clients and patients throughout the facility.

· Control access to facilities other than waiting rooms, particularly drug storage or pharmacy areas.

· Prohibit employees from working alone in emergency areas or walk-in clinics, particularly at night or when assistance is unavailable. Do not allow employees to enter seclusion rooms alone.

· Establish policies and procedures for secured areas and emergency evacuations.

· Establish a system—such as chart tags, log books, or verbal census reports—to identify patients and clients with assaultive behavior problems. Keep in mind patient confidentiality and worker safety issues. Update as needed.

· Treat and interview aggressive or agitated clients in relatively open areas that still maintain privacy and confidentiality (such as rooms with removable partitions).

· Use case management conferences with coworkers and supervisors to discuss ways to effectively treat potentially violent patients.

· Prepare contingency plans to treat clients who are “acting out” or making verbal or physical attacks or threats. Consider using certified employee assistance professionals or in-house social services or occupational health services staff to help diffuse patient or client anger.

· Transfer assaultive clients to acute care units, criminal units, or other more restrictive settings.

· Ensure that nurses and physicians are not alone when performing intimate physical examinations of patients.

· Discourage employees from wearing necklaces or chains to help prevent possible strangulation in confrontational situations. Urge community workers to carry only required identification and money.

· Survey the facility periodically to remove tools or possessions left by visitors or maintenance staff that could be used inappropriately by patients.

· Provide staff with identification badges, preferably without last names, to readily verify employment.

· Discourage employees from carrying keys, pens, or other items that could be used as weapons.

· Provide staff members with security escorts to parking areas during evening and late hours. Ensure that parking areas are highly visible, well lit, and safely accessible to the building.

· Use the “buddy system,” especially when personal safety may be threatened. Encourage home health care providers, social service workers, and others to avoid threatening situations.

· Advise staff to exercise extra care in elevators, stairwells, and unfamiliar residences; leave the premises immediately if there is a hazardous situation; or request a police escort if needed.

· Develop policies and procedures for home health care providers, such as contracts on how visits will be conducted, policies regarding the presence of others in the home during the visits, and the refusal to provide services in a clearly hazardous situation.

· Establish a daily work plan for field staff to keep a designated contact person informed about their whereabouts throughout the workday. Have the contact person follow-up if an employee does not report in as expected.

Class Discussion

Determine How You Would Assess the Likelihood of Violence in the Workplace

· What legal standards are applied to the duty to warn and confidentiality in my state?

There are advantages and disadvantages to involving the client if the case manager believes that the situation warrants a duty to warn. One way to involve the client is to remind him or her of your duty to violate confidentiality when there is a threat to harm self or others. The case manager can ask the threatening client to warn the intended victim. Although involving the client in this way can serve to maintain the trust of the relationship, it may also enrage the client and put the helping professional in danger. The client may feel cornered and become even more determined to carry out the destructive act.

Continue to Learn More about the Client

The case manager’s development of a detailed client history should continue throughout the process. As information is acquired, special attention should be given to any indications of past acts of violence and evidence of impulsivity or anger. Look for other clues or warnings of danger, such as threats, a plan, or a weapon.

Document in Writing

The case manager should document any indications of violence, threats, or expressed anger. Such notes are to be written as objectively as possible.

Welfel (2013) provides guidelines for counselors to use when dealing with clients who represent a threat to themselves or others. They are relevant for case managers, too.

· Remind the client of your ethical and legal obligation to warn.

· Invite the client to participate in the process if possible.

· If possible, develop a plan with the client to surrender any weapons.

· Inform your supervisor, your attorney, law enforcement personnel, the local psychiatric hospital, and the intended victims.

· Keep the client committed, or have him or her committed for treatment.

· Keep careful records of all actions taken.

4-1eWorking in the Managed Care Environment

Today, many case managers work with managed care organizations to determine the services for which their clients are eligible. Understanding managed care is even more relevant in the environment of the implementation of the Affordable Care Act. The context of managed care is based on clearly defining client problems, determining the most effective and efficient service to provide, and measuring outcomes. Managed care organizations operate within a business atmosphere where the ultimate goal is accruing the financial foundation needed to remain in business. Many case managers, who are committed to act in the best interest of their clients, encounter ethical dilemmas as they work with managed care. Two of these challenges are providing “best” services to clients and advocating for the client. There are times, in the opinion of the case manager, when the client may be harmed by the recommended services.

Managed care organizations are making decisions for treatment that balance the high cost of services with the needs of the client. This dilemma is well documented throughout the helping professions; many of these professions have responded by creating guidelines for working with managed care organizations (Rutigliano, 2010; Reid & Silver, 2002). In addition, the rights of patients within the managed care system emerged as support for patients seeking quality care (Foundation for Tax Payer & Consumer Rights, 2005). The following vignette exemplifies in a simple, but dramatic, way the difficulties that occur when clients are denied treatment they need.

In this situation, the case manager, as the leader of the team, receives the report from the managed care organization. It is the case manager’s responsibility to advocate for the client. The case manager talks with the managed care assessment coordinator, writes an appeal, and visits with the agency. These activities are all in response to the ethical commitment to support what is best for the client. The case manager also works with the client and the family to help appeal the decision. What makes this situation difficult is its prevalence. Case managers today spent a good deal of time working with managed care organizations on behalf of their clients (Mullahy, 2010).

The second situation related to decisions made by managed care organizations expands the first challenge: that of providing the services needed to the client. The dilemma occurs when managed care offers treatment that the case manager believes will be harmful to the client. It is possible that in the process of a review of recommendations made by the case manager on behalf of the treatment team, the managed care organization will not only reject the recommendation but also recommend an alternative solution. The following short vignette illustrates this dilemma.

Suzie, an 8-year old, is attending a public school. For the first 3 years, she attended a school for children with special needs. Her primary diagnosis was mild autism. A team has worked with Suzie’s parents for the past 3 years. One of the goals of the team has been to reduce the medication that Suzie is taking. The team, with full support of the parents, would like to substitute weekly counseling and group therapy for the meds. Because Suzie has recently begun to attend public school and is involved in a “mainstreaming” effort, the case manager believes it is a good time to suggest this more drug-free approach. The managed care review rejected the request and suggested heavier doses of medication.

This decision made by the managed care organization places the case manager in the advocacy role, because the treatment team and the parents believe that more medications will decrease Suzie’s abilities to function well in the public schools. The medication suggested by the managed care organization will sedate Suzie. Attending school in a sedated state does not allow the professionals to help Suzie to develop her socialization and coping skills. The case manager decides to appeal the decision and encourages the parents to appeal the decision. The case manager may also collect professional literature reflecting the current “standard of care” for children with mild autism. The psychologist on the team also will write a letter for support for the current plan.

Managed care is a part of the health and mental care system. Case managers have a responsibility to work with these organizations if they are to serve their clients effectively. Several suggestions support the work of the case manager as an important link between the client and the managed care organization. These suggestions follow.

The purpose of managed care organizations is to provide the minimum services that will meet the client’s needs. If the case manager understands that this is the focus of the managed care organization, then the case manager can help these organizations by making a strong and documented case for services that help meet client’s needs.

Work with the System

If the case manager establishes relationships with professionals who work in the managed care environment, then it is easier to work with them than against them. A good relationship allows case managers to place phone calls to their “colleagues” and to talk with them about how they might use the system to promote better care for their clients.

Help Clients Understand Managed Care

Many clients are not aware of their rights concerning managed care, their ability to appeal decisions, and their rights to request a review of their cases. Teaching clients how to effectively advocate for themselves helps clients and case managers speak with one voice.

Recognize the Demand for Detailed Records and Report of Client Progress

Managed care organizations request detailed recordkeeping and documenting of client needs and client progress before services are authorized. Keeping the documentation and authorization requirements up to date is an important part of the case manager’s job. It is necessary for case managers to set aside time in their workday for paperwork. This responsibility will reduce the time available for client care.

Write Clear, Well-Documented Treatment Plans

Many managed care decisions are based solely on the documentation sent forward by the case manager. Plans and requests should be well written, and needs for services should be well documented.

Following these guidelines should help the case manager develop a relationship with the managed care professionals and advocate for clients. At times, using the voice of the treatment team strengthens the case for a request for services.

4-1fAutonomy

Mrs. Zeno is married and has three children. She has been a client of Child and Family Services for the past 2 years. She is now going to school and studying to earn an associate’s degree. She intends to work full-time after she completes her education. According to Mrs. Zeno, her husband takes all the money that she receives from Child and Family Services and from welfare. He gives her a small allowance, from which she buys groceries and pays for the rent and utilities, but there is never enough money for clothes for her children or educational supplies for herself. Mrs. Zeno is reluctant to challenge her husband. She does not want to disrupt her home, and she needs her husband’s support if she is to finish school. In her last meeting with her case manager, Mrs. Zeno firmly stated that she would do nothing about her husband’s behavior. The case manager believes that Mrs. Zeno should, at the very least, talk with her husband about the problem.

In dealing with issues of autonomy and self-determination, asking the following questions can help the case manager and guard the client’s autonomy.

What Are the Facts of the Case?

Before any autonomy issues can be thoroughly understood, the case manager must gather relevant information.

Can You Understand the History of the Case and the Current Situation, and Can You View It from the Client’s Perspective?

It is important to understand the client’s perspective, which determines his or her preferences and choices.

Is the Client Competent?

It is difficult to determine competence. Clients may be able to make good decisions at certain times but not at other times. Also, they may demonstrate competence in one area of decision making but not in other areas. Only with great caution should a client be declared incompetent.

What Does the Client Want?

Learn exactly what the client wants. Inform them fully of all the alternatives available, and help them understand the consequences (positive and negative) of each alternative.

What Are the Barriers to What the Client Wishes?

For many reasons, clients may not be able to get what they want. Sometimes policies and regulations restrict the case manager’s ability to support client choices. Often, there are resource problems; the services are not available or funds are insufficient to pay for them.

Can These Obstacles be Overcome?

It is the responsibility of the case manager to break down barriers to client autonomy. When making any decision that violates client autonomy, the case manager must inform him or her of the reasons for making that decision.

In determining whether to violate client autonomy, one must calculate the risks to the client and others. If a client’s decision would cause harm to self or others, then the case manager must overrule him or her.

What Is the Advice of the Treatment Team?

The opinions of the treatment team members must be sought and considered. These professionals have much at stake in their own work with the client. If any of the professionals involved does not regard client autonomy as a high priority, then this issue must be addressed early in the case management process.

How Can the Case Manager Guard the Values of the Client?

The values of the client should guide the planning of services. If the client has conflicting values, then the case manager should work with him or her to determine the priorities.

4-1gClient Preferences: One Component of Autonomy

To develop the care plan, case managers take client preferences into account. In every part of the plan, client preferences receive priority, and everyone involved must respect those preferences. Sometimes this creates problems, as illustrated in the following examples.

The case manager who is developing a plan for Ms. Toomey has limited funds, but part of the money available is designated for health and recreation activities 3 days per week. Ms. Toomey hates any mention of good health; she especially dislikes exercise and fresh air. Ms. Toomey really loves to go to the movies; she does not watch them at home. The case manager is trying to decide whether she should use the resources available to pay for an attendant to take Ms. Toomey to the movies 3 days per week (which is Ms. Toomey’s preference) or to have the attendant walk with her in the park at least once every week. The case manager is not sure that she can justify movies three times every week to the funding source.

Mr. Krutch needs childcare for his baby while he works during the evening at a factory. Almost all of the available childcare workers are Latino and speak little English, but they work well with children. Mr. Krutch refuses to have a Latino person in his home or caring for his child.

The case manager should consider the following guidelines when faced with issues involving client preferences.

Ask What the Client Needs

The case manager must have a clear idea of the client’s needs. The client’s perspective is important in identifying these needs.

Ask why the Client has a Particular Need

For each of the needs listed, articulate clearly why the client needs the proposed services or support. The client and the case manager then understand why each of the needs is important. During this process, the cultural background of the client must be considered (Williams, 1993). Too often, case managers do not realize the preferences of their clients, particularly when they come from different cultures.

Can Each of the Needs be Addressed?

How Are Client Preferences Met?

Respect for client autonomy means that the case manager works to meet the preferences of the client. Creative advocacy and problem solving can help to find ways to meet client needs. By advocating institutional adjustments to client preferences, the case manager builds trust and strengthens the relationship. Within a good relationship, clients are more willing to make their preferences known.

When Is a Preference Not Legitimate?

The case manager has a responsibility to follow the agency’s policies; for example, one client is not entitled to an undue share of the case manager’s time or of any other resource at the agency’s disposal.

Let us look at how to apply these guidelines to the cases presented. With Ms. Toomey, the case manager faces a dilemma. Ms. Toomey does not want to take part in any activities involving exercise or good health. She has made it clear that she only wants to go to the movies. The funding agency insists that its money is not to be used to pay for three movies every week. The agency will only fund one movie per week; the criteria for funding eligibility require a variety of activities that are related to physical health. In this case, the treatment team agrees with the funding agency. It suggests that an exercise program and an activity that will challenge her intellect will better support the goals set for Ms. Toomey. With this information, the case manager can discuss options with Ms. Toomey. The case manager is confident that she and Ms. Toomey will find a solution. She also knows that she has limited time to spend on the matter because she is responsible for 35 other cases.

The service provider working with Mr. Krutch to find childcare is in a difficult position. When Mr. Krutch expressed his disdain for individuals of Latino origin, the care coordinator listened carefully. Two issues emerged. First, most of the available childcare workers are Latino. They are very able and have excellent recommendations. Second, the agency has a carefully stated commitment not to discriminate in hiring based on race, gender, religion, or national origin. However, the care coordinator working with Mr. Krutch realizes that it is important for him to have a good relationship and to trust whoever cares for his child. In this case, the care coordinator decides to try to find a non-Latino childcare worker, but she also gives Mr. Krutch a realistic picture of what candidates are likely to be available. She explores Mr. Krutch’s reasons for his reluctance to hire a Latino worker, and she prepares him for the possibility that he may have to give such a worker a try. One criterion she used when deciding to seek a non-Latino worker was to ask what harm hiring a Latino worker might do to the client. Mr. Krutch was vehemently against such a hire, and going against his wishes would not have been helpful to the goals of the care process.

Class Discussion

Thinking About the Issue of Autonomy

As a class, in small groups, or as an individual, develop your own scenario in which you as a case manager will face an issue related to autonomy. In your scenario, name your client, describe family and friends, describe client needs, and write about the issue of autonomy that arises. Pass your scenario to another individual or group. Each group will discuss the new scenario and outline how to respond and why. Discuss the downside of your decision.

When you have completed this exercise, share this information with your classmates.

4-1hAutonomy and End-of-Life Issues

In this chapter, we discussed the ethical issues of decision making that relate to patients who are dying and incompetent, and therefore unable to make their own decisions about their own end-of-life care. Today, case managers are becoming increasingly involved in the care of competent individuals at the end of their lives because they work with elderly persons in long-term care facilities, with terminally ill inmates in correctional facilities, with AIDS patients, with people who have chronic illnesses, and with children and families caring for those who are dying. To give their clients more autonomy regarding their end-of-life decisions, case managers are helping clients consider establishing advance directives that will guide end-of-life care.

The family is facing a problem. Next month, the mother is having bypass surgery and she will need her husband to help her during her recovery. Neither she nor her husband will be available to provide care to their son. Mr. Sams knows that he needs daily care, so he has consented to hire an aide to stay with him and give him the help he needs. According to agency policy, however, his parents cannot receive any agency support for any care they give him for 6 months after the aide is hired.

To protect the client, the agency has established a rule that members of the family who receive in-kind or monetary support for client care must be providing such care on a continuous basis. If the care is interrupted for more than 14 days, then the family cannot be supported by the agency as caregivers for 6 months. This rule works for stability of care and discourages families from providing help only when it is convenient for them. Another policy states, “The assistance must be provided by an individual whose sole responsibility is the care of the client.” Thus, in this case, the father may not be reimbursed if he cares for both his wife after her surgery and for his son.

Ms. Dimatto, the caseworker, has a conflict to resolve. In accordance with the rules, she could hire an attendant to stay with Mr. Sams until his death. His parents could then visit him as they wish, but they would not receive any compensation for the care they give their son, nor could the father receive a stipend for caring for his wife. Ms. Dimatto could also suggest that the parents return after 14 days, asking the father to care for both his wife and his son. This solution would violate another policy—that the care of Mr. Sams is the father’s sole responsibility—because the father would also be taking care of the mother during the postoperative period.

What Does the Client Lose and What Does the Client Gain if the Rule Is Followed?

The case manager carefully articulates the client’s gains and losses in the event that a rule is broken. The weighing of advantages and disadvantages helps the case manager think through the issue and place client welfare at the center of consideration.

Is This a Life-or-Death Situation for the Client?

The answer to this question often gives perspective to consideration of the rule’s effect on client welfare. If the answer to this question is yes, then the case manager has an argument worth considering for bending or breaking the rule.

Asking for Help

In breaking or ignoring rules for the client’s benefit, the case manager must keep in mind three considerations: good decision making, use of supervision, and asking for exceptions. He or she must ask the preceding questions to have a firm basis for decision. When using supervision or asking for an exception, violation of the rules may be only one of several concerns. When asked for help, the supervisor may respond in one of several ways. First, he or she may tell the case manager not to violate the rule. At that point, the case manager must decide whether to obey the rule and the supervisor or to break the rule and ignore instructions; there are negative consequences for both actions. Second, the supervisor may give the case manager permission to violate the rule. If the case manager does so, then both the case manager and the supervisor are liable for the consequences. The supervisor may also ask the case manager not to act until an appeal for an exception has been filed.

Appealing for an Exception

Petitioning for an Exception Can Provide an Impetus for Change

It helps those who make the rules see that rigid enforcement may violate the reason for which the rule was made in the first place. In some situations, there is no way exceptions can be made. It can be useful to appeal for an exception even when there is no clear channel for such an appeal. Authorities may then understand the need to establish appeal procedures, because rules are not appropriate in every situation that arises.

4-1jMaking Sense of Ethical Issues

Mullahy (2014), in her book The Case Manager’s Handbook (5th edition), provides some wisdom about working through ethical challenges in her chapter related to ethical issues and the case manager. She offers advice for thinking about ethical issues suggested by John Banja, who is a Professor and Medical Ethicist at Emory University in Atlanta. Dr. Banja presents three steps for his No Brainer Test of Ethical Behavior (Mullahy, 2014, p. 354).

Ask yourself three questions:

1. Is it legal?

2. Would my mother approve?

3. What if my behavior was described on the front page of tomorrow’s New York Times?

We suggest expanding Question 1 to include “Does it follow agency policy or written procedure?” Banja’s Questions 2 and 3 address a more personal orientation and comfort with ethical decision making.

Mullahy (2014) also suggested practical decision-making guidelines proposed by Frank Lewis (2012), the National Director of Clinical Outcome Services of Neuroestortive Clinic providing care for individuals with brain injury. We summarize Lewis’ guidelines here.

· Identify that ethical conflict exists. Write about the nature of the conflict. You may understand the conflict if you summarize it in writing.

· Bring together the facts from the various points of view represented. The facts may appear differently for each of those involved.

· Be clear with each individual involved regarding all of the facts you gathered. Each individual needs to have a clear picture of the varying perspectives.

· Ask others to help you generate solutions to the dilemma(s) identified.

· As the discussion of the solutions unfolds, be sure to involve others in asking questions and generating answers to the questions.

· Choose a solution and put it into effect.

· Evaluate the implementation of the solution.

Class Discussion

Making Sense of Ethical Issues

As a class, in small groups, or as an individual, choose one of the issues presented in this chapter or develop an issue for which you have an interest. Then, use Lewis’ steps to work through the dilemma. Finally, work through Banja’s personal test to assess your work.

When you have completed this exercise, share this information with your classmates.

Consuela is a 24-year-old woman in the master’s of human services program at the University of Nebraska. Her bachelor’s degree is in English and she plans to pursue licensure as a human service professional upon completion of her program. She is currently meeting her internship requirement at the Children First Center in Lincoln, Nebraska. She spends 10 hours each week shadowing different administrators, social workers, and counselors as they provide therapy for children and their families who have been referred for incidences of abuse and neglect.

During the first half of her internship, Consuela enjoyed all that she was learning and received high marks on her midterm evaluation from her site and faculty supervisors. She described her experience as “significantly increasing” her knowledge of child abuse, family therapy, and counseling skills for children and adolescents. On a particularly busy day, just after her midterm evaluation, Consuela’s site supervisor is absent from work. One of the other therapists, Jessica, with whom Consuela does not have a strong relationship and by whom she often feels intimidated, is in charge of providing her duties and responsibilities for the day. She asks Consuela to co-facilitate a parents’ group, work with Tonya in the file room, and then check back in with her for further assignments.

After completing these tasks, Consuela finds Jessica, who describes how “swamped” they are with the state officers coming in tomorrow. She explains to Consuela that an aunt has just brought a little girl into the office and the aunt thinks she may have been sexually abused. She says that the aunt just wants to talk with someone before they check the girl out, but “our protocol requires an evaluation for any suspicion of sexual abuse.” Jessica explains, “you never know who is telling the truth,” but they need to start the paperwork, complete an evaluation, and then conduct an initial interview. Jessica gestures toward the other employees and says, “there’s no one else that is free to do it but you and I.” She asks Consuela if she has shadowed a physical evaluation. Consuela says that she has and Jessica responds, “Great! Then I will start the paperwork while you take the girl for the evaluation and we can meet together so you can shadow me on the initial interview.”

Consuela starts to express reservation, but before she can speak Jessica pats her on the shoulder and says, “I really appreciate this and won’t forget it on your next evaluation. Days like this make me wonder why I ever get out of bed.” Confused by the mix of emotions surrounding the afternoon and concerned about the impact of expressing hesitancy toward the assignment, Consuela conducts the physical evaluation.

Morgan, C. (2012). Unpublished manuscript, Knoxville, Tennessee. Used with permission.

Discussion Questions

1. What key legal issues are present in this scenario?

2. How might this scenario present problems for the case manager? The client? The family?

3. In working with this type of population, what are the issues the case manager encounters?

4. What options does Consuela have in this situation? Who might be among her first choices for consultation before following through with the physical evaluation?

Author Note: We think that it is important for you to review the chapter you just read. We suggest the following.

· First, re-read the class discussion questions in the text and answer these as comprehensively as possible.

Introduction

· Understand how knowledge of diverse populations supports the work of the case manager.

· Describe the movement between viewing the client as an individual and viewing the client and his or her culture.

· Identify two reasons why understanding another’s culture is difficult.

Working with Diverse Populations

· For each of the following populations, African Americans, Arab Americans, Asian Americans, European Americans, Latinas/Latinos, Native Americans, Women and Men, Sexual Minorities, and Individuals with Disabilities, describe the following:

· History

· Ethnic or racial identity

· Role of the family

· Religion/spirituality

· Challenges

· Approaches to case management.

Multicultural Case Management: Your Next Steps

· List the possible steps you might take to help you develop sensitivity when working with diverse populations.

5-1 Introduction

In this chapter we examine why understanding the diverse nature of the individuals with whom you will work is important. We discuss most populations in terms of history, ethnic or racial identity, role of the family, religious/spiritual, challenges, and approaches to case management. Prior to describing the populations, let us look at case managers and their experiences working with diverse clients.

I am a case manager in an HIV/AIDS clinic. At our site we provide case management services for women. The programs and case management we provide differ for different ethnic, racial, and age groups. Of course, by providing services to women, we already target by gender. We find the needs are different for women. Our three programs include African American teen girls, African American adult women, and Haitian teen girls and adult women. We also integrate women clients into a mixed ethnic and racial group.

—Director, HIV/AIDS clinic, Florida

—Case manager, elder advocacy, Michigan

Honestly, I have a great job. Well, most of the time. When clients are ready to leave the mental health residential care facility, I help plan the aftercare. I work primarily with the clients and their families. It is almost always a multicultural event. I am White and an Arab American male. Clients usually don’t know where I am from, but they think I am from a different country. Once a client challenged me about my nationality. I didn’t disclose. After 9/11, being Middle Eastern here in the United States is not helpful in much of my work with clients.

—Case manager, mental health residential program, Alabama

As you read about the various populations presented in this chapter, you will begin to understand why an organization would decide to use their resources and develop their programs in such a way. In the first quote, the director of an HIV/AIDS clinic introduces us to the way in which her agency tailors their services by gender, ethnicity, race, and, at times, age. So, for this organization, the case management programs match much of the case management process to the cultural expectations of the client and the family. For example, within the African American population they serve, most of the teens are single mothers. They live at home and their family and extended kin provide support. The agency offers services for the teen and also for the family members.

The third quote is from a young man who is an Arab American working in mental health residential care. He works with children and their families to plan aftercare prior to a teen’s discharge, primarily into the care of the family, foster parents, or residential homes. Although he did not share this in his quote, he faces discrimination in his work and in social situations. He feels his country of origin does influence his work. Also, he believes that his youth does not help him. Most of the time, he builds rapport with his residential clients fairly easily. But his work with families and foster care families does not always go well. He has developed an organized approach to aftercare planning and builds on strengths. At client-related staffing meetings, he continues to learn the struggles other aftercare planners experience in their work.

For these professionals, their work with case management includes working on diverse case management teams and/or with diverse client populations; both provide opportunities and challenges. This chapter will help you understand various populations to serve them more effectively. First, we consider race and cultural identity development.

My Story

Sharon Bello, Entry 5.1

When I first started thinking about diversity, I was flooded with thoughts about myself and my family, my husband and his family, and my children. It took me a while to regroup and consider myself. There is always some sadness when I think about my husband who has passed. And thinking about my children makes me think about Sean and Juan, and that brings a sadness that is hard to bear. It also reminded me again that, in our family, we are such a mixture of cultures and races. My mom told me about the challenges that she and my dad had. Because my mom was African American and from the north and my Dad was a Hispanic man from El Salvador, she had lots to tell. My dad used to carry on about his “place” in the family. He laughed and kidded my mother about how he passes for African American! He made her laugh about the differences.

We were raised in a mixed culture, but African American was mostly what I thought I was. But I looked really different from either side of the family. And my kids, well, they are a mixed race, too. At least they think they are because their father and I are not of the same race. Their dad was raised as White. But that is a story, too. He had a White mother and an African American dad. So, his background and his race and culture were mixed, too, but he looks White.

5-3dReligion/Spirituality

Understanding Identity Development Is Important

Consider the concept of identity in terms of what you learned in the section entitled Working with African Americans. Answer the following questions.

1. How does identity relate to the African American population’s experience of oppression and discrimination?

2. How might African Americans find strengths in their identity? Barriers?

3. How is the African American population different from your own culture? Similar? If you are African American, then consider how this description of African Americans differs from your own experience.

Share this information with your classmates.

5-4 Working with Arab Americans

5-4aHistory

1. Making an effort to gain knowledge of the client’s culture. Be respectful of the differences.

2. Being sensitive to issues that relate to assimilation and acculturation. Assess, either formally or informally, the degree of assimilation and stressors so related (Basma & Gibbons, in press).

3. Considering the family support of the client, taking care to understand any isolation the client may feel (Ferguson, 2009).

4. Carefully describing a helping relationship to the client and indicating expectations related to client responsibility and confidentiality (Larson et al., 2013).

5. Using a direct and concrete approach.

6. Because the family is important, involving the family depending on the client’s comfort with this involvement.

7. Delivering the case management process within the client’s cultural context.

8. Seeking feedback from the client about the effectiveness of the case management process. This feedback may not be easy for the client to deliver because of the hierarchical nature of the culture.

5-5 Working with Asian Americans

The Eastern view of the world and the values held are, in most ways, very different from those of the West. Asians tend to see life as a cycle or circle, appreciate self-sacrifice, and practice integrating respect for past traditions into daily living—all somewhat counter to Western values of progression in linear stages, independence, and individual achievement (Brammer, 2012). The group defined as Asian is found in more than 20 countries in the East and Near East, and within those individual countries there are significant cultural differences.

5-5aHistory

5. In the past, Asian Americans experienced discrimination, and they continue to do so today. Look for signs of anxiety, depression, and low self-esteem. Incorporate strength building in the case management process.

6. Building a relationship and maintaining harmony is critical for the case manager’s relationship with the client. Reciprocity is important so that appropriate self-disclosure is important.

Class Discussion

Comparing the History, Beliefs, and Traditions of Arab American and Asian Americans

Arab Americans and Asian Americans have very different histories, beliefs, and traditions. Answer the following questions to enhance your understanding of both of these populations.

1. Take some time to compare and contrast the Arab American and Asian American populations in terms of

· a)

immigration to the United States,

· b)

experience of oppression,

· c)

dominant society’s view,

· d)

role of the family, and

· e)

religion/spirituality.

2. What do you see as the strengths of each of these populations? Barriers? How might each strength and barrier influence the case management process?

Share this information with your classmates.

5-6 Working with European Americans

5-6aHistory

European Americans constitute a diverse group. Their racial category is White and their ancestry represents European nations. For purposes of clarity, the designation of “White” refers to even broader origins, such as Western European, Eastern European, Arab, Jewish, South American, and Australia (Brammer, 2012). Although being White means belonging to the dominant group in the United States, some members of sub-groups of Whites have been oppressed. For example, in the 1800s, individuals immigrated from many areas of Europe. The Irish experienced oppression in the United States, were viewed as the other, and were stereotyped as lazy, stupid, and prone to drunkenness (Daniels, 2009). Another example is the Holocaust and the continuing anti-Semitism that exists today. Also, there is discrimination against Whites who live in poverty; results of this discrimination include low education attainment, low employment opportunities, high likelihood of being involved in the corrections system, and fewer housing choices. Many of these persons who live in poverty live in rural areas (Eisenberg, 2015). Despite the different countries of origin, there exists a belief that all White Americans are one, representing the dominant culture in the United States (Richmond & Guindon, 2013).

5-6bRacial or Ethnic Identity

4. Recognize the possibility of discrimination for European American clients. Help them find ways to cope with this.

5. Help clients develop their own goals and definitions of achievement and success. This helps addresses a feeling of unworthiness.

6. For women, help these clients be heard and participate in the process of advocating for themselves.

5-7 Working with Latina/Latino Americans

5-7aHistory

The Latina/Latino population is as diverse as the African American or Asian American populations. As indicated, the term “Hispanic” is used by the United States Census to define ethnicity: Hispanic or non-Hispanic (United States Census Bureau, 2011). Many believe this term incorrectly reflects that Hispanics are all very similar (Delgado-Romero et al., 2013). There is a history of oppression and discrimination for this population from outside the population and within the population, in both the countries of origin and in the United States (Cain, 2009). Stereotypes include seeing Latinas/Latinos as lazy, illegal aliens, uneducated, and emotional (Delgado-Romero et al., 2013). Many live in fear because without proper documentation, they have little access to help or support and continually worry about deportation (PBS Kids, 2008).

5-7bRacial or Ethnic Identity

Brammer (2012) suggests that Latin American heritage represents three groups: indigenous groups whose languages are the dialects of their local area; groups that blend the indigenous group and the Spanish heritage; and groups that are made up of direct descendants of colonization by Spain. The term Latina/Latino is also used to reflect connections with Latin America, although there are many countries in the region. There are commonalities within the culture such as  personalismo, valuing relationships ( familismo), valuing the extended network of family, and seeking pleasant relationships with others ( simpatia).

In a recent study by the Pew Research Center (Gonzalez-Barrera & Lopez, 2015), two-thirds of Hispanics describe that both their ethnicity and their race are Hispanic. In another study conducted by the Pew Research Center (Taylor et al., 2012), individuals surveyed indicated that they represent varying cultures rather than one culture, with the common connection being the Spanish language, and that adults who speak Spanish believe it is important to continue its use.

Sharon Bello and Alma Grady, Entry 5.3

Ms. Grady and I are writing heritage section together. Because my dad was Hispanic, she and I have been talking about what part that heritage in my life. What I know is that my dad was my hero. Until he died, I was his girl and he took care of me. Nobody since has taken care of me like that. This is nothing against my mother who is my rock, but dad was head of the family and he cared for us. That is until he passed. Sometimes I think he is still there looking over me. My mother assumed a more active role after my father’s death. And I think that I ended up being just like her.

Also, I know that I am so stressed right now. And my dad used to keep our spirits up. He was relaxed and I know my grandparents (my dad’s parents) were also like that. I tried to be that type of mother until the stress just became too great. I couldn’t keep myself up and I sure couldn’t lighten the mood for anybody else. I wish that my kids, and now just my girls, had my dad in their lives. Alma says that this talk of happiness and an easing of spirits are important as I continue my education. I need some of that lightheartedness to return. We are finding out ways to get it back.

Class Discussion

Examining How Your Own Viewpoint Influences Your Thoughts About European American and Latina/Latino Populations

As you read about the European American population and the Latina/Latino population, write down your first thoughts.

1. Review these responses.

2. How do these responses relate to your own race and cultural identity development?

3. How will these responses influence your work as a case manager?

Share this information with your classmates.

5-8 Working with Native Americans

5-8aHistory

There is an extensive history of oppression and discrimination toward Native American populations. These populations include various tribes and groups, such as American Indians, Eskimos, Alaskan Natives, and Aluets. During the nineteenth and early twentieth centuries, Whites working for the government conducted programs and actions intended to target and destroy Native American culture, language, and spiritual and religious traditions (Brammer, 2012). Those not exterminated were subjected to assimilation and relocation, thus destroying the traditional ways of life and guaranteeing abject poverty (Negy, 2009a). Much of this oppression and discrimination linger today. Approximately one-third of these populations live below the poverty line. Many do not complete high school (Negy, 2009a). Today, the Native American population is increasing. The US Census Bureau (2012) reported that, according to the US 2010 Census, the Native American population increased 39% since 2000.

5-8bRacial or Ethnic Identity

5-9bGender Identity

Many women and men will not strictly fit defined gender roles, and thus they may become confused or conflicted about gender identity. Results of this identity conflict may include feelings of humiliation, fear, shame, confusion, guilt, isolation, alienation, and loneliness (Brammer, 2012). When women and men do not fit the norms and roles socially expected of them, they often become victims of oppression and discrimination. They may experience microagressions that challenge their self-worth, cause stress, and often result in depression and anxiety (Sue & Sue, 2012).

5-9eApproaches to Case Management

Approaches to case management for women and men may be different. One of the influences is the gender match between case manager and client (Trepal et al., 2013). Although women tend to seek help and are self-referred more often, seeking help is apparently difficult. Women enter the helping process looking for both relationships and problem solving. Men view helping as straightforward and matter of fact; they see helping as almost entirely problem solving (Winerman, 2005). We describe specific approaches that case managers may use for working with each sex. These suggestions are limited because they do not consider other aspects of identity such as race, ethnicity, or culture (e.g., African American, Hispanic, role of the family).

Working with Women

1. Encourage female clients to tell their own stories. Develop a relationship and rapport by listening and demonstrating a willingness to understand.

2. Pay attention to strengths and building on them.

3. Explore female clients’ expressed identities and demonstrate ways they might develop and/or expand them.

4. Help clarify environmental factors that influence women clients’ situations, including the experiences of oppression and discrimination.

5. Provide women clients a collaborative role in the case management process.

6. Help women clients develop self-esteem, self-confidence, and assertiveness skills.

7. Help women celebrate their successes.

Working with Men

1. Recognize that for many male clients, seeking help means acting counter to the picture of the ideal male (e.g., independent, tough, and self-sufficient). Approach the initial case management session with clear information about the process. Normalize participation in the case management process.

2. Use a problem-solving model and a collaborative approach to case management.

3. Counter the possible shame of needing help that many male clients may feel by identifying and discussing client strengths.

4. Help male clients understand the boundaries of confidentiality.

5. Assess male clients with attention to the issues that men most often exhibit, such as depression, substance abuse, anger, and violence (Englar-Carson, Evans, & Duffey, 2014).

6. Understand the different aspects of men’s lives and work with these as strengths (e.g., men in family relationships, men as fathers, men in the workplace, men and health, men as members of a sexual minority, men of color, men as seniors, men as veterans, men with substance abuse issues, men with trauma-related issues) (Englar-Carson, Evans, & Duffey, 2014).

Alma Grady, Sharon Bello’s Case Manager, Entry 5.4

I wanted to talk about my experiences as a case manager working with women and with men. It is difficult to begin this discussion based on my work with various populations. Communication with Asian American men is very different than communication with European American men. Similarly, communication with an Arab American woman is different from communication with a Hispanic woman. Because you will continue to learn about my work with Sharon, I will now discuss working with men.

I just returned from a Rehabilitation Annual Conference where I learned about employment and individuals with disabilities. According to the speaker, citing the Bureau of Labor Statistics 2014 report, individuals with disabilities are more likely to be older women. And Blacks and Whites are more likely to have disabilities than Hispanics and Asians. These statistics don’t reflect the demographics of the clients I serve. More than 70% of my clients are male, and many are in their 20s, 30s, and 40s. This has been the case for the past 5 years.

Many of the male clients that I serve have been involved in social services for a period of time. Some have had substance abuse problems, mental health issues, have been homeless, and/or have been incarcerated and are now on probation or parole. These individuals also have one or more of the following types of disabilities: mobility and physical; sensory; health; psychological; intellectual; learning; and attention disorders. Male clients are rarely self-referred. In most cases, an application for rehabilitation services becomes part of another agency’s plan for the client. These clients don’t know what to expect. Many come with an attitude or are so depressed they have little spirit.

Despite the stereotypes of male dominance, aggressiveness, and reticence to talk and self-disclose, many of the males I work with share information with me about their lives. I admit this ability to talk and to collaborate make take some time, but when these male clients realize they have everything to gain when they participate, they do so to varying degrees.

For instance, Jeffrey was a parolee, age 50, referred to Rehabilitation Services. His eye sight was impaired and he had lost 85% of his hearing in one ear, both from an automobile accident. Before prison, he was a gifted mechanic, but his sensory disabilities decreased his ability to work. When he applied for Vocational Rehabilitation, he made an appointment and was a no-show. His parole officer called and asked us to give him a second opportunity. We did so. During the initial interview, his victim attitude disappeared when he talked about his work as a mechanic. He came with an attitude of distrust, but his desire to regain and retool his skills as a mechanic overrode his initial feelings. Yes, Jeffrey did fit the persona of the stereotypic male; he was aggressive, sometimes surly, and he didn’t want to talk about his past. But he was much more than that. He wanted to work and he returned to technical school. There, he established a relationship with his teacher/mentor and his advisor. And, for us, he became a reliable client.

Class Discussion

Preparing to Work with the LBGT Population

As a case manager working with members of the LBGT population, we believe it is essential for you to assess the knowledge you have about the LBGT population, become aware of the cultural messages about sexual orientation, and become aware of heterosexual privilege. We help you begin this assessment focused on your attitudes about sexual orientation.

1. Do you know the following terms: lesbian, gay, bisexual, transgender, transvestite, transsexual, and intersex?

2. Describe any experiences you have had with a member of a sexual minority.

3. What would be your reaction to interacting with sexual minorities:

· a)

as a student,

· b)

as a colleague at work,

· c)

as a supervisor,

· d)

as a friend,

· e)

as a neighbor,

· f)

as a family member?

4. Do you consider the following situations serious, somewhat serious, or not at all serious?

· a)

a company refuses to hire sexual minorities

· b)

a social club bans sexual minorities as members

· c)

a home owner will not rent to an individual who is a sexual minority

· d)

a member of a sexual minority is not welcome in a church, temple, or synagogue

To further assess your attitudes about sexual minorities, consider the following questions suggested by Szymanski (2013).

· a)

“What stereotypes exist in the general culture (e.g., dominant United States) about lesbians, gay men, and bisexual persons? What impact do you think these stereotypes might have on heterosexuals and sexual minority clients?” (Szymanski, 2013, p. 421). Also, answer the following questions for transgender clients.

· b)

“How have your attitudes about sexual orientation developed over time?” (Szymanski, 2013, p. 421). Also, how have your attitudes developed about sexual identity?

· c)

“What are your values, beliefs, and thoughts about working with individuals in the LBGT population?”

After you have answered each of these questions, discuss the results with your classmates.

5-10 Working with Sexual Minorities

In this section, we focus on such sexual minorities: lesbian, bisexual, gay, and transgender (LBGT) individuals. Because of limitation of space in this chapter, we speak primarily, although not entirely, of lesbian and gay individuals. We encourage you to expand your knowledge of these sexual minorities and develop your skills in working with members of the LGBT populations.

· Lesbian A lesbian is “a woman whose sexual orientation is to women” (The Free Dictionary, n.d.).

· Transsexual (male-to-female or female-to-male) The definition of transsexual is “a person whose sexual identification is entirely with the opposite sex” (The Free Dictionary, n.d.). A female transsexual feels strongly that she is a male. A male transsexual feels strongly that he is a female.

· Intersex A hermaphrodite, male pseudohermaphrodite, or female pseudohermaphrodite. The term “intersex” refers to “a group of conditions where there is a discrepancy between the external genitals and the internal genitals (testes and ovaries)” (Medline Plus, n.d.).

5-10aHistory

Sexual minorities in the United States include sexual identity (lesbian, gay, and bisexual individuals) and gender identity (transgender). Although members of these group are unique, all experience oppression and discrimination by the dominant culture once their orientation is recognized by others (Szymanski, 2013). Such oppression and discrimination of lesbians, gays, bisexuals, and transgender (LGBT) have occurred as early as the Middle Ages (Brammer 2012). In the United States today, the attitudes toward sexual minorities fall into three categories. First, there are individuals who believe that lesbian, gay, bisexual, and transgender individuals are immoral and commit “crimes against nature” (Szymanski, 2013, p. 418). Oppression and discrimination of members of sexual minorities include heinous acts (hate crimes) such as murder, torture, and the experience of microaggressions and macroaggressions (Speak Up to Stop Discrimination, 2013). Oppression also means less access to educational opportunities, less access to employment opportunities, and fewer rights. In the past, the American Psychological Association categorized homosexuality as a mental illness. But in 1987, the DSM-III-R dropped the category. Others accept members of sexual minorities as if they are ‘invisible.” There are individuals who have attitudes of acceptance toward minority expressions of sexual and gender identities (Szymanski, 2013).

In the United States, there are changing attitudes toward sexual orientation, with high acceptance from those educated and younger than 30 (Smith, Son, & Kim, 2014). Such acceptance of homosexuals is consummate with current research that the lives of homosexuals, in many ways, do not significantly differ from individuals who are heterosexual (Weiten, Dunn, & Hammer, 2015). Other evidence of such acceptance is reflected in the 2015 Supreme Court decision that granted the right of gay couples to marry (Liptak, 2015). This ruling has the potential to improve the lives and rights of members of sexual minorities. Although there have been gains in the tolerance or acceptance of sexual minorities, oppression and discrimination are still common.

5-10bIdentity Development

Identity development for lesbians and gay men occurs as individuals move from beginning to feel different from others to being able to integrate their sexual identity with other aspects of self. Szymanski (2013) combines several models of sexual identity development and proposes a four-phase model. The first phase describes the experience of sexual identity as being confused and being different. In this phase, the individual begins to think about his or her sexual identity and considers the question, “Might I be gay or lesbian?” For the majority of lesbians, gay men, and bisexuals, this occurs during the teen years (Pew Research Center, 2013).

Identity issues differ for lesbians, gay men, bisexual individuals, and transgender individuals. Lesbians, as women, reject how men define them; they want to define their own sense of what it is to be a woman. Lesbians build sexually intimate relationships with other women (Brammer, 2012). Even though gay men may look for intimacy in a sexual relationship, they have fewer skills to build relationships, even though they may wish to do so (Weiten, Dunn, & Hammer, 2015). Bisexual identity is complicated by how one views one’s identity and what one practices. For example, a bisexual woman could be in a lesbian relationship but still view herself as being attracted to men.

5-10cRole of the Family

For individuals who are sexual minorities, families play an important role. One aspect of the role of the family is related to the third phase of sexual identity described previously. The act of coming out means disclosing one is gay or lesbian to others, including one’s own family. For most individuals, talking to parents about their sexual identity is a significant milestone (Pew Research Center; 2013). Such individuals are more likely to share information about sexual identity with their mothers. For most individuals, family relations remain positive (Pew Research Center, 2013). When family members, especially parents, reject the new sexual identity, and also their children, depression, a sense of alienation and loss, and loss of self-worth may result (Szymanski, 2013). Two reasons offered for not coming out to parents were that they did not feel that it was important for their parents to know and that the topic of sexual orientation did not come up in discussion. For some family members, the process of acceptance is just that, negotiating feelings of denial, anger, shame, guilt, and depression (Brammer, 2012). There are risks involved, and parents and other family members may never accept the news.

Another consideration of family is when members of the LGBT population form families of their own. These form in multiple ways, including parenting children from another relationship (heterosexual), donor insemination adoption, and surrogacy (Goldberg, Gartrell, & Gates, 2014). Prior to assuming parenthood, parents of LGB individuals provide less support than same-sex couples, but once the child enters the family, the support is similar. When considering the family of same-sex parents and their children, research indicates that the children demonstrate normal “self-esteem, quality of life, psychological adjustment, or social functioning” (Goldberg, Gartrell, & Gates, 2014, p. 3).

5-10dReligion/Spirituality

5-10eChallenges

The difficulties and stresses faced by members of the LBGT community are numerous. First, the overt and covert oppression and discrimination influence social acceptance, the likelihood of physical and psychological danger, lower educational attainment, fewer employment opportunities, and unique health issues such as those associated with HIV/AIDS (associated primarily with gay men) and consequences of hormonal treatment (associated with transgender individuals) (Brammer, 2012). Within the area of social relationships, there exists an undervaluing of relationships, less social support, fewer role models for creating relationships, and possible domestic violence (Szymanski, 2013).

5-10fApproaches to Case Management

Before case managers work with individuals who belong to a sexual minority, they must confront their own phobias and prejudices and develop knowledge of inappropriate and damaging responses and interventions. First, case managers should be aware of their own beliefs and values related to sexual minorities, many of which reflect the biases held by the dominant heterosexual culture. The second step is to build a knowledge base about the lives and challenges that members of the LBGT community face, emphasizing the uniqueness among individuals. Further complicating challenges for LGBT clients occur when these clients are also members of other oppressed groups (e.g., women, persons of color). For example, when a gay man is also African American, he is uniquely at risk. We suggest some ideas about how to work with sexual minorities (Brammer, 2012; Szymanski, 2013).

1. Be cautious when making assumptions about the client’s sexual orientation.

2. Be cautious when making assumptions about the client’s sexual identity development.

3. Develop skills to respond appropriately to sexual or gender identity disclosures.

4. Introduce any topic about sexual orientation as you would with a heterosexual client.

5. During the case management process, engage the client in exploring feelings and making plans.

6. Intervene in ways that develop a client’s self-esteem (e.g., focus on strengths and build a collaborative relationship).

7. Be aware of unique relationship strengths and challenges of intimate relationships and support of families, partners, or spouses.

8. Pay attention to outcomes related to oppression, discrimination, and stigma.

9. Pay attention to health-related issues.

My Story

Sharon Bello, Entry 5.5

I remember one gentleman who quietly confided to me that he was a gay man. He told me that he had never shared that secret with anyone. I listened to his story. At the end he looked at me to see if I was shocked or disgusted with what he had to say. I just smiled and told him I was glad he could finally share his story and I would not share this information with anyone.

Many of the staff opposed this welcoming policy. These individuals did not wear the rainbow band.

5-11 Working with Individuals with Disabilities

5-11aHistory and Definition

In the remaining chapters of this text, you will be gaining knowledge and developing skills to assume the responsibilities of and performing the tasks of a case manager. You will continually engage with individuals, families, groups, and communities that need your help. Many of these individuals will have experienced oppression and discrimination because of their race, ethnicity, gender, sexuality, age, or disability. We believe that becoming a multiculturally competent case manager requires a lifetime commitment. And you can begin now.

First, as you read the remainder of the chapters in this text, continue to think about ways that you can integrate a multicultural perspective throughout the entire case management process. Here are some guidelines that will help you increase your understanding and develop your skills. These guidelines were inspired by Brammer’s (2012) work.

· Self-exploration Continue your own self-exploration of your racial, ethnic, and cultural self. Identify that self, how it developed and how it is developing, and how it influences your work as a student and as a case manager.

· Engage with Others Seek out opportunities to engage with individuals and groups that are different from yourself. This can be as simple as attending an international event (e.g., food festival or film) or building relationships with individuals of a different race or ethnicity.

· View Others as the Expert Work personally and professionally to see others as the expert. In your personal life, listen to be influenced (Greenberg, 2016). What this means is that you should pay attention to others and ask open-ended follow-up prompts, such as “Tell me more about that” or “I am curious why you say that,” as a way to extend the conversation and know the other person better.

· Be Yourself Even though we provide suggestions in this text about how to interact with and plan case management interventions, each of your interactions must feel natural to you and must be adapted to the needs of the client. In multicultural case management, the product description “one size fits all” does not apply.

· Address Instances of Oppression Consult with others when you feel that position of privilege or prejudice emerge. During case management there is an opportunity for you to take charge of the process and assume that you know best, or you could also be appalled by the lack of understanding or values your client holds.

· Help Clients Tell Several Versions of Their Stories Many times when clients have internalized oppression and discrimination, they hold negative views of themselves. They suffer from lack of self-respect and self-worth. Constructing a case management plan that builds on strengths allows clients to view themselves in a positive light and live with hope.

· When You Are Puzzled, Ask Many times you will not have knowledge of the client’s worldview or culture, or you may express to your client your understanding and they may indicate that you are wrong. You may always admit you are unclear about the client’s culture and ask for help understanding it.

· Promote Advocacy As stated in the principles of case management and the codes of ethics, all case managers are committed to social justice. Look for opportunities to advocate for individual clients and client populations.

Author Note: We think that it is important for you to review the chapter you just read. We suggest the following.

· First, re-read the class discussion questions in the text and answer these as comprehensively as possible.