CLINICAL HANDBOOK OF SCHIZOPHRENIA

314 V. SYSTEMS OF CAREformed by case managers typically includes medication and symptom monitoring; crisisplanning and emergency response; teaching of life skills to promote client independence(budgeting, money management, cooking, shopping, housekeeping, parenting, use ofpublic transportation); psychoeducation (e.g., signs and symptoms of schizophrenia, thenegative effects of co-occurring substance abuse, influence of stress on course and severityof mental illness); coping and social skills training; supportive counseling; family educationand support; coordinating and/or providing specialized services for co-occurringsubstance use disorders; and social integration—helping to fortify and expand clients’natural social supports and community involvement.Given that people with schizophrenia tend to have very limited social networks, enhancingsocial supports is a critical function of case management. The quality of socialsupports is associated with a number of factors, including a sense of self-efficacy and personalempowerment. Social supports can be either naturally occurring or orchestrated aspart of formal case management interventions. Enhancing social supports may take manyforms, ranging from encouraging clients to try out mutual-help groups, such as AlcoholicsAnonymous; facilitating the development of a consumer group for persons withmental illness; or linking clients with church and other groups of interest. Case managersmay have to help clients optimize the potential benefits from social supports by helpingthem to improve their social skills.Case managers are in a unique position to provide social skills training in the community,including demonstration and practice of selected skills and positive reinforcementfor utilizing skills appropriately. Certainly, enhancing social skills in persons with schizophreniais challenging, and results vary based on the client’s level of social deficit, as wellas the seriousness of co-occurring problems, such as substance abuse. Rather than broadbasedefforts, case managers might focus on one or two specific circumstances in whichthe client would likely benefit most from improvement (e.g., engaging in light conversationon the job or reducing argumentative interactions with acquaintances in the client’ssocial club environment).Teaching self-monitoring skills to clients enables them to begin to link certain adversecircumstances or experiences with the potential for relapse, and perhaps to identifyemotional upset, discouragement, suicidal thoughts, anger, conflict or other troubling experiencesas a “warning signal” to seek social supports or to contact someone on theirmental health team to reduce the likelihood of further problems. Case managers also canidentify areas of opportunity where clients can practice their social skills and stress managementskills to reduce the likelihood of crises and enhance their sense of self-efficacy,confidence, and overall well-being.EVIDENCE SUPPORTING CLINICAL CASE MANAGEMENTThere is relatively little outcome research specific to clinical case management due inpart to the ambiguity in distinguishing clinical case management from other, similarderivations of the ACT model (e.g., intensive community treatment, continuous treatmentteams). In reviewing both the descriptive and the outcome literature, one encountersa variety of what can generically be referred to as “clinical skills” embedded invarious case management models, with the exception of a straightforward brokeringtypecase management, in which various services are procured and loosely coordinatedfor the client. Clinical case management activities are not consistently represented inthe literature, but they seem to include some or all of the following: relationship buildingand therapeutic engagement processes; psychosocial assessment; psychoeducation