Bridging Gaps: The Symbiosis of Case Managers and Patients With Psychosis

Schizophrenia is one of the most commonly known diagnoses of psychosis. As an early psychosis team, our goal is to identify and intervene when a patient is experiencing their first episode of psychosis to increase chances of recovery outcomes.¹

As case managers, we utilize a unique approach to promote a symbiotic relationship with patients experiencing psychosis to bridge the gaps of recovery. We work to foster positive relationships with our patients while minimizing the negative stigma associated with their diagnoses by providing opportunities in the community which normalize and activate beliefs of capability.² Our patients do not strive to be the best patient, they strive to be their best self so that they can be the best family member and friend. We refer to our “patients” as a “young person” or “client” to decrease stigma of being defined by their diagnoses.

The stigma related to psychosis in today’s society is extremely prevalent to a client’s recovery. Family members, friends, coworkers, and others in society frequently stereotype individuals with psychosis or schizophrenia as dangerous, uncontrollable, incapable, and “crazy.” These stereotypes often lead the young person to form untrue beliefs about themselves which can hinder their recovery.³

As case managers, creating and building trust in the relationships with our clients has become one of the most important tools in supporting their recovery. We facilitate these relationships by engaging with our youth in community settings to promote normalized social interaction with peers and others in the community. With our clients, we frequent community locations community like coffee shops, food establishments, community centers, local neighborhoods, and parks, among many other areas of client interests. We engage our clients in natural settings that promote socialization, including with other peers who have similar experiences. Sharing common interests in these settings with our clients while doing something natural and fun has created positive and trusting relationships between client and case manager. Additionally, we interact with our clients by using everyday language instead of clinical language, which can sometimes be perceived as stigmatizing by the young person. Valuing our client’s dignity and respect while treating them as an everyday person has helped greatly in minimizing the stigma related to psychosis.

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Another key component in continuing to foster a positive, trusting relationship with our clients is showing up to support them wherever they are at in their recovery. Sometimes this includes going above and beyond to engage a client in treatment when they have decided to go off their medications and are increasingly symptomatic, potentially in an inpatient setting and in need of extra support, or when they are not feeling motivated to get out of bed and socialize with peers, or to go to work. For us, this can look like showing up to their house and encouraging them to get out of bed and get ready every day of the week.

We often come up with creative ways to engage a client when they are not at their best self or not as motivated to work towards recovery. When they have been removed from their typical setting into an inpatient setting due to safety concerns, we have learned to accommodate and innovate ways to engage them into a more natural state of being and minimize the patient stigma. Supporting our clients and showing up for them when they are at their best—but also at their worst—has been key in the continuous development of the symbiotic relationship between client and case manager.

“Gabriella” is a young woman with a diagnosis of psychosis and autism spectrum disorder. Approximately 8 months ago, Gabriella moved into a group home to help stabilize her on medications and develop daily living skills after a lengthy inpatient psychiatric hospitalization. She obtained a job and attended regular groups with the first episode team, while also navigating the community independently. After being stable for 5 months and managing her life with support from the team as well has her parent, Gabriella relapsed after discontinuing medication on her own by refusal. Within 2 days, she was admitted to the hospital psychiatric inpatient unit after experiencing auditory/visual hallucinations and catatonia. Gabriella became completely nonverbal and struggled to hold herself up or walk independently due to the severity of symptoms. Case managers visited Gabriella in the hospital to create a natural interaction in an institutionalized setting. After case managers talked with the prescribing psychiatrist, they were asked to “try to get her to take her medications” as she continued to refuse medications.

We treated Gabriella how we would if she was out in the community, while using empathy and validation due to her current state of well-being. We used everyday language in conversation, utilizing humor, discussing interests such as music and sports, despite Gabriella’s current mental and physical health and inability to verbally communicate with case managers or other medical professionals. As this interaction progressed, she started to respond to case managers using nonverbal cues. Case managers then engaged her in adaptive mode to activate positive beliefs by playing music and dancing in hospital room.² Case managers were able to encourage her in the moment to join in on something she had previously been interested in prior to being admitted to the hospital. Gabriella started moving and dancing in her hospital bed after being severely catatonic while actively experiencing hallucinations. While engaged in adaptive mode, Gabriella agreed to take her medication, due to engaging in a meaningful activity that connected her with those she has a trusting relationship with—her case managers.

We continue to use the Recovery-Oriented Cognitive Therapy Model throughout the entirety of our work with clients experiencing different types of mental health diagnoses.² The goal is to access a person’s “best self” through connecting with common interests or expertise.² As we continue to utilize adaptive mode with our youth, we have learned that the best treatment does not necessarily look like treatment.² We help our clients to activate positivity with how they see themselves and how they feel while connecting with others to show how that can benefit their recovery.

The intimate collaboration of the first episode treatment team—including case managers, therapists, a community nurse, and a psychiatric provider—have been crucial in the overall success of our clients’ recovery due to our level of support and care provided through wrap-around services. The entire first episode psychosis team is community based, which has been beneficial in fostering positive, trusting relationships between clinicians and clients. All members of our team engage with our youth in community settings to continue promoting normalized social interactions. In addition to the clinical team, we also collaborate with the client’s family and friends to be able to provide the most appropriate support through psychoeducation. Our clients frequently trust the team psychiatric provider more when they are able to engage with her on a more personal level, engaging in an activity where adaptive mode is activated.

Case managers and therapists collaborate with the provider daily to provide updates regarding any client symptoms, behaviors, progresses, or challenges, which help her to be able to identify and offer the best medical options to our clients. Our community nurse frequently helps our clients with follow through of medication adherence by teaching our clients skills for medication management. He is also able to meet them physically to accomplish tasks such as lab work or injections, due to potential housing or transportation barriers. Within this team, our team-lead focuses on placing clients with the case manager who may be the best fit for a client while considering culture, personalities, interests, and potential conflicting circumstances, which improves the success of our client outcomes. The first episode team is a cohesive set of clinicians who work together daily, supporting not only our clients but also supporting one another on our journey to improve the lives of these youths.

As case managers on an early or first episode psychosis team, we are very passionate about providing early intervention to improve recovery outcomes. We have adapted a unique approach to foster positive and trusting relationships via natural interactions in the community and minimize the stigma related to psychosis. We continue to bridge the gaps in client recovery by creating a functional clinical team, all with the same mission in mind: To support our clients not in becoming the best patient, but in becoming their best self so that they can be the best family member and friend.

Ms Spradley is a 7-year mental health professional currently working in Missouri as a case manager on a first episode psychosis team. Ms Gris is a 3-year mental health professional currently working in Missouri as case manager on a first episode psychosis team.

2. Beck AT, Grant P, Inverso E, et al. Recovery-Oriented Cognitive Therapy for Serious Mental Health Conditions. Guilford Press; 2020.

Bridging Gaps: The Symbiosis of Case Managers and Patients With Psychosis

Key Takeaways

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