Discussing a medical condition with a stranger, such as a case manager, can be daunting. Doing so is doubly difficult when it comes to discussing feelings of depression, anxiety, and other mental health conditions.
Complicating matters, signs of many mental health conditions such as substance abuse, depression, or anxiety can be subtle, and difficult for even the most skilled case manager to detect. Melinda Baxter of the ROSE® Consulting Group sat down with Kate Harri, MA, Licensed Psychologist, Disability and Workers’ Compensation Specialist and Consultant, who recently delivered a webinar titled “Oh no, now what! What to do when mental health concerns impact medical cases?” This digital seminar for the ROSE Consulting Group explored the value of active listening and motivational interviewing skills. For more on how ROSE nurse consultants can help meet your case management needs, reach us at firstname.lastname@example.org.
In your recent webinar, you mention behavioural health problems in the high-needs medical population and suggest that mental health conditions often appear alongside common medical diagnoses. What are some examples of this?
If you look at statistics, you will see that depression is experienced by 5% of those without chronic medical conditions. This number climbs to 8% in people with one chronic condition,10% in people with two chronic conditions, and 12% in people with three or more chronic medical conditions.
Among those with chronic obstructive pulmonary disease, 44% of female patients and 27% of male patients also develop Major Depressive Disorder (MDD). Persons with MDD are 60% to 80% more likely to develop cardiovascular disease than those without depression. Depression has also been identified as a risk factor for mortality and additional cardiovascular events.
Looking at alcohol abuse and cardiovascular disease, there are abundant examples of how alcohol overuse negatively impacts blood pressure, heart conditions, certain cancers, and liver and brain function. And then there's the connection between anxiety and diabetes: people with diabetes are 20% more likely than those without that condition to suffer from anxiety at some point in their lives. The same linkages can be found between depression and cancer.
How can case managers identify mental health concerns?
The warning signs aren’t obvious. For example, when it comes to drug abuse or addiction, people don't volunteer: “Hey, I'm an alcoholic! Let me sign up for treatment.” But frequent falls, minor injuries, arrests and or convictions for driving under the influence, car accidents, or incidents of falling asleep at work are all potential signs there may be alcohol problems present. Case managers can also look into a member’s medical history to determine whether that person has a record of substance of abuse, gambling issues, or depressive episodes.
Also look for a history of engaging in high-risk behaviors, such as assaults or disorderly conduct. These are all things that might show up in the course of doing a review, either through conversations with a member or their providers or by simply looking at the files. I tell people to really listen.
When I was a probation officer back in the day, I was conducting an assessment on a gentleman who came in at eight o'clock in the morning smelling strongly of alcohol. When I asked how much he drank, he noted that he had had “a couple.” But I didn’t just accept that – I asked a couple of what? The answer: The man and his friend polished off a couple of kegs of beer. Remember that when asked about the number of drinks they have consumed; most people minimize their alcohol consumption.
What about a mental health condition itself?
With major depression, look first for a consistent depressed mood and loss of interest over a two-week period. People with depression also report eating and sleeping disturbance, psychomotor agitation or retardation, fatigue or loss of energy, irritability, tearfulness, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, recurrent thoughts of death, suicidal ideation, or even a suicide attempt.
For generalized anxiety disorders, look for persistent and excessive anxiety or worry over at least six months. To identify a panic disorder, look for recurrent unexpected panic attacks and changes of behavior to avoid having another attack. Common symptoms of panic include shortness of breath, tightness in the chest, palpitations, and dizziness.
Case managers can identify behaviors, but not feelings. How can case managers help their members seek help?
It all starts with the initial interview. Keep in mind that the person is certainly in physical distress, in addition to suffering feelings of uncertainty and fear. The member is more likely to be easily upset and to have reduced coping skills. Acknowledge these feelings, respect them, and demonstrate empathy.
If the member is in distress, note that it “sounds as if you may be feeling frustrated” or “I know that it is very hard for you to discuss this” or “this sounds like it's upsetting and difficult to manage.” Let the person talk without interruption. Focus on what the member is saying – and not what you, as a case manager, are going to say next. Paraphrase and summarize and ask follow-up questions to show you’re interested and you care. For example ask a member: “What are your goals?” All this helps you establish the rapport that melts resistance and helps create a path toward change and recovery.
You mention listening. Why is that so important?
It feels good when someone listens. Plus, we only get one chance to make a first impression – and that happens in about 30 seconds. If you take the time on the front end to appreciate the position the member is in, you set the stage for every single interaction thereafter.
In your ROSE webinar presentation, you call on case managers to resist the “Righting Reflex.” Could you explain?
That’s key. The successful case manager understands and explores an individual’s own motivation to change, empowering and encouraging hope and optimism. This begins by recognizing that the member is in charge – not the case manager. If the member doesn't want to change, it isn't going to happen. So regardless of what you think is right or in a member’s best interest, if you tell that person what to do, they will be less likely to cooperate. Instead, ask where the member would like to be three months from now. Ask how he or she hopes to enhance personal situations or regain productivity. Ask the member: “What do you want to get back in your life?” The resistance in the responses will reveal the barriers to overcome.
You mention resistance. How do you know a member is resisting, disengaging, or otherwise not being forthcoming?
If the person is resistant, you will hear one key phrase: “Yeah but … I could make a change, but, but, but …” This is resistance, and it’s a common trap we can fall into.
Many case managers gloss over this and try to get someone to set a goal. That individual will not set a goal because he or she knows you are not listening. The member will say what you want to hear just to please you, but not because the change is important to him or her. Instead, address the issue through motivational interviewing. Ask: “What's bugging you the most? What are you afraid of or anxious or unsure about?” Ask: “What would you like me to do? What are you willing to do before we talk again that will help?”
This approach enhances your ability to ask questions to gain a better understanding of what's going on, and it helps the person make decisions to improve the situation.
Motivational interviewing sounds like a lot of work.
Yeah, it's a lot of work at the front end, and there’s also a lot of value. You get to know the person; the member gets to tell his or her story. You avoid making assumptions. The member feels heard and listened to. It's a more flexible, interactive approach.
Motivational interviewing offers an opportunity for collaboration toward recovery because you are inviting a discussion, and not demanding an action. I just did a review with a woman who has had chronic pain since childhood. Of course, she has depression and anxiety, and case managers weren’t making headway with her.
Rather than requiring certain steps, we decided to ask questions: “How would you begin if you decided to take a step? What are some reasons to do this? How important is it to you? What are the benefits to you if you do it? What do you stand to lose if you don't do it?” She felt supported and began the process of initiating change to start feeling better. She said she wanted to see a psychologist who could help her manage the emotional part of the chronic pain.
You will be very surprised by the answers you get and the trust you gain through this discussion when you are genuine, and show empathy and respect.
If you could end with one piece of advice, what would it be?
Change won’t be immediate – and sometimes it can be painfully slow. But if you are willing to actively listen and use motivational strategies, you will be able to establish the relationship. From that point, the case manager and the member can make incredible progress together.