Requiring Case Management Meetings to Be Conducted Outside the Clinic

When I became a client of New Hampshire's behavioral health services in the spring of 2007, one-hour meetings with my case manager were held outside the clinic's offices. This was and is their policy; as stated in policy He-M 426.12(c): “Individualized Resiliency and Recovery Oriented Services shall not be eligible for reimbursement if provided in an office setting, with the exception of Illness Management and Recovery, crisis intervention and medication support” (1). Clients and their case managers can meet in the client's home, but I did not feel comfortable with doing so. My life was already under examination, and I considered my home to be my sacred space; having my case manager in my home would have felt disempowering. Furthermore, I didn't want the neighbors to see my case manager coming to visit. Being psychiatrically disabled is not something I am proud of and want others to know. Other consumers have expressed dislike of home visits (2). I chose to meet with my case manager in the local library, a two-minute drive from my apartment. My case manager was basically a personal counselor regarding all facets of life. This resource has been elemental to my recovery process. I was told initially that meeting in the community was a way of “engaging the psychiatric patient into the community.” Many clients happen to be housebound, and this is a way of getting them out into society and observing their functional skills.

Assertive community treatment demonstrated 30 years ago that meeting in the community fosters skill development and community integration for people who had been hospitalized for many years (3). Later I learned that meeting in the community was also a billing issue. Most case managers have only a bachelor's degree and administer therapeutic behavioral services, which are required by state policy to be done in the community. If the case manager has a master's degree, the client can meet at the psychiatric clinic and be billed for therapy. However, few case managers have master's degrees.

After a year, I wanted a change of venue because I started feeling uncomfortable meeting in the library. I tried meeting in the cafeteria of the hospital, but it meant awkwardly explaining to the parking lot attendant that I had a meeting with a psychiatric worker and wondering whether anyone I knew might see me with my case manager in the large cafeteria. So I went back to meeting at the library. I then met with my case manager in the same building that contains the psychiatric health services in a common seating area. However, this was uncomfortable too, because people would often walk by. So I went back to meeting at the library. I felt defeated; there was no place to meet with adequate privacy.

The topics of case management meetings usually involve issues about work, family, government benefits, housing, transportation, general health, psychiatric health, or even societal issues. Over time I found that I sometimes discussed subjects that were quite personal, such as a death in the family, family dynamics, my losses of the past, my deficits or challenges, or even a sensitive health problem. These were the times I felt uncomfortable, embarrassed, or even ashamed. I felt that I was being subjected to a form of public humiliation. Sometimes I avoided important topics because we were in a public place.

In a therapeutic relationship, privacy is essential. Case management is a form of therapy; case managers are bound by confidentiality, and they report to the psychiatrist the positives and negatives of a client's psychological health. In a counseling relationship, sensitive personal issues dealing with trauma, loss, deficits, and problems are often discussed. Most people seek privacy when confiding in others about such issues and do not want everything broadcast. Many therapists place white-noise machines outside offices to protect patients' privacy and confidentiality. Privacy is important in the psychiatric profession because psychiatric illness leaves people vulnerable to their conditions and also to the stigma concerning mental illness (4). The research on the importance of confidentiality in psychiatry indicates that there are therapeutic gains when patient or client is assured of privacy (5). In today's world of modern technology, with cell phones widely available with instant recording and photographing capabilities, privacy is being further eroded.

The U.S. Constitution's fourth amendment has been successfully cited in Supreme Court cases as a protection for an individual's reasonable expectation of privacy. Privacy involving medical health is so important to citizens in our country that the government instituted the Health Insurance Portability and Accountability Act (HIPAA) regarding the confidentiality of health information of all persons. HIPAA states that health care providers may not identify a person's health condition. Requiring case management functional support services to be provided outside of the clinic may potentially identify people who have a psychiatric disorder. Also, health care providers must take reasonable precautions to prevent conversations about personal information from being overheard (6).

I live in a rural area where many people know one another, not in a metropolitan area where this is some anonymity. Thus many people in my area know who the case managers are; if someone is consistently seen with one, people know that he or she has a psychiatric disorder. Furthermore, I specifically recall times that I discussed my medical condition with my case manager in public, including going over questions on the consent-to-treatment form, which I was required to read and sign. The policy is different in the neighboring twin state: according to a Vermont Mental Health administrator, consumers in Vermont have the choice to meet in the clinic, although it is not a written policy (personal communication, Flint L, Jan. 19, 2010). “Case managers and community support workers are highly encouraged to provide services in the community. However, meetings with clients are not required, by policy or otherwise, to be held in the community. Sometimes case managers (and employment staff) will report that issues around confidentiality keep them from meeting in the community, even if they want to. Administrative staff report that, as in New Hampshire, the towns in Vermont are small and everyone knows each other; by simply being seen with a case manager it is disclosing that you are receiving services from the community mental health center” (personal communication, Flint L, Sept 22, 2010). Being identified as having a disability might also jeopardize one's safety. Persons with psychiatric disorders are often victimized, at rates six to 23 times greater than that of the general population (7). Furthermore, according to the Privacy Rule summary of HIPAA, “health plans must accommodate reasonable requests if the individual indicates that the disclosure of all or part of the protected health information could endanger the individual. The health plan may not question the individual's statement of endangerment” (8).

Being identified as a person with a psychiatric disability potentially leaves one open to stigma. Many people with psychiatric disabilities often are not fully employed, receive disability benefits and health care, live in subsidized housing, have limited social networks or odd behavior, and smoke cigarettes or use substances. Some people view people with psychiatric disabilities as damaged, dependent citizens who should be treated with caution as if possessed by some demon. Unfortunately, this stigma still exists. Yet most persons with psychiatric disabilities are aware of their disenfranchisement in society and their shortcomings and dependency and would like to overcome their challenges and be full participants in society. Their inability to do so often internalizes this stigma; they come to believe that they are damaged goods of little value to society. This sense of shame decreases self-esteem and increases such symptoms as anxiety, depression, and confusion.

The requirement for meetings to occur outside of the clinic is the policy of the Department of Health and Human Services of New Hampshire. This policy is unjust and creates a “stigma by exposure”—by putting persons with psychiatric disabilities on public display within their communities. This can seem like punishment, and yet consumers often have done nothing wrong and did not seek out their disability: they had neither the resources nor knowledge about how to handle their conflicts or challenges. This public pillorying adds insult to injury. Stated another way, what if people with specific health disorders were forced to meet in public places for psychotherapy or to discuss their cancer?

An element of psychiatric recovery is community integration—finding employment, having social networks, and interacting in the community—but requiring that case management occur outside of the clinical setting is not community integration. Simply being in public is not, in itself, being integrated into the community. As I have argued, meeting with one's case manager in public may, in fact, be antithetical to the worthy goal of community integration by intensifying public stigma and self-stigma through the subjective sense of disincorporation in society. Meeting in the community should be a personal choice. Meeting in public can amount to a public display, which makes most people uncomfortable and ashamed, which in turn can foster resentment and thwart the healing process. Consumers with psychiatric disabilities should be able to meet with their case managers in a private, clinical setting if they so choose. America is a country founded on a belief in freedom, and the hallmark of freedom is choice. In the Gettysburg Address, Abraham Lincoln referred to America as a test in both liberty and a government of the people. America is far more than that: it is an experiment in human dignity. All citizens should be treated with equal respect and not be humiliated because they are different. The government of New Hampshire needs to change this policy.