The strengths model case management with people with psychiatric disabilities

Match or Mismatch: Use of the Strengths Model with Chinese Migrants Experiencing Mental Illness: Service User and Practitioner Perspectives

Samson Tse

Department of Social Work and Social Administration, Faculty of Social Sciences, The University of Hong Kong, Hong Kong

Monika Divis

Affinity Services, Auckland, New Zealand

Ying Bing Li

Centre for Asian Health Research and Evaluation, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

The strengths model assists service users and mental health practitioners to identify individual and environmental strengths and to secure resources to facilitate integration into the community and improve quality of life. Interven- tions are based on goals determined by the person with the mental illness and include support in accessing resources required to achieve goals. Aim: The study aimed to explore the use of the strengths model as a recovery inter- vention with Chinese people with mental illness in New Zealand. Method: This study was a qualitative study using individual interviews and focus

Address correspondence to Samson Tse, Department of Social Work and Social Administration, Faculty of Social Sciences, The University of Hong Kong, Hong Kong. E-mail: samsont@hku.hk

American Journal of Psychiatric Rehabilitation, 13: 171–188, 2010

Copyright # Taylor & Francis Group, LLC

ISSN: 1548-7768 print=1548-7776 online

DOI: 10.1080/15487761003670145

171

groups to explore the views of Chinese service users, significant others, and health practitioners who have experience in using the strengths model. Analysis: Data were analyzed using a general inductive approach to identify key themes relevant to the research objectives. Results: The focus on personal and collective strengths and pragmatic approach adopted by the strengths model were regarded by participants as distinctive features of the model. On the whole, the service user participants regarded the strengths model as helpful in assisting their settlement and integration into the host society. Practitioners were confronted by the following three challenges in applying the model with Chinese migrants: passive role played by service users, diffi- culties in understanding the concept of strengths, and service users with complex needs. Conclusion: The Chinese migrant population is a growing community in most English-speaking countries. To provide culturally respon- sive strengths-based mental health services to Chinese migrants, it is critical for a number of factors to be taken into account, including language barriers and settlement issues, the Chinese cultural values of working with the family, and assessment and training tools that need to be translated from English to Chinese. It is important to measure the effectiveness of applying strengths- model interventions with Chinese users, particularly in comparison with conventional practice of case management.

Keywords: Cross-cultural approaches; Culturally responsive services; Recovery

Since the 1950s, the major trend in health care for people with persistent mental illness has moved away from long-term institu- tionalization toward community-based support. More recently, the focus has been on achieving wellness and recovery rather than merely on rehabilitation and treatment of illness (Mental Health Commission, 1998; Ministry of Health, 2005). The strengths model of case management is designed to enhance recovery outcomes for mental health service users (Chamberlain & Rapp, 1991; Rapp & Goscha, 2006; Rapp & Wintersteen, 1989). The strengths model assists the mental health practitioner and service user (a) to ident- ify individual and environmental strengths, desires, and aspira- tions and (b) to secure the resources needed by the service user to facilitate integration into the community and improve quality of life (Rapp & Chamberlain, 1985; Stanard, 1999). Interventions are based on goals determined by the service user and include providing support in accessing the resources required to achieve their goals. These goals may be in any one or more of six life domains: (a) daily living, (b) financial situation, (c) vocational and=or educational, (d) social support, (e) health, and (f) leisure

172 S. Tse et al.

and=or recreational, cultural, and spiritual. In practice, the strengths model is guided by six principles:

1. People with mental illness can recover, reclaim, and transform their lives.

2. The focus is on individual strengths rather than deficits. 3. The community is viewed as an oasis of resources. 4. The service user is the director of the helping process. 5. The practitioner-service user relationship is primary and essential. 6. The primary setting for our work is the community. (Rapp & Goscha,

pp. 54–72)

It is predicted that approximately 47% of the total population in New Zealand will experience a mental disorder at some time in their lives and that almost 40% had already met criteria for a disorder by 2006 (Oakley Browne, Wells, & Scott, 2006). New Zealand’s ethnic distribution is rapidly changing, with Asian being the fastest growing population group (Statistics New Zealand, 2007). Consequently, it is imperative that the New Zealand health system is responsive to the growing language and cultural differ- ences amongst Asian peoples presenting to health services (Tse, 2004). Mental health services, in particular, need to modify inter- ventions to address the unique needs of identified population groups.

For Chinese people, depression and psychosomatic illness are frequently observed together with a complex interplay including social isolation (from migration), language barriers, underemploy- ment, or unemployment (Ho, Au, Bedford, & Cooper, 2002). The stigma of psychiatric illness contributes to reluctance by Asian people with mental illness and=or their family members seeking early treatment, which further compounds problems. One of the few studies on Chinese people’s mental health reported that up to 26% of older Chinese migrants recruited through Chinese com- munity organizations and general practitioners met the criteria for depressive symptomatology (Abbott, Wong, Giles, Young, & Au, 2003).

Rationale for Study

First, previous research studies show that the strengths model intervention produces promising outcomes for people with mental illness. These outcomes include reduction in psychiatric

Strengths Model with Chinese Migrants 173

hospitalization, significant improvement in overall physical and mental health, increase in people’s rate of goal setting, positive effects on social functioning and social supports, and improved subjective measures of quality of life (Barry, Zeber, Blow, & Valenstein, 2003; Bjorkman, Hansson, & Sandlund, 2002; Macias, Farley, Jackson, & Kinney, 1997; Stanard, 1999). However, to date, there has been no published study on the application of the strengths model for service users from diverse cultural back- grounds. Chinese traditions, in general, regard the family as the fundamental unit of society and source of strengths in times of adversity (e.g., experience of serious mental illness), whereas Western strengths-based models tend to focus on the individual (e.g., Lin & Cheung, 1999; Yip, 2003). Chinese concepts of mental health advocate a holistic and naturalistic approach. This involves the notion of harmony, an integration of individual and family as well as the wider social context such as villages in Chinese rural areas or political party of the country. These characteristics suggest that the strengths model may not be easily transferable from European culture to another culture. It demands a careful examin- ation of the application of a strengths model in Chinese as outlined in the present study. Second, concern has been raised about the mental health of Asian migrants in New Zealand (e.g., Abbott et al., 2003; Ho et al., 2002). It is increasingly important to identify an intervention that could be used and=or adapted to contribute to Chinese mental health care both in New Zealand and abroad. Third, unlike other case management approaches in the mental health field, the strengths model (Rapp, 1998; Rapp & Goscha, 2006) is relatively well-defined in terms of assessment and data collection, therapeutic process, quality assurance, and evaluation.

Aim and Objectives

The overall aim of this qualitative study is to investigate the use of the strengths model as a form of community mental health service for Chinese people in a New Zealand setting. The specific objectives of the study were the following:

1. To investigate how the strengths model is viewed from a Chinese cultural perspective.

2. To identify the challenges encountered by practitioners in the appli- cation of the strengths model.

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METHOD

Research Design

A partnership was established between university researchers and Affinity Services to enhance the feasibility and integrity of the pro- ject. Affinity Services is the longest operating nonprofit community mental health provider in Australasia and applies Charles Rapp’s Strengths Model and Mary Ellen Copeland’s Wellness Recovery Action Plan (Copeland, 1997) in daily operational service delivery.

We used qualitative methods to explore and critically evaluate the optimal use of the strengths model for Chinese populations. Indivi- duals were invited to participate in both individual and focus group interviews. Topics covered in the interviews included the following:

. Participants’ experiences receiving or working with strengths model mental health support services.

. Individuals’ reflections about the association (or otherwise) between the strengths model and their cultural values and practices.

. Challenges in application of the strengths model with Chinese people.

We obtained ethical approval from the Auckland Ethics Commit- tee of New Zealand on August 10, 2004 for a period of 16 months (Reference AKX=04=07=203).

Sample

Three groups of people were involved in this study: (a) service users who self-identify as Chinese, (b) service user’s family mem- bers interested in sharing their understanding of the strengths model, and (c) practitioners of Charles Rapp’s strengths model supporting people recovering from psychiatric illness. Participants were 16 years of age or older and resided in the Auckland region of New Zealand. Individuals who were unable to concentrate for a 45-min interview or focus group and those who posed danger to self or others were not included in the present study. Tables 1 and 2 summarize the distribution and background of research participants. Altogether, 35 individuals participated in this study.

Data Collection Procedures

We conducted individual and focus group interviews with service users in Mandarin or Cantonese, and interviews with practitioners

Strengths Model with Chinese Migrants 175

T A B L E 1 . In d iv id u a l in te rv ie w : su

m m a ry

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in te rv ie w

n G e n d e r

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1 2 (n e w

re fe rr a ls )

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th e st re n g th s m o d e l; se co n d a p p ro x im

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176

T A B L E 2 . F o cu

s g ro u p d is cu

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a In cl u d e s so m e se rv ic e u se rs

w h o w e re

in te rv ie w e d in d iv id u a ll y .

b In cl u d e s a ll 5 co m m u n it y su

p p o rt

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177

in English. Data were recorded in note form in the language used in the first instance; notes were translated to English by a registered translator, for subsequent analysis and reporting.

Data Analysis

Data collection and analysis took place concurrently. Analysis commenced following the first interview and focus group discus- sions. Initial data and the research objectives were used to create a preliminary framework within which emerging topics were identified and addressed in subsequent interviews and focus groups. In other cases, as the findings emerged, we modified the interview guidelines or searched for unique individuals such as who reported experiencing particular difficulties with the use of strengths model but still had positive recovery outcomes. Data were analyzed using a general inductive approach to identify key themes relevant to the research objectives (Thomas, 2006). The steps included the following: (a) initially reading participants responses or the transcripts from individual interviews and focus groups, (b) identifying text segments specifically related to the research objectives, (c) labeling segments of text to create themes and sub- themes, (d) creating new themes and subthemes if findings evident in later interviews or focus group discussions did not readily relate to the existing framework, and (e) reducing overlap and redundant themes and subthemes. An important part of the rigor in the present study was the confirmation of qualitative accounts with participants. Consistent with the principles of members checking, we presented the data and interpretations to the research parti- cipants in the present study to verify that their experiences were adequately represented in the findings.

RESULTS

Theme 1: Perceived Features of the Strengths Model and Its Alignment with Chinese Values and Beliefs from Service User, Family, and Practitioner Perspectives

The subsequent sections summarize participants’ experiences receiving or working with the strengths model and understandings about the association (or otherwise) between the strengths model and Chinese cultural values and practices.

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Focus on Strengths. Most participants identified a positive focus on personal and collective strengths as the predominant feature of the strengths model. Participants reported that this focus replaces the shame and blame often associated with mental illness among Chinese people.

‘‘Think of good things, more positive things, so I am able to talk with people. Telling me positive things are important . . . compared with traditional treatment received in hospital, SM is dealing with the nice and ‘healthy’ part of me.’’ (Service User 11)

‘‘She (the practitioner) asks me to recall previous successful experiences to be strong and provides very helpful life support.’’ (Service User 4)

‘‘Service users can get help to see their strengths during times when they usually feel bad or ashamed about themselves and see things in a negative light.’’ (Practitioner 2)

‘‘In China, if someone has a mental illness, it means he or she is being punished for what they did in their former life. The person has to be locked in a hospital and lose their freedom . . . whereas the Model advocates identifying and using patients’ strengths during their recovery. There is no blame, no judgement . . . ’’ (Service user focus group)

‘‘Chinese (recovering from mental illness) can see themselves very negati- vely . . . SM helps them see their own strengths. Mental illness is just part of the person.’’ (Practitioner 1)

The Practitioner–Service User Relationship. A perceived feature of the strengths model for many service users was the respectful and supportive relationship they had with their strengths model practitioner.

‘‘In Chinese culture, people with mental illness suffer prejudices and discrimination. SM services workers’ attitudes and personalities are good. The services are continuous, not one-off.’’ (Service User 13)

‘‘The community practitioner listens and talks to me, he treats me like a friend and shows his understanding . . . has a very kind attitude and nice personality.’’ (Service User 2)

‘‘He has never used any negative words or made judgement on the things I have done, he is a good listener . . . has a variety of knowledge and experiences in many fields so he can approach his service users easily and establish rapport with them.’’ (Service User 14)

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Furthermore, the relationship was not considered prescriptive or instructive. Rather, service users and family members were offered suggestions and opportunities to evaluate their options and choose a course of action.

‘‘Community practitioners help patients find direction, meaning in their life and options, then patients can build up their self-esteem to recover.’’ (Service User 12)

‘‘The worker shows her respect to us . . . she is straight to the point, she does not tell us what to do. She provides us with analysis of the situation and suggestions.’’ (Family member focus group)

‘‘The SM helps patients learn self-help. It helps patients recognise their power, their rights.’’ (Service user focus group)

It is not entirely evident how much of the client-centeredness was attributed to the strengths model per se or the general recovery approach used by mental health professionals practicing in New Zealand.

Practical Service Delivery Method. The strengths model was described as a very practical model by service users and practi- tioners. Its focus on setting goals toward recovery outcomes coupled with regular reviews provided service users with practical assistance with addressing everyday needs and generating motiv- ation and achievement.

‘‘Chinese and other Asian service users like the SM because it is a prag- matic approach. Asian service users want results. They set goals and achieve them bit by bit.’’ (Practitioner 2)

‘‘The worker goes to court with me . . . she helps me read English letters and explains my situation to relevant organisations or services.’’ (Service User 3)

Connection to Chinese Values and Beliefs. Some parti- cipants considered the strengths model a good fit with Chinese values and beliefs as Chinese place a strong emphasis on being achievement focused. This is best captured by the following comment:

‘‘The SM fits well with Chinese culture. Chinese people are good at setting up goals in their life for example, strict educational achievements, hard-working attitude.’’

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Others considered some aspects of the strengths model to be not compatible with Chinese traditional values and practices. Com- pared with Europeans, Chinese people tend to be reserved and less inclined to talk about their successes and strengths. However, dur- ing further discussions, participants reframed this incompatibility as an opportunity to learn from Western culture and adopt a differ- ent worldview toward mental illness.

‘‘There are potential conflicts between Chinese tradition and the SM. Chinese tradition tends to be critical about oneself and emphasises modesty and being humble. The SM talks about strengths and what one is good at. But that’s why we go overseas. We have to accept the emphasis on strengths, giving people praise and encouragement.’’ (Service user focus group)

Some participants reported that the strengths model practitioner helped to improve family relationships. Among Chinese people, mental illness may be considered a threat to the balance or har- mony of family relationships because of the shame associated with mental illness. Practitioners worked alongside family to restore the family as the source of support and unity in times of adversity.

‘‘Mental illness is seen as a shame in Chinese families. The family try to protect the patient at home and do not allow them to go out . . . it is impor- tant to work with their family effectively.’’ (Practitioner 2)

‘‘The worker also deals with my family problems, he organised counselling services to help improve my family relationships.’’ (Service User 15)

‘‘My community practitioner is very kind and helpful. I never received this kind of support services before in my home country. She also works with my husband and my daughter to support me.’’ (Service User 16)

Benefits for Migrants. Service users and practitioners ident- ified that the strengths model is a useful tool for Chinese migrants who experience mental illness. As a mainstream model, it was per- ceived to support integration into the host community. It was also considered beneficial because it encouraged reconnection to the capacity and resourcefulness Chinese migrants had shown in their country of origin, thus rebuilding self-confidence and self-esteem.

‘‘Migrants easily feel negative and think they failed. The SM shifts their mindset from negative to positive.’’ (Practitioner 5)

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‘‘Most Chinese migrants have excellent talents that are not known by people in New Zealand. The SM is a useful tool to find out their strengths that are normally ignored.’’ (Practitioner 4)

‘‘Chinese people are a minority group in New Zealand. The SM is a mainstream model that helps us integrate with the society.’’ (Service user focus group)

‘‘The SM is flexible so it can accommodate Chinese service users’ needs at different stages of their recovery from mental illness and settlement in the country.’’ (Practitioner focus group)

Theme 2: Challenges in Applying the Strengths Model with Chinese People with Mental Illness (Practitioner Perspectives)

Service User Expectations. Practitioners reported the fore- most challenge in applying the strengths model is balancing their role with service user expectations. In the view of practitioners, Chinese service users often perceive practitioners as professionals, and their perception of a professional is one who will dictate a required plan of action to get results on behalf of the service user.

‘‘Demanding Chinese service users, service users who have a lot of practi- cal needs are difficult to deal with . . . community practitioners need to work for service users as ‘maid.’ Some service users treat workers as their drivers and use them.’’ (Practitioner 6)

‘‘Community practitioners are not there to provide solutions to their pro- blems—immediate needs, obtaining social welfare benefits, settling their immigration issues.’’ (Practitioner 7)

Service user expectations of practitioners are further complicated for those service users who have been in the mental health system for an extensive period of time. They had greater difficulty accept- ing the concept of making shared decisions about their own lives. Practitioner 8 stated, ‘‘Long-term institutionalised service users want people to tell them what to do . . . there is some resistance in talking about strengths . . . You’re the professional. You should do it for me.’’

Difficulty Understanding Concept of Strengths. Practi- tioners explained that Chinese service users’ expectations of the practitioner possibly stems from their lack of understanding about

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emerging concepts in Western mental health care. Notions of service user-centeredness, self-determination, self-efficacy, and autonomy are foreign concepts for Chinese people, particularly among Chinese service users who come from less-developed regions of their country of origin and=or have limited education. Independent of their ability to speak the language, practitioners found it difficult to explain these concepts in terms that were true to their meaning as well as understood by the service user in the context of their culture. Some of these concepts are core compo- nents of the strengths model, which further hinders Chinese service users’ opportunity to take full advantage of the model.

‘‘Language barrier! Even I can speak Chinese and come from the same country of origin. It is very hard to explain certain concepts to Chinese ser- vice users, for example, ‘autonomy, and independency.’ Those are abstract words and lead to different interpretations. I have to convey the meaning by using simple, plain, everyday words.’’ (Practitioner 6)