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Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

  • Theresa Cerulli, MD
  • Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

examples of case studies for mental health

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

examples of case studies for mental health

Cara Lustik is a fact-checker and copywriter.

examples of case studies for mental health

Verywell / Colleen Tighe

  • Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

  • Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
  • Gives researchers the chance to collect information on why one strategy might be chosen over another
  • Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

  • It cannot necessarily be generalized to the larger population
  • Cannot demonstrate cause and effect
  • It may not be scientifically rigorous
  • It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

  • Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
  • Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
  • Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

  • Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
  • Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
  • Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
  • Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
  • Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
  • Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

  • Archival records : Census records, survey records, and name lists are examples of archival records.
  • Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
  • Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
  • Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
  • Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
  • Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

  • Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
  • Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
  • Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
  • Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

  • Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
  • Read examples of case studies to gain an idea about the style and format.
  • Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

  • Case Studies

Mental Health General

examples of case studies for mental health

CASE STUDIES

Reminder and warning.

The following case studies detail real-life situations where mental health has impacted lives in a significant way. Sometimes, this has tragically ended in death. These case studies look at individuals from a wide array of backgrounds – this shows that mental health problems do not discriminate, they can affect anyone. Please note that these case studies will be tough to read. They contain themes of death, suicide, murder, drug abuse, trauma, crime and other sensitive materials. Please proceed with caution. If you are affected by any of the content in this section, we recommend looking at our Crisis Resources.

ANXIETY CASE STUDIES

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Avicii and Mental Health: Don’t Judge a Book By Its Cover

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Sophie Gradon: The Mental Health Struggles of Reality TV Laid Bare

Bipolar disorder case studies, depression case studies.

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Sol Pais: A Misunderstood Soul

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Annalise Braakensiek: Actress, Model and Mental Health Advocate

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Ashley Massaro: Forever Remembered

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Peggy Salters: A Victim of Electroconvulsive Therapy

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Francis Mossman: A Light Goes Out

Dissociative disorders case studies.

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The Freyd Family: Ripped Apart Over Alleged Recovered Memories

Eating disorders case studies, obsessive compulsive spectrum case studies, personality disorders case studies.

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Marsha M. Linehan: DBT Creator’s Strength Through Adversity

Psychosis case studies.

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Martha Mitchell: Delusions Can Be Real

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Rupert Green: A Tragic Tale of the Dangers of Drugs

Ptsd & trauma case studies.

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David Reimer: An Endless Victim of a Cruel World

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Lady Gaga: An Inspiration to Many, for Multiple Reasons

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Ariana Grande: A Battle with PTSD

Schizophrenic spectrum case studies.

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Brian Reimer: A Life of Struggle

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Romechia Simms: Lives Destroyed

Somatic disorders case studies.

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Gypsy Rose and Dee Dee Blanchard: A Match Made in Hell

Substance related disorders case studies.

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Stephany and Ashley Gay: Two Sisters Addicted to Heroin

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Brendan Cole: A Deadly Path to Heroin

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Wynne Doyle: Death by Opiates

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  • Published: 01 April 2021

Three case studies of community behavioral health support from the US Department of Veterans Affairs after disasters

  • Tamar Wyte-Lake   ORCID: orcid.org/0000-0001-8449-7701 1 , 2 ,
  • Susan Schmitz 1 ,
  • Reginald J. Kornegay 3 ,
  • Felix Acevedo 4 &
  • Aram Dobalian 1 , 5  

BMC Public Health volume  21 , Article number:  639 ( 2021 ) Cite this article

2156 Accesses

1 Citations

Metrics details

Community disaster resilience is comprised of a multitude of factors, including the capacity of citizens to psychologically recover. There is growing recognition of the need for public health departments to prioritize a communitywide mental health response strategy to facilitate access to behavioral health services and reduce potential psychological impacts. Due to the US Department of Veterans Affairs’ (VA) extensive experience providing trauma-informed behavioral healthcare to its Veterans, and the fact that VA Medical Centers (VAMCs) are located throughout the United States, the VA is well situated to be a key partner in local communities’ response plans. In this study we examined the role the VA can play in a community’s behavioral health response using case studies from three disasters.

This study investigated experiences of VA employees in critical emergency response positions ( N  = 17) in communities where disasters occurred between 2017 and 2019. All respondents were interviewed March–July 2019. Data were collected via semi-structured interviews exploring participants’ experiences and knowledge about VA activities provided to communities following the regional disasters. Data were analyzed using thematic and grounded theory coding methods.

Respondents underscored VA’s primary mission after a disaster was to maintain continuity of care to Veterans. The majority also described the VA supporting community recovery. Specifically, three recent events provided key examples of VA’s involvement in disaster behavioral health response. Each event showed VA’s integration into local response structures was facilitated by pre-existing emergency management and clinical relationships as well as prioritization from VA leadership to engage in humanitarian missions. The behavioral health interventions were provided by behavioral health teams integrated into disaster assistance centers and non-VA hospitals, VA mobile units deployed into the community, and VA telehealth services.

Conclusions

Recent disasters have revealed that coordinated efforts between multidisciplinary agencies can strengthen communities’ capacity to respond to mental health needs, thereby fostering resilience. Building relationships with local VAMCs can help expedite how VA can be incorporated into emergency management strategies. In considering the strengths community partners can bring to bear, a coordinated disaster mental health response would benefit from involving VA as a partner during planning.

Peer Review reports

Disaster behavioral health

The current COVID-19 pandemic, while still underway, has already demonstrated the need for psychological interventions to manage the isolation, stress, and trauma stemming from the ongoing disaster [ 1 , 2 , 3 , 4 , 5 ]. While the scale of the event is unprecedented, interest in understanding the psychological consequences of disasters is not unique to the pandemic [ 6 , 7 , 8 , 9 , 10 ]. Generally, studies exploring the impacts of disasters on behavioral health have found increases in psychological distress in the short term, with the potential for some individuals to experience long-term psychiatric disorders such as posttraumatic stress disorder, depression, and anxiety [ 6 , 7 , 8 , 9 , 10 ].

To ameliorate the potential negative health effects to impacted populations, numerous early interventions have been explored [ 7 , 11 , 12 , 13 , 14 ]. Some countries such as the Netherlands and Iceland use federally structured plans to implement disaster behavioral health interventions [ 12 , 15 ]. And countries like New Zealand have invested heavily in developing extensive mental health programs in response to large scale disaster events [ 16 , 17 ]. In the United States, federal entities strive to create resources and guidance on implementing behavioral health services after disaster, however, interventions are generally managed and delivered by state, territory, and local agencies [ 14 , 18 , 19 ]. Often, after federally declared disasters, the US Federal Government additionally provides funding through the Crisis Counseling Assistance and Training Program (CCP) to community behavioral health programs [ 8 , 13 , 20 ]. Yet the structure and content of interventions are left to the discretion of the implementing agency.

Regardless of the services provided, having a plan in place prior to a disaster can facilitate implementation [ 8 , 11 , 12 , 13 , 19 , 21 , 22 ]. Few publications detail the creation of a local disaster behavioral health response plans [ 15 , 18 , 20 ] or describe the process in which interventions were deployed following an incident [ 7 , 10 , 15 , 20 , 23 , 24 ]. Common themes arising in studies exploring disaster behavioral health plans or interventions are the need for interdisciplinary teams and interagency collaboration [ 8 , 12 , 18 , 19 , 20 ] and strong community response [ 16 ].

The United States Department of Veterans Affairs

One interagency partner often overlooked in the United States is the U.S. Department of Veterans Affairs (VA) Veterans Health Administration (VHA). Previous publications on VHA’s participation in collaborative disaster planning and preparedness efforts with local communities identified barriers to its involvement [ 25 , 26 ]. One such barrier is that the community, and sometime even VHA employees, are unaware that VHA is tasked with planning for and acting to support “national, state, and local emergency management, public health, safety and homeland security efforts” [ 9 , 27 ]. This responsibility to contribute to community efforts is called the VA’s Fourth Mission and is in addition to VHA’s duty to ensure continuity of services to veterans after a disaster.

The expertise of VHA’s 322,030 healthcare professionals and support staff who provide a range of services at its 1255 healthcare facilities spread throughout the U.S. and its territories makes VHA a valuable potential partner in disaster response [ 28 ]. In addition to inpatient and ambulatory medical care, VHA provides a variety of reintegration programs including trauma recovery and behavioral health services for Veterans and their families at its facilities and through community-based care at Vet Centers, Mobile Vet Centers, and college and university campuses [ 29 ]. How these services are applied in community response efforts has been detailed in the grey literature [ 28 , 30 , 31 , 32 ].

This study highlights the potential role of local VA facilities in supporting local behavioral health activities after a disaster, and specifically, presents three exemplars of VHA integrating into communities’ disaster behavioral health response and providing behavioral health support to non-Veterans. The three VA facilities and the events they responded to are: (1) VA Pacific Island Healthcare System (VAPIHC), which is based in Honolulu, Hawaii but provides care to Veterans throughout numerous Pacific Islands. On October 24th, 2018, Super Typhoon Yutu made direct landfall on the Mariana Islands, a US Commonwealth with a nascent established VA tele-mental health clinic on the island of Tinian. This was the strongest typhoon ever recorded to strike the area, severely damaging or destroying many buildings and much of the critical infrastructure of Tinian [ 33 ]; (2) Orlando VA Healthcare System, which serves east central Florida, and encompasses 7 counties. On June 12, 2016, a domestic terrorist attack [ 34 ], targeted hate crime, and one of the deadliest mass shootings in the U.S. occurred at a local establishment, Pulse Nightclub. In a matter of hours, 49 people were killed and 53 were wounded before law enforcement breached the building and ended the violence [ 35 ]; and (3) VA Southern Nevada HCS (VASNHCS), located in and providing care throughout Las Vegas, Nevada. On October 1, 2017, the worst mass shooting in modern history took place at the Route 91 Harvest Music Festival on the downtown Las Vegas Strip. A gunman opened fire on a crowd of more than 22,000, killing 58 people and wounding 413 [ 36 ]. These cases provide examples of interagency partnerships and the implementation of collaborative responses for communities developing their own plans to address the behavioral health needs of their citizens during disasters, including the ongoing COVID-19 pandemic.

Study design

The results presented in this paper stem from a larger study broadly examining the role of local VA facilities in responding to regional large-scale disasters. This study used qualitative interview methods to elicit study participants’ experiences during disasters impacting the U.S. between 2016 and 2018 (see Table  1 for the full list of the disasters covered in the study, the impacted US states and territories, and VA entities affiliated with the impacted areas). Findings on disaster behavioral health functions were pulled as a subset of data and analyzed. The VA Greater Los Angeles Healthcare System Institutional Review Board (Los Angeles, California USA) approved this study.

Setting and sample

The full study sample was purposively chosen to represent individuals with emergency response roles critical to coordinating VA’s local response to disasters. Emergency management personnel at various levels of the VA were the first point of contact and, when applicable, identified additional individuals with critical response roles to interview. Additional respondents were recruited independently by the project team These facilities made up the broad recruitment sample. Due to some respondents covering multiple disasters or being deployed to disasters outside their normal service region, not all entities were included in the final sample.

Data collection methods

Data were collected through semi-structured, 60-min telephone interviews between March–August 2019, using an interview guide developed for this study (see Additional file  1 ). Interviews were conducted individually with each respondent and led jointly by at least two of the authors. Interviews explored participants’ experiences and knowledge about VA activities in the community, specifically focusing on how VA networked and coordinated with non-VA community agencies. Interviews were audio-recorded, although one respondent declined to be recorded.

Analysis plan

A total of 17 individuals were interviewed. However, five interviews did not indicate collaborating with non-VA entities and were therefore not included in the analysis. Due to their involvement in multiple disasters, two respondents were interviewed twice. At completion of the interviews, this resulted in 13 interview recordings being transcribed, and one set of interview notes (due to interviewee declining to be recorded), resulting in a total of 14 interviews that were analyzed with Atlas.ti (v.7) using a grounded theory approach. In phase one of analysis, one author reviewed all 14 interviews, using inductive coding to identify emergent themes in the data, and informed by extensive conversations about project findings held by the project team at the conclusion of each interview [ 37 ]. As a product of this process, a significant emergent theme [ 37 ] was the presence of interagency partnerships implementing collaborative responses to address the behavioral health needs of local citizens during disasters. A decision was made by the project team to narrow the focused coding analyses [ 37 ] to the way local VA facilities engaged in a behavioral response within their local community, in response to their respective large-scale disaster events.

In phase two of the analysis, the initial codes identified by SS were reviewed by TWL for consistency and agreement. Codes not deemed consistent to the focus topic were dropped. Additional grounded themes were confirmed by the team and applied to the data set [ 37 ]. Consensus on final codes was achieved, and one code list was finalized. In phase three of the analysis, the final code list was applied across all relevant interviews. The final code list had a focus on behavioral health response, including behavioral health activities, method of delivery, reactions of staff, and types of impacted community populations, but also included an identification of high level themes across all disasters, including VA expertise, integrating into local, established response activities, identification of local needs, and logistical challenges. Authors TWL and SS then independently coded each interview and resolved discrepancies by consensus.

All respondents played a substantial role in VA’s activities following the respective disasters. However, only 12 participants indicated the VAMC they supported collaborated with non-VA partners during the event in question. Included disasters ranged from widespread to geographically contained; weather-related to acts of violence; and direct impact on VA facilities ranged from none to significant. Though not all respondents described intensive engagement with the community following the event, all respondents described the importance of integrating into local, established response activities. This translated into involvement in community-wide drills and planning committees and following the lead of local incident command. Respondents indicated one of the areas where the VA could provide support to the community was in disaster behavioral health relief operations.

Activities described by respondents were often centered around tasks where the VA could reduce the caseload of other community agencies by identifying Veterans obtaining services in the community and meeting their needs regardless if they were previously enrolled in VA benefits. One key activity described by several respondents included outreach into local shelters. As one respondent explained, VA staff at shelters “[distribute] fliers [that] outline that our counselors are experts in trauma, loss, and in readjustment. They also provide referrals to Veterans for a variety of services, including housing and employment. We also offered free counseling for all community members impacted .”

Identifying where shelters were established and receiving authorization to deploy VA assets to those locations required coordination with local authorities. Multiple respondents mentioned connecting with emergency management running relief efforts to describe available VA resources and detail the services available to both Veterans and the community at large. In some of the events explored in this study, the non-VA authorities were unaware of what the VA could offer while others had pre-existing relationships that allowed for more transparent understanding of how the VA could support response efforts. One respondent went on to describe how the disaster that impacted their VAMC led to additional outreach to local jurisdictions and shelter coordinating agencies (e.g., the American Red Cross) to build relationships and understanding specifically of the behavioral health services the VA could deploy, if needed and approved.

Respondents noted there were specific benefits to conducting outreach in locations where other agencies provided services to the people impacted such as shelters and Local Assistance Centers. They noted that VA staff could more easily reach Veterans to enroll them, if eligible, into VA services and offer care to those who usually used non-VA health and mental health facilities, thereby supporting local agencies by reducing potential patient loads elsewhere. Additionally, by positioning resources at a central location, VA could more readily offer community members services as an extension of their work with Veterans. One specific resource identified as useful for Veteran and community support was Mobile Vet Centers, which have the primary goal of providing social work and mental health services to Veterans. In cases where respondents mentioned this resource, they underscored that non-Veteran community members who requested services in the first days after the disaster were never turned away.

Three community profiles

Three disaster events described by respondents distinctly highlighted cases where the VA was deeply involved in the local community’s disaster behavioral health response. Each event showed VA’s integration into local response structures was facilitated by pre-existing emergency management and clinical relationships, as well as prioritization from VA leadership to engage in humanitarian missions to support the community.

Telehealth in Tinian, Mariana Islands

Prior to Super Typhoon Yutu impacting the Mariana Islands, the VA Pacific Island Healthcare System (VAPIHC) established tele-mental health services on the island of Tinian. These services were located at a non-VA owned healthcare clinic using pre-positioned VA telemedicine equipment and coordinated with the clinic director and staff. Typhoon Yutu devastated the island and led to many Tinian healthcare clinic employees losing their homes. The clinic with VA tele-mental health equipment became a temporary housing site for staff as it was undamaged by the storm. The clinic director realized that in addition to sheltering needs, employees also experienced significant trauma. However, there were limited mental health resources on the island. Once VA became aware of the need, it worked with other federal agencies to manage the logistics of implementing services that took advantage of pre-positioned VA resources.

“… it was a relationship that we had with [the US Department of Health and Human Services] (HHS) and a relationship that we had with the folks on Guam and Saipan … we have a lot of relationships going on. So, we knew that we had that telehealth equipment. We also knew that Tinian was … hit pretty hard. And that there was a lot of grief. And so I can’t say how it totally emerged, but there’s so many relationships and there’s so much communication during an emergency.”

Respondents reported it was initially challenging to identify whether VA could provide mental health services in the community and how the services would be funded. Staff at all levels of the VA worked with the Federal Emergency Management Agency (FEMA) and HHS to get official authorization as well as receive federal funding for VAPIHC to provide time limited tele-mental health interventions to clinic staff on Tinian. VAPIHC Tele-mental Health Hub coordinated with the local clinic director to inform employees about available services and utilized technology onsite to provide weekly support groups for 13 health center employees.

Director’s 50 in Orlando, Florida and the pulse nightclub shooting

The Orlando VA Healthcare System (OVAHCS) houses a unique emergency response team “The Director’s 50.” Made up of multi-disciplinary VA healthcare workers, including mental health professionals (i.e. psychologists, psychiatrists, mental health nurses), the Director’s 50 can deploy a team of up to 50 volunteers within 2 hours to areas throughout the region when authorized by the Orlando VAMC Director. As described by one respondent, the mission of the team is,

“to provide an immediate gap fill to an emergency before VA can get its assets organized and into a formal support and response role. So the team is multi-disciplinary and multi-functional with its capabilities, so that it can immediately address the needs of the emergency response until VA can formalize how it’s going to provide their support to the community.”

The Director’s 50 includes interdisciplinary clinical and service support training for all members such as triage and treatment services, mental health intervention, peer counseling, and psychological support to trauma. Through participation in community-wide exercises and drills, the Director’s 50 has built versatile capabilities and strong relationships with local emergency management agencies and area hospitals.

In response to the Pulse Nightclub Shooting, VA Central Office requested OVAHCS to deploy the Director’s 50 to provide VA resources and support the community’s response. The team activated their mass notification system to alert their nearly 100 volunteer members and quickly assembled an initial response team of about 15 clinical, mental health, and support professionals within 1 hour. Respondents noted having internal approval can speed up the process of deploying teams. In general, to distribute VA resources into the community, a federal disaster declaration is required to initiate the Robert T. Stafford Disaster Relief and Emergency Assistance Act or where the HHS Secretary has activated the National Disaster Medical System, both of which grant VA the ability to provide assistance. Therefore, respondents noted a need to balance expectations of leadership to help quickly, while also ensuring VA resources were legally allowed to be used in the response.

One thing that facilitated OVAHCS’s integration into the local response system was a pre-existing relationship with the City of Orlando’s Office of Emergency Management and the Central Florida Medical Disaster Coalition, which facilitated the Director’s 50 integration into the city’s response and allowed them to report to the victim reunification center. The team was tasked.

“to be the initial communication to the family members for those victims that actually passed away. So, 49 victims, our team was assigned to go ahead and be the initial contact to let them know that their loved ones had passed, and to begin the coordination for services, grief counseling and victim advocacy, you know, to help them prepare the initial points of piecing together their lives after being notified of such tragic events.”

Accordingly, the initial multi-disciplinary team narrowed its focus to mainly members with mental health expertise. Over the next 2 weeks, the team worked with the community, helping to manage vigils and gatherings for the public, and continuing grief counseling and mental health support for the whole community, including providing peer behavioral health support to municipal first responders. Since this act of violence targeted people who were Lesbian Gay Bisexual Transgender Queer (LGBTQ) frequenting Pulse Nightclub, not only were relatives of victims or survivors from inside the building affected, but the entire LGBTQ community felt the traumatic impact of the shooting. One respondent described the importance of providing mental health support from multiple community agencies when a disaster of this magnitude occurs,

“And they [the people who were at the shooting] truly needed a place, and this is why we were there for greater than just the 24-48 hours of initially identifying the people who was killed during the shooting, you had everyone that was inside of the club who were seeking a place where they could go and receive the care and support that they needed as well. And obviously, you know, this is something that is an endemic issue with healthcare as a whole, is the access to mental health counseling and services. So VA, as well as some other partnering mental health organizations were able to supply that need right there at the site where they were doing victim notification or victim reunification and family support. We were able to do that.”

One respondent noted a key point to remember about the Director’s 50, “they are all volunteers...And these people will go—you know, 24 hours a day, day in and day out, to execute that mission. And we have to think about team resiliency.” This included caring for team member’s well-being by rotating staff and providing and attending to the mental heath of one another. As described by one respondent,

“Because when it was all said and done, the team was very affected by what they had to do. You know, just imagine hearing—you know, overwhelming grief for every one of the 49 victims’ families that would show up. And the team took that burden on … and I will tell you, to this day, it still affects the people who went and supported that mission. And they really—those who supported that mission have a greater reverence for what we do now, as a team. So you’d never have to ask them to—whether they are going to support anything related to the Director’s 50. That comradery that’s there, they won’t let their own kind of—go into the bowels of despair like that, alone.”

Integrating into community response in Las Vegas, Nevada after the route 91 harvest festival shooting

As a large city with many national and international visitors, respondents described Las Vegas as having a very centralized emergency response structure. Relationships between VA Southern Nevada HCS (VASNHCS) and local response agencies and area hospitals were described as “tightknit” with great working relationships where organizations plan and prepare for disasters together. As one respondent put it,

“what I do know is my community. I know my community partners. I know what they have, what they don’t have, they know what I have, what I don’t have. And that’s what makes us so resilient. That’s community.”

Although located too far away from the Las Vegas Strip to actively receive injured victims when the shooting occurred at the Route 91 Harvest Music Festival, VASNHCS activated its Hospital Incident Command System so it could actively participate in the community’s response and organize efforts. A Multi-Agency Coordination Center (MACC) organized the response activities, and respondents underscored the value of both pre-existing relationships and an understanding of the county’s emergency response structure. As explained by a respondent,

“You can’t wait for your community to ask you. You have to be on the forefront and know what they need. And you only do that by knowing your community. You know, I spent probably as much time in my community as I do in my medical center. A lot of the time, it’s my own time, but again, it builds that relationship that when they’re updating their mass casualty plan, one of the people they’re calling is [me].”

This previous collaboration, as well as being present at the MACC, allowed VASNHCS to identify community needs that it could address.

As news of the shooting spread, VA leadership tasked VASNHCS with deploying staff into the community. However, it was challenging to balance the push from VA to deploy with continuing to respect established local coordination structures. VASNHCS maintained a presence within the Medical Area Surge Command of the MACC to offer resources and expertise, waiting for requests, instead of directly deploying assets outside of the established system.

In the immediate response, VASNHCS assisted with managing fatalities. It offered morgue space to the county and initiated the mass fatality plan to increase morgue capacity. This provided the county and partner hospitals space for victims until they could be processed, and families could claim them. Additionally, VASNHC offered a Psychological First Aid (PFA) team.

Initially, VASNHCS deployed their PFA team to the community’s family reunification center. The team was composed of social workers, psychologists, psychiatrists, administrators (as support staff), canteen services (for water and snacks to sustain clients and staff), and the medical center’s Chief of Staff. As the situation evolved, the MACC received requests from local agencies for psychological assistance and VASNHCS transitioned to directly integrating into area hospitals.

Three Las Vegas hospitals received the bulk of the injured or dead and recognized the need for psychological interventions with their staff. Due to their close relationships with other hospitals, one respondent explained that they were familiar with the Employee Assistance Program (EAP) at these hospitals. The respondent knew it would take time for the EAP to arrive onsite and they would most likely focus on clinical staff involved in directly treating the injured. Therefore, VASNHCS developed a three-pronged approach to complement EAP services at the receiving hospitals. Firstly, the PFA team provided what one respondent called “ trauma therapy ” to hospital staff, regardless whether they worked the night of the shooting. The assistance extended beyond clinical staff to non-clinical departments, such as environmental services/housekeeping, whose staff were also impacted through their response roles.

Respondents reported one of the reasons their response in the hospitals was so successful was that the team was multidisciplinary, allowing staff from different departments to talk to people in similar positions, which was valued by the recipients.

“So for example, we have a nurse that’s trained in trauma, psychological first aid. So they want the nurses at [the hospital with a patient surge], they want to talk to our team. They were still processing. But when we brought our nurse into the ward, they were more than willing to open up to her, because she was one of them. She was part of their tribe. So we try to match our tribe to their tribe, and that’s why we were successful.”

Secondly, the VASNHCS team worked with victims of the shooting, providing PFA and social work services. Thirdly, they integrated with family members of patients at the hospitals and provided them items that they did not otherwise have because they were visitors to Las Vegas. Examples included coordinating free transportation to and from hospitals and hotels, connecting them to local mortuary services, and providing information about how to access services when they returned home.

The PFA team ran for 24 h a day, for 7 days in those three impacted hospitals. To balance VA patient care with the community response mission, VASNHCS staff volunteered shifts outside of their normal work hours. One respondent described the overwhelming desire of VA staff to help their community.

“And while it didn’t impact our staff or our clinics, or our patients, it impacted our community. I think another thing that still amazes me to this day, was the outpour of our staff and what I mean by that is they were coming out of the woodwork to support. We had more volunteers working an eight-hour shift and then coming in [to volunteer] at five o’clock or four o’clock and working to midnight to two in the morning and not go home until four or five in the morning, and then go to work the next day, because we didn’t want to impact our patient care. And they were doing this out of their—you know, because they care. They care about the community, they care about the event, they care about the people. And then at the end of the day, you know, we had more volunteers than we had placements, because we did not want to overwhelm the health systems with all of these VA personnel.”

However, with new volunteers each shift, a key lesson learned was to have a daily team debrief. As people changed daily, a debrief provided key information and a running tally of support being provided to save time and avoid reinventing the wheel identifying contacts or systems already developed.

Another lesson was that preparedness requires ongoing maintenance. The importance of ongoing preparedness was underscored when VASNHCS realized that leading up to the shooting, they had reduced their focus on PFA training. As described by one respondent, “ We noticed that we need that continuous [psychological first aid] training, that we need continuous exercising, and it’s not an easy fit, to send a bunch of people to someone else’s hospital or an area to do that kind of service .” They also realized the first wave of personnel went into community hospitals without basic supplies they needed to provide services, including basic items such as pens, PFA guides, and informational brochures.

Three months following the shooting, the VASNHCS Emergency Manager, working with the Chief of Social Work hosted a lunch for staff who volunteered to thank them for their involvement. During that event, they realized volunteers were not only impacted by the event itself, but also by their time providing support in the community. They therefore created a forum to again gather staff who had deployed at the 6 month and 9 month marks to eat and talk about the impact of the event on the healthcare system and themselves. On the 1 year anniversary, management had a special event for the volunteers,

“we actually had people from the community that we supported coming in and they broke bread with our team and what they did was, they talked about what the impact of the VA Southern Nevada Healthcare System was going into that event, and how we helped them bridge the gap [of mental health support] that was crucial at that time, and how appreciative they were to our cause and our Clark County Office of Emergency Management gave all our staff that responded T-shirts that said Vegas Strong, because they wanted them to know that we—they appreciated the work that we did for them to support our community.”

The need for attention to the psychological well-being of individuals during and after a disaster has been well proven as disasters have been found to be associated with both short and long-term symptoms and disorders [ 6 , 7 , 8 , 9 , 10 , 38 ]. Although in some parts of the world there are federally structured plans to implement disaster behavioral health interventions, in the United States there is a patchwork system that often relies on support and resource allocation from a multitude of agencies [ 8 , 13 , 14 , 18 , 19 , 20 ]. In this study we examined the role the VA can play in a community’s disaster relief effort and highlighted the opportunity for VA to support behavioral health response focusing specifically on case studies from three disasters.

Essential to effective emergency management is an understanding of, and engagement with, available resources in a local community. This is of particular importance when considering complex individual and group needs such as behavioral health support. VA Medical Centers can be seen as challenging partners to work with because they are both a federal entity and a local healthcare facility [ 26 ]. However, in the case of Super Typhoon Yutu, the federal positioning of the VA and its connection with HHS and FEMA facilitated the deployment of VAPIHC virtual resources. The regional respondents who supported the VA disaster mission in Tinian described how preexisting relationships with federal partners facilitated authorization and funding.

Another potential challenge to incorporating the VA into response efforts is that prior to offering services, VA leadership must balance the mission of the agency with community needs, without contradicting the restrictions of the Stafford Act. In all three presented cases, VA’s behavioral health support was not formally included in a city or county response plan, and yet pre-existing relationships between key stakeholders facilitated the provision of VA behavioral health services to support identified community needs. Respondents also described participating in interagency coordinating groups, response trainings, and exercises before the disaster. These activities aided in a deeper understanding of the response structures each partner operated under and encouraged strong rapport between agencies.

Relationships between VA emergency management and local emergency management proved invaluable as VA staff understood that services should not be provided without first engaging local response coordinators. All VA facility leadership and emergency managers are required to be trained in the Incident Command System (ICS) and National Incident Management System (NIMS), which are the coordinating structures all U.S. response agencies work within [ 39 ]. As a health care provider at a national level, VHA falls within the operations section Essential Support Function (ESF) 8: Public Health and Medical Services to support the Department of Health and Human Services [ 40 ]. Local jurisdictions may also connect with VAMCs through ESF 8 representation. For example, the VA has provided significant support to communities impacted by COVID-19. As of July 8, 2020, VA provided more than 330,000 pieces of Personal Protective Equipment (PPE) in support of the Fourth Mission, as well as hand sanitizer, laundry support, test kits and testing support, and webcams for use with existing equipment to state and local facilities. In addition, VA has admitted 279 non-Veterans to VA Medical Centers because of the pandemic [ 27 ]. Much of this coordination was done through ESF 8 coordination at a local or national level.

While respondents did not go into detail about their participation in the emergency management structure, some participants described their VA’s roles within emergency operations as liaisons. Groups such as this could report to either the planning, operations, or command sections within the ICS. Group supervisors would most commonly report to the operations section chief, likely through branch directors, given that the focus of the work would be more on specialized functions as needed for tactical operations. Regardless of where they fit, their presence at emergency operations centers and command posts facilitated communication to allow for VA’s integration into incident action plans. Particularly during the response to mass casualty events in Orlando and Las Vegas, understanding the local response network and then proffering available services was essential to avoid confusion or duplication of activities. By working within the established coordination centers, VA’s efforts were effectively integrated into the greater community behavioral health response and were deployed to points of greatest need. Although a detailed understanding of the integration of VA activities into ICS structures fell outside of the scope of this work, future assessment of the integration of VA representatives into local, state, and/or regional ICS structures could help clarify roles and identify which section liaisons best support (e.g., operations, planning, logistics) [ 40 ].

VA is increasingly strengthening partnerships with agencies that provide behavioral health services to Veterans and their families who use non-VA community-based care [ 41 ]. In each case example, the primary support provided by VA to the community was the provision of behavioral health services in response to an identified need. Respondents described this as being due, in large part, to the recognition of VA’s expertise in trauma and post-trauma treatment, thereby allowing these resources to come to the forefront. While not mentioned by the respondents, an additional value that VA providers add to disaster behavioral health responses is their exposure to and understanding of the unique needs of various populations throughout their communities. In addition to ensuring care is culturally competent to the unique identity of being a Veteran, VA staff must respect the diversity of Veterans themselves. Just like the U.S. population at large, Veterans represent a range of ages, races, genders, sexual orientations, socioeconomic statuses, etc. and mental health services must be considerate of this diversity. The VA recognizes this and offers training to providers to understand and respect their patients’ unique needs [ 42 ]. Working with a variety of populations preposition VA staff to have a deeper understanding of the post-disaster needs of the wider community.

Two of the case examples described in this study especially bring to the forefront the importance of disaster behavioral health response planning and implementation teams understanding unique experiences of community members. Super Typhoon Yutu directly impacted an archipelago housing a majority Asian and/or Pacific Island population. The Pulse Nightclub shooting, while a terrorist event, was a targeted hate crime intended to inflict violence on the LGBTQ community. Disaster behavioral health interventions for these affected groups not only need to take into consideration the importance of cultural competency but also the potential of re-traumatization and distinct population mental health needs.

In the Northern Mariana Islands, while there is a mix of ethnic groups (Filipino, Chamorro, Chinese, Carolinian, Korean, Palauan, etc.), many either identify as or are categorized more broadly as Asian and/or Pacific Islanders. Although there are more than 1.4 million people who are considered Pacific Islanders living the in the U.S., there is a dearth of information on the mental health of this population [ 43 ]. Similarly, the prevalence and incidence rates of mental illness in the Mariana Islands is not well studied [ 44 ]. Some sources attribute this lack of understanding to a disproportionate underuse of mental health services [ 43 ]. However, Asian and Pacific Islanders within the U.S. and those territories affiliated with it often experience transgenerational trauma, discrimination, continued loss from colonization, historical trauma, and mental health stigma which can impact psychological wellbeing and help seeking behavior. Additionally, cultural elements (collectivism, reverence for the past, hierarchical social order, etc.) of this population are important to understand when providing behavioral health services [ 43 , 45 ]. One of the reasons respondents indicated that the VA was asked to provide assistance following Typhoon Yutu was the lack of availability of mental health services in Tinian. The established VA telehealth technology increased accessibility to behavioral practitioners from VAPIHC who most likely were experienced working with Asian and Pacific Island populations since more than 55,000 Veterans who identify as this ethnicity live in Island Areas or Hawaii [ 46 , 47 ].

The Pulse Nightclub Shooting was a terrorist driven hate crime targeting individuals who identified as LGBTQ. Members of this group often experience discrimination, stigma, and trauma throughout their lives. Discrimination and heterocentric health and mental health practices can marginalize this population and impact help seeking behavior [ 48 , 49 ]. This is of particular concern as individuals who are LGBTQ face numerous mental health disparities with a higher likelihood of experiencing depression, anxiety, substance misuse, and suicide attempts. The shooting not only targeted LGBTQ people but it also took place during Latin Pride Night meaning many of the victims and casualties were LGBTQ Latinx. The resulting psychological impacts of the Pulse Nightclub shooting on those directly impacted, people who are LGBTQ Latinx, and individuals in the wider LGBTQ community have been investigated and show experiences of trauma and impacts on perceived safety [ 50 ]. At the time of the shooting, the Orlando VAMC had established relationships with LGBTQ local mental health services and had staff knowledgeable in the needs of this community [ 51 ]. In fact, in the recent past, the VA has increased its efforts to ensure Veterans who are LGBTQ receive the highest quality patient-centered care possible [ 52 ]. Mental health services in particular have bolstered recognition of the complex needs of these Veterans [ 52 ].

All three cases demonstrate innovative ways VA can provide behavioral health support outside of their facilities, i.e., via telehealth capabilities across an ocean and into a healthcare clinic, teams of mobile units reaching directly into the community to support victims, victims’ families, and the community at large, and finally by incorporating PFA teams directly into hospitals to support staff, patients, and patients’ families. This flexibility across sites to address different needs and populations while using varying available infrastructure support, is paramount to any local jurisdiction’s ability to meet on the ground needs following a disaster. It demonstrates the variability between VAMCs and the importance of local disaster behavioral health planning teams to pre-identify resources to assess local capacity. Plans can then be developed that access and deploy the tools/skills of interdisciplinary and interagency teams. Building processes to deploy local health and mental health practitioners can lead to more rapid implementation of interventions and help ensure the diversity of the impacted community is recognized and respected. Additional studies focused on how communities develop disaster behavioral health plans could provide insight into which agencies are involved and how they collaborate. It may also be useful to assess whether and how these plans are implemented to identify best practices.

In addition to the people directly impacted by disasters, respondents underscored the importance of offering support to responders as well. There is growing recognition that health care workers are themselves front-line response workers who may be psychologically impacted when caring for others, leading to a growing emphasis on the importance of selfcare and employee wellbeing [ 39 , 40 , 41 , 42 ]. In all three case studies, behavioral health support was, at least in part, directed toward healthcare workers. In the case of Las Vegas, a respondent highlighted the advantage of having behavioral health support come from individuals who understood the culture of the population they were helping, e.g., nurses supporting nurses. Further, respondents in Las Vegas and Orlando highlighted the importance of supporting deployed behavioral health team members. They detailed actions to maintain staff well-being by having rotating shifts, encouraging peer support, and facilitating gatherings for staff to publicly thank them for their efforts and allow them to address their experiences together as a group. Understanding the needs of healthcare and behavioral health personnel and building support networks into response frameworks can help better sustain and strengthen the overall response process.

A primary limitation of this study is that interviews were conducted up to one and a half years after the disasters described, potentially impacting recall. However, multiple interviewees corroborated the information presented for each of the case studies. Another limitation is that this study focused exclusively on the experiences of VA employees fulfilling mission requirements and their description of instances where VA acted in support of the Fourth Mission. Very few of the respondents directly provided the behavioral health interventions. These perspectives could provide deeper understanding of the interventions themselves as well as the impacts they may have on practitioners. Neither community members nor coalition partners were interviewed in this study. Future research would benefit from both interviewing non-VA participants to explore additional perspectives and gain greater insight on how local jurisdictions experienced collaborating with VA representatives and exploring alternative approaches to mental health units within and outside VA to examine whether and when different approaches may be preferable.

As the largest integrated healthcare system in the United States, VA can play an important role in disaster response across the country. As recognition of VA’s expertise in behavioral health grows, particularly around trauma and post-trauma treatment, VA should be considered a strong potential partner in behavioral health responses. Local VAMC staff are part of the community in which they live and the Veterans they serve are a microcosm of the larger population of the U.S. As the respondents in this study showed, there is a deep desire by VA staff to provide support following a disaster if they are able. Anticipating potential behavioral health concerns, and having a plan to address them, can foster community disaster resilience. While these plans may be different for each jurisdiction, they can be strengthened by identifying and incorporating a range of partners. Having preexisting relationships where VA’s capabilities are known before a disaster occurs can facilitate the rapid deployment of VA resources into identified areas of community need. The case studies presented demonstrate the flexible nature of these resources. By extending knowledge about innovative ways to share behavioral health and other resources in a disaster response, communities and healthcare coalitions can be better prepared to engage collectively and rapidly mobilize essential assets to support the wellbeing of those who need it most.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Crisis Counseling Assistance and Training Program

U.S. Department of Veterans Affairs

Veterans Health Administration

VA Medical Center

VA Pacific Island Healthcare System

VA Southern Nevada HCS

Veterans Health Administration Health Care System

Veterans Integrated Service Network

Office of Emergency Management

US Department of Health and Human Services

Federal Emergency Management Agency

Lesbian Gay Bisexual Transgender Queer

Multi-Agency Coordination Center

Psychological First Aid

Employee Assistance Program

Personal Protective Equipment

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Introduction: Case Studies in the Ethics of Mental Health Research

Joseph millum.

Clinical Center Department of Bioethics/Fogarty International Center, National Institutes of Health, Bethesda, MD

This collection presents six case studies on the ethics of mental health research, written by scientific researchers and ethicists from around the world. We publish them here as a resource for teachers of research ethics and as a contribution to several ongoing ethical debates. Each consists of a description of a research study that was proposed or carried out and an in-depth analysis of the ethics of the study.

Building Global Capacity in Mental Health Research

According to the World Health Organization (WHO), there are more than 450 million people with mental, neurological, or behavioral problems worldwide ( WHO, 2005a ). Mental health problems are estimated to account for 13% of the global burden of disease, principally from unipolar and bipolar depression, alcohol and substance-use disorders, schizophrenia, and dementia. Nevertheless, in many countries, mental health is accorded a low priority; for example, a 2005 WHO analysis found that nearly a third of low-income countries who reported a mental health budget spent less than 1% of their total health budget on mental health ( WHO, 2005b ).

Despite the high burden of disease and some partially effective treatments that can be implemented in countries with weaker healthcare delivery systems ( Hyman et al., 2006 ), there exist substantial gaps in our knowledge of how to treat most mental health conditions. A 2007 Lancet Series entitled Global Mental Health claimed that the “rudimentary level of mental health-service research programmes in many nations also contributes to poor delivery of mental health care” ( Jacob et al., 2007 ). Its recommendations for mental health research priorities included research into the effects of interactions between mental health and other health conditions ( Prince et al., 2007 ), interventions for childhood developmental disabilities ( Patel et al., 2007 ), cost-effectiveness analysis, the scaling up of effective interventions, and the development of interventions that can be delivered by nonspecialist health workers ( Lancet Global Mental Health Group, 2007 ). All of these priorities require research in environments where the prevailing health problems and healthcare services match those of the populations the research will benefit, which suggests that research must take place all around the world. Similarly, many of the priorities identified by the Grand Challenges in Mental Health Initiative require focus on local environments, cultural factors, and the health systems of low- and middle-income countries. All the challenges “emphasize the need for global cooperation in the conduct of research” ( Collins et al., 2011 ).

Notwithstanding the need for research that is sensitive to different social and economic contexts, the trend of outsourcing to medical research to developing countries shows no sign of abating ( Thiers et al., 2008 ). Consequently, a substantial amount of mental health research will, in any case, take place in low- and middle-income countries, as well as rich countries, during the next few years.

The need for local research and the continuing increase in the international outsourcing of research imply that there is a pressing need to build the capacity to conduct good quality mental health research around the world. However, the expansion of worldwide capacity to conduct mental health research requires more than simply addressing low levels of funding for researchers and the imbalance between the resources available in rich and poor countries. People with mental health disorders are often thought to be particularly vulnerable subjects. This may be a product of problems related to their condition, such as where the condition reduces the capacity to make autonomous decisions. It may also result from social conditions because people with mental disorders are disproportionately likely to be poor, are frequently stigmatized as a result of their condition, and may be victims of human rights abuses ( Weiss et al., 2001 ; WHO, 2005a ). As a result, it is vitally important that the institutional resources and expertise are in place for ensuring that this research is carried out ethically.

Discussion at a special session at the 7th Global Forum on Bioethics in Research revealed the perception that many mental health researchers are not very interested in ethics and showed up a lack of ethics resources directly related to their work. This collection of case studies in the ethics of mental health research responds to that gap.

This collection comprises six case studies written by contributors from around the world ( Table 1 ). Each describes a mental health research study that raised difficult ethical issues, provides background and analysis of those issues, and draws conclusions about the ethics of the study, including whether it was ethical as it stood and how it ought to be amended otherwise. Three of the case studies are written by scientists who took part in the research they analyzed. For these cases, we have asked scholars independent of the research to write short commentaries on them. It is valuable to hear how the researchers themselves grapple with the ethical issues they encounter, as well as to hear the views of people with more distance from the research enterprise. Some of the ethical issues raised here have not been discussed before in the bioethics literature; others are more common concerns that have not received much attention in the context of international research. The case studies are intended to both expand academic discussion of some of the key questions related to research into mental health and for use in teaching ethics.

Case studies are an established teaching tool. Ethical analyses of such cases demonstrate the relevance of ethics to the actual practice of medical research and provide paradigmatic illustrations of the application of ethical principles to particular research situations. Concrete cases help generate and guide discussion and assist students who have trouble dealing with ethical concepts in abstraction. Through structured discussion, ethical development and decision-making skills can be enhanced. Moreover, outside of the teaching context, case study analyses provide a means to generate and focus debate on the relevant ethical issues, which can both highlight their importance and help academic discussion to advance.

People working in mental health research can benefit most from case studies that are specific to mental health. Even though, as outlined below, many of the same ethical problems arise in mental health research as elsewhere, the details of how they arise are important. For example, the nature of depression and the variation in effectiveness of antidepressive medication make a difference to how we should assess the ethics of placebo-controlled trials for new antidepressants. Moreover, seeing how familiar ethical principles are applied to one's own research specialty makes it easier to think about the ethics of one's own research. The cases in this collection highlight the commonalities and the variation in the ethical issues facing researchers in mental health around the world.

The current literature contains some other collections of ethics case studies that may be useful to mental health researchers. I note four important collections here, to which interested scholars may want to refer. Lavery et al.'s (2007) Ethical Issues in International Bio-medical Research provides in-depth analyses of ethically problematic research, mostly in low- and middle-income countries, although none of these cases involve mental health. Cash et al.'s (2009) Casebook on Ethical Issues in International Health Research also focuses on research in low- and middle-income countries, and several of the 64 short case descriptions focus on populations with mental health problems. Two further collections focus on mental health research, in particular. Dubois (2007) and colleagues developed short and longer US-based case studies for teaching as part of their “Ethics in Mental Health Research” training course. Finally, Hoagwood et al.'s (1996) book Ethical Issues in Mental Health Research with Children and Adolescents contains a casebook of 61 short case descriptions, including a few from outside the United States and Western Europe. For teachers and academics in search of more case studies, these existing collections should be very useful. Here, we expand on the available resources with six case studies from around the world with extended ethical analyses.

The remainder of this introduction provides an overview of some of the most important ethical issues that arise in mental health research and describes some of the more significant ethics guidance documents that apply.

Ethical Issues in Mental Health Research

The same principles can be applied in assessing the ethics of mental health research as to other research using human participants ( Emanuel et al., 2000 ). Concerns about the social value of research, risks, informed consent, and the fair treatment of participants all still apply. This means that we can learn from the work done in other areas of human subjects research. However, specific research contexts make a difference to how the more general ethical principles should be applied to them. Different medical conditions may require distinctive research designs, different patient populations may need special protections, and different locations may require researchers to respond to study populations who are very poor and lack access to health care or to significant variations in regulatory systems. The ethical analysis of international mental health research therefore needs to be tailored to its particularities.

Each case study in this collection focuses on the particular ethical issues that are relevant to the research it analyzes. Nevertheless, some issues arise in multiple cases. For example, questions about informed consent arise in the context of research with stroke patients, with students, and with other vulnerable groups. To help the reader compare the treatment of an ethical issue across the different case studies, the ethical analyses use the same nine headings to delineate the issues they consider. These are social value, study design, study population, informed consent, risks and benefits, confidentiality, post-trial obligations, legal versus ethical obligations, and oversight.

Here, I focus on five of these ethical issues as they arise in the context of international mental health research: (1) study design, (2) study population, (3) risks and benefits, (4) informed consent, and (5) post-trial obligations. I close by mentioning some of the most important guidelines that pertain to mental health research.

Study Design

The scientific design of a research study determines what sort of data it can generate. For example, the decision about what to give participants in each arm of a controlled trial determines what interventions the trial compares and what questions about relative safety and efficacy it can answer. What data a study generates makes a difference to the ethics of the study because research that puts human beings at risk is ethically justified in terms of the social value of the knowledge it produces. It is widely believed that human subject research without any social value is unethical and that the greater the research risks to participants, the greater the social value of the research must be to compensate ( Council for International Organizations of Medical Sciences [CIOMS], 2002 ; World Medical Association, 2008 ). However, changing the scientific design of a study frequently changes what happens to research participants, too. For example, giving a control group in a treatment trial an existing effective treatment rather than placebo makes it more likely that their condition will improve but may expose them to adverse effects they would not otherwise experience. Therefore, questions of scientific design can be ethically very complex because different possible designs are compared both in terms of the useful knowledge they may generate and their potential impact on participants.

One of the more controversial questions of scientific design concerns the standard of care that is offered to participants in controlled trials. Some commentators argue that research that tests therapeutic interventions is only permissible if there is equipoise concerning the relative merits of the treatments being compared, that is, there are not good reasons to think that participants in any arm of the trial are receiving inferior treatment ( Joffe and Truog, 2008 ). If there is not equipoise, the argument goes, then physician-researchers will be breaching their duty to give their patients the best possible care ( Freedman, 1987 ).

The Bucharest Early Intervention Project (BEIP) described in the case study by Charles Zeanah was a randomized controlled trial comparing foster care with institutional care in Bucharest, Romania. When designing the BEIP, the researchers wrestled with the issue of whether there was genuine equipoise regarding the relative merits of institutional and foster care. One interpretation of equipoise is that it exists when the professional community has not reached consensus about the better treatment ( Freedman, 1987 ). Childcare professionals in the United States were confident that foster care was superior, but there was no such confidence in Romania, where institutional care was the norm. Which, then, was the relevant professional community?

The equipoise requirement is justified by reference to the role morality of physicians: for a physician to give her patient treatment that she knows to be inferior would violate principles of therapeutic beneficence and nonmaleficence. As a result, the equipoise requirement has been criticized for conflating the ethics of the physician-patient relationship with the ethics of the researcher-participant relationship ( Miller and Brody, 2003 ). According to Miller and Brody (2003) , provided that other ethical requirements are met, including an honest null hypothesis, it is not unethical to assign participants to receive treatment regimens known to be inferior to the existing standard of care.

A subset of trial designs that violate equipoise are placebo-controlled trials of experimental treatments for conditions for which proven effective treatments already exist. Here, there is not equipoise because some participants will be assigned to placebo treatment, and ex hypothesi there already exists treatment that is superior to placebo. Even if we accept Miller and Brody's (2003) argument and reject the equipoise requirement, there remain concerns about these placebo-controlled trials. Providing participants with less effective treatment than they could get outside of the trial constitutes a research risk because trial participation makes them worse off. Moreover, on the face of it, a placebo-controlled trial of a novel treatment of a condition will not answer the most important scientific question about the treatment that clinicians are interested in: is this new treatment better than the old one? Consequently, in situations where there already exists a standard treatment of a condition, it has generally been considered unethical to use a placebo control when testing a new treatment, rather than using the standard treatment as an active-control ( World Medical Association, 2008 ).

Some psychiatric research provides scientific reasons to question a blanket prohibition on placebo-controlled trials when an effective intervention exists. For example, it is not unusual for antidepressive drugs to fail to show superiority to placebo in any given trial. This means that active-control trials may seem to show that an experimental drug is equivalent in effectiveness to the current standard treatment, when the explanation for their equivalence may, in fact, be that neither was better than placebo. Increasing the power of an active-control trial sufficiently to rule out this possibility may require an impractically large number of subjects and will, in any case, put a greater number of subjects at risk ( Carpenter et al., 2003 ; Miller, 2000 ). A 2005 trial of risperidone for acute mania conducted in India ( Khanna et al., 2005 ) was criticized for unnecessarily exposing subjects to risk ( Basil et al., 2006 ; Murtagh and Murphy, 2006 ; Srinivasan et al., 2006 ). The investigators' response to criticisms adopted exactly the line of argument just described:

A placebo group was included because patients with mania generally show a high and variable placebo response, making it difficult to identify their responses to an active medication. Placebo-controlled trials are valuable in that they expose the fewest patients to potentially ineffective treatments. In addition, inclusion of a placebo arm allows a valid evaluation of adverse events attributable to treatment v. those independent of treatment. ( Khanna et al., 2006 )

Concerns about the standard of care given to research participants are exacerbated in trials in developing countries, like India, where research participants may not have access to treatment independent of the study. In such cases, potential participants may have no real choice but to join a placebo-controlled trial, for example, because that is the only way they have a chance to receive treatment. In the Indian risperidone trial, the issue of exploitation is particularly stark because it seemed to some that participants were getting less than the international best standard of care, in order that a pharmaceutical company could gather data that was unlikely to benefit many Indian patients.

This is just one way in which trial design may present ethically troubling risks to participants. Other potentially difficult designs include washout studies, in which participants discontinue use of their medication, and challenge studies, in which psychiatric symptoms are experimentally induced ( Miller and Rosenstein, 1997 ). In both cases, the welfare of participants may seem to be endangered ( Zipursky, 1999 ). A variant on the standard placebo-controlled trial design is the withdrawal design, in which everyone starts the trial on medication, the people who respond to the medication are then selected for randomization, and then half of those people are randomized to placebo. This design was used by a Japanese research team to assess the effectiveness of sertraline for depression, as described by Shimon Tashiro and colleagues in this collection. The researchers regarded this design as more likely to benefit the participants because for legal reasons, sertraline was being tested in Japan despite its proven effectiveness in non-Japanese populations. Tashiro and colleagues analyze how the risks and benefits of a withdrawal design compare with those of standard placebo-controlled trials and consider whether the special regulatory context of Japan makes a difference.

Study Population

The choice of study population implicates considerations of justice. The Belmont Report, which lays out the ethical foundations for the United States system for ethical review of human subject research, says:

Individual justice in the selection of subjects would require that researchers … should not offer potentially beneficial research only to some patients who are in their favor or select only “undesirable” persons for risky research. Social justice requires that distinction be drawn between classes of subjects that ought, and ought not, to participate in any particular kind of research, based on the ability of members of that class to bear burdens and on the appropriateness of placing further burdens on already burdened persons. ( National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1978 )

Two distinct considerations are highlighted here. The first (“individual justice”) requires that the researchers treat people equally. Morally irrelevant differences between people should not be the basis for deciding whom to enroll in research. For example, it would normally be unjust to exclude women from a phase 3 trial of a novel treatment of early-stage Alzheimer disease, given that they are an affected group. Some differences are not morally irrelevant, however. In particular, there may be scientific reasons for choosing one possible research population over another, and there may be risk-related reasons for excluding certain groups. For example, a functional magnetic resonance imaging study in healthy volunteers to examine the acute effects of an antianxiety medication might reasonably exclude left-handed people because their brain structure is different from that of right-handed people, and a study of mood that required participants to forego medication could justifiably exclude people with severe depression or suicidal ideation.

The second consideration requires that we consider how the research is likely to impact “social justice.” Social justice refers to the way in which social institutions distribute goods, like property, education, and health care. This may apply to justice within a state ( Rawls, 1971 ) or to global justice ( Beitz, 1973 ). In general, research will negatively affect social justice when it increases inequality, for example, by making people who are already badly off even worse off. The quotation from the Belmont Report above suggests one way in which research might violate a requirement of social justice: people who are already badly off might be asked to participate in research and so be made worse off. For example, a study examining changes in the brain caused by alcohol abuse that primarily enrolled homeless alcoholics from a shelter near the study clinic might only put at further risk this group who are already very badly off. An alternative way in which research can promote justice or injustice is through its results. Research that leads to the development of expensive new attention deficit hyperactivity disorder medication is likely to do little, if anything, to make the world more just. Research on how to improve the cognitive development of orphaned children in poor environments (like the BEIP) is much more likely to improve social justice.

This last point suggests a further concern about fairness—exploitation—that frequently arises in the context of international collaborative research in developing countries. Exploitation occurs, roughly, when one party takes “unfair advantage” of the vulnerability of another. This means that the first party benefits from the interaction and does so to an unfair extent ( Wertheimer, 1996 ). These conditions may be met in international collaborative research when the burdens of research fall disproportionately on people and institutions in developing countries, but the benefits of research, such as access to new treatments, accrue to people in richer countries. A number of case studies in this collection raise this concern in one way or another. For example, Virginia Rodriguez analyzes a proposed study of the genetic basis of antisocial personality disorder run by US researchers but carried out at sites in several Latin American countries. One of the central objections raised by one of the local national research ethics committees with regard to this study was that there appeared to be few, if any, benefits for patients and researchers in the host country.

Risks and Benefits

Almost all research poses some risk of harm to participants. Participants in mental health research may be particularly susceptible to risk in several ways. First, and most obviously, they may be physically or psychologically harmed as a result of trial participation. For example, an intervention study of an experimental antipsychotic may result in some serious adverse effects for participants who take the drug. Less obvious but still very important are the potential effects of stopping medication. As mentioned above, some trials of psychoactive medications require that patients stop taking the medications that they were on before the trial ( e.g ., the Japanese withdrawal trial). Stopping their medication can lead to relapse, to dangerous behavior (like attempted suicide), and could mean that their previous treatment regimen is less successful when they attempt to return to it. Participants who were successfully treated during a trial may have similar effects if they do not have access to treatment outside of the trial. This is much more likely to happen in research conducted with poor populations, such as the Indian mania patients.

The harms resulting directly from research-related interventions are not the only risk to participants in mental health research. Participation can also increase the risks of psychosocial harms, such as being identified by one's family or community as having a particular condition. Such breaches of confidentiality need not involve gross negligence on the part of researchers. The mere fact that someone regularly attends a clinic or sees a psychiatrist could be sufficient to suggest that they have a mental illness. In other research, the design makes confidentiality hard to maintain. For example, the genetic research described by Rodriguez involved soliciting the enrollment of the family members of people with antisocial personality disorder.

The harm from a breach of confidentiality is exacerbated when the condition studied or the study population is stigmatized. Both of these were true in the case Sana Loue describes in this collection. She studied the co-occurrence of severe mental illnesses and human immunodeficiency virus risk in African-American men who have sex with men. Not only was there shame attached to the conditions under study, such that they were euphemistically described in the advertisements for the research, but also many of the participants were men who had heterosexual public identities.

Informed Consent

Many people with mental disorders retain the capacity (ability) and competence (legal status) to give informed consent. Conversely, potential participants without mental problems may lack or lose capacity (and competence). Nevertheless, problems with the ability to consent remain particularly pressing with regard to mental health research. This is partly a consequence of psychological conditions that reduce or remove the ability to give informed consent. To study these conditions, it may be necessary to use participants who have them, which means that alternative participants who can consent are, in principle, not available. This occurred in the study of South African stroke patients described by Anne Pope in this collection. The researcher she describes wanted to compare the effectiveness of exercises designed to help patients whose ability to communicate was compromised by their stroke. Given their communication difficulties and the underlying condition, there would inevitably be questions about their capacity. Whether it is permissible to enroll people who cannot give informed consent into a study depends on several factors, including the availability of alternative study populations, the levels of risk involved, and the possible benefits to participants in comparison with alternative health care they could receive.

In research that expects to enroll people with questionable capacity to consent, it is wise to institute procedures for assessing the capacity of prospective participants. There are two general strategies for making these assessments. The first is to conduct tests that measure the general cognitive abilities of the person being assessed, as an IQ test does. If she has the ability to perform these sorts of mental operations sufficiently well, it is assumed that she also has the ability to make autonomous decisions about research participation. A Mini-Mental State Examination might be used to make this sort of assessment ( Kim and Caine, 2002 ). The second capacity assessment strategy focuses on a prospective participant's understanding and reasoning with regard to the specific research project they are deciding about. If she understands that project and what it implies for her and is capable of articulating her reasoning about it, then it is clear that she is capable of consenting to participation, independent of her more general capacities. This sort of assessment requires questions that are tailored to each specific research project and cannot be properly carried out unless the assessor is familiar with that research.

Where someone lacks the capacity to give consent, sometimes a proxy decision maker can agree to trial participation on her behalf. In general, proxy consent is not equivalent to individual consent: unless the proxy was expressly designated to make research decisions by the patient while capacitated, the proxy lacks the power to exercise the patient's rights. As a result, the enrollment of people who lack capacity is only acceptable when the research poses a low net risk to participants or holds out the prospect of benefiting them. When someone has not designated a proxy decision maker for research, it is common to allow the person who has the power to make decisions about her medical care also to make decisions about research participation. However, because medical care is directed at the benefit of the patient, but research generally is not aimed at the benefit of participants, the basis for this assumption is unclear. Its legal basis may be weak, too. For example, in her discussion of research on South African stroke patients, Pope notes the confusion surrounding the legality of surrogate decision makers, given that the South African constitution forbids proxy decision making for adults (unless they have court-appointed curators), but local and international guidance documents seem to assume it.

Although it is natural to think of the capacity to give consent as an all-or-nothing phenomenon, it may be better conceptualized as domain-specific. Someone may be able to make decisions about some areas of her life, but not others. This fits with assumptions that many people make in everyday life. For example, a 10-year-old child may be deemed capable of deciding what clothes she will wear but may not be capable of deciding whether to visit the dentist. The capacity to consent may admit of degrees in another way, too. Someone may have diminished capacity to consent but still be able to make decisions about their lives if given the appropriate assistance. For example, a patient with mild dementia might not be capable of deciding on his own whether he should move in with a caregiver, but his memory lapses during decision making could be compensated for by having his son present to remind him of details relevant to the decision. The concept of supported decision making has been much discussed in the literature on disability; however, its application to consent to research has received little attention ( Herr, 2003 ; United Nations, 2007 ).

The ability to give valid informed consent is the aspect of autonomy that is most frequently discussed in the context of mental health research, but it is not the only important aspect. Several of the case studies in this collection also raise issues of voluntariness and coercion. For example, Douglas Wassenaar and Nicole Mamotte describe a study in which professors enrolled their students, which raises the question of the vulnerability of student subjects to pressure. Here, there is both the possibility of explicit coercion and the possibility that students will feel pressure even from well-meaning researchers. For various reasons, including dependence on caregivers or healthcare professionals and the stigma of their conditions, people with mental illnesses can be particularly vulnerable to coercion.

Post-Trial Obligations

The obligations of health researchers extend past the end of their study. Participants'data remain in the hands of researchers after their active involvement in a study is over, and patients with chronic conditions who enroll in clinical trials may leave them still in need of treatment.

Ongoing confidentiality is particularly important when studying stigmatized populations (such as men who have sex with men as discussed by Sana Loue) or people with stigmatizing conditions (such as bipolar disorder). In research on mental illnesses, as with many medical conditions, it is now commonplace for researchers to collect biological specimens and phenotypic data from participants to use in future research (such as genome-wide association studies). Additional challenges with regard to confidentiality are raised by the collection of data and biological specimens for future research because confidentiality must then be guaranteed in a long period of time and frequently with different research groups making use of the samples.

Biobanking also generates some distinctive ethical problems of its own. One concerns how consent to the future use of biological specimens should be obtained. Can participants simply give away their samples for use in whatever future research may be proposed, or do they need to have some idea of what this research might involve in order to give valid consent? A second problem, which arises particularly in transnational research, concerns who should control the ongoing use of the biobank. Many researchers think that biological samples should not leave the country in which they were collected, and developing country researchers worry that they will not be allowed to do research on the biobanks that end up in developed countries. This was another key concern with the proposed study in Latin America.

In international collaborative research, further questions arise as a result of the disparities between developing country participants and researchers and developed country sponsors and researchers. For example, when clinical trials test novel therapies, should successful therapies be made available after the trial? If they should, who is responsible for ensuring their provision, to whom should they be provided, and in what does providing them consist? In the case of chronic mental illnesses like depression or bipolar disorder, patient-participants may need maintenance treatment for the rest of their lives and may be at risk if treatment is stopped. This suggests that the question of what happens to them after the trial must at least be considered by those who sponsor and conduct the trial and the regulatory bodies that oversee it. Exactly on whom obligations fall remains a matter of debate ( Millum, 2011 ).

Ethics Guidelines

A number of important policy documents are relevant to the ethics of research into mental disorders. The WMA's Declaration of Helsinki and the CIOMS' Ethical Guidelines for Biomedical Research both consider research on individuals whose capacity and/or competence to consent is impaired. They agree on three conditions: a) research on these people is justified only if it cannot be carried out on individuals who can give adequate informed consent, b) consent to such research should be obtained from a proxy representative, and c) the goal of such research should be the promotion of the health of the population that the research participants represent ( Council for International Organizations of Medical Sciences, 2002 ; World Medical Association, 2008 ). In addition, with regard to individuals who are incapable of giving consent, Guideline 9 of CIOMS states that interventions that do not “hold out the prospect of direct benefit for the individual subject” should generally involve no more risk than their “routine medical or psychological examination.”

In 1998, the US National Bioethics Advisory Commission (NBAC) published a report entitled Research Involving Persons with Mental Disorders That May Affect Decision-making Capacity ( National Bioethics Advisory Commission, 1998 ). As the title suggests, this report concentrates on issues related to the capacity or competence of research participants to give informed consent. Its recommendations are largely consistent with those made in the Declaration of Helsinki and CIOMS, although it is able to devote much more space to detailed policy questions (at least in the United States context). Two domains of more specific guidance are of particular interest. First, the NBAC report considers the conditions under which individuals who lack the capacity to consent may be enrolled in research posing different levels of risk and supplying different levels of expected benefits to participants. Second, it provides some analysis of who should be recognized as an appropriate proxy decision maker (or “legally authorized representative”) for participation in clinical trials.

Finally, the World Psychiatric Association's Madrid Declaration gives guidelines on the ethics of psychiatric practice. This declaration may have implications for what is permissible in psychiatric research, insofar as the duties of psychiatrists as personal physicians are also duties of psychiatrists as medical researchers. It also briefly considers the ethics of psychiatric research, although it notes only the special vulnerability of psychiatric patients as a concern distinctive of mental health research ( World Psychiatric Association, 2002 ).

The opinions expressed are the author's own. They do not reflect any position or policy of the National Institutes of Health, U.S. Public Health Service, or Department of Health and Human Services.

Disclosure : The author declares no conflict of interest.

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Mental health practice case studies

Each of these short films presents a case study of a potentially difficult mental health situation that practitioners may need to deal with as part of their practice. Topics covered include appropriate listening skills, confidentiality, drug use, professional conduct, anger, social isolation, sexual advances and stereotyping. The aim of these films is to stimulate discussion and reflection about these particular situations and the issues that arise from them.

The following group of case studies form part of the Online Assessment Workbook.

See also Mental health case studies which were filmed as part of the SELF Project.

Return to film Index

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  • Children's mental health case studies
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Explore the experiences of children and families with these interdisciplinary case studies. Designed to help professionals and students explore the strengths and needs of children and their families, each case presents a detailed situation, related research, problem-solving questions and feedback for the user. Use these cases on your own or in classes and training events

Each case study:

  • Explores the experiences of a child and family over time.
  • Introduces theories, research and practice ideas about children's mental health.
  • Shows the needs of a child at specific stages of development.
  • Invites users to “try on the hat” of different specific professionals.

By completing a case study participants will:

  • Examine the needs of children from an interdisciplinary perspective.
  • Recognize the importance of prevention/early intervention in children’s mental health.
  • Apply ecological and developmental perspectives to children’s mental health.
  • Predict probable outcomes for children based on services they receive.

Case studies prompt users to practice making decisions that are:

  • Research-based.
  • Practice-based.
  • Best to meet a child and family's needs in that moment.

Children’s mental health service delivery systems often face significant challenges.

  • Services can be disconnected and hard to access.
  • Stigma can prevent people from seeking help.
  • Parents, teachers and other direct providers can become overwhelmed with piecing together a system of care that meets the needs of an individual child.
  • Professionals can be unaware of the theories and perspectives under which others serving the same family work
  • Professionals may face challenges doing interdisciplinary work.
  • Limited funding promotes competition between organizations trying to serve families.

These case studies help explore life-like mental health situations and decision-making. Case studies introduce characters with history, relationships and real-life problems. They offer users the opportunity to:

  • Examine all these details, as well as pertinent research.
  • Make informed decisions about intervention based on the available information.

The case study also allows users to see how preventive decisions can change outcomes later on. At every step, the case content and learning format encourages users to review the research to inform their decisions.

Each case study emphasizes the need to consider a growing child within ecological, developmental, and interdisciplinary frameworks.

  • Ecological approaches consider all the levels of influence on a child.
  • Developmental approaches recognize that children are constantly growing and developing. They may learn some things before other things.
  • Interdisciplinary perspectives recognize that the needs of children will not be met within the perspectives and theories of a single discipline.

There are currently two different case students available. Each case study reflects a set of themes that the child and family experience.

The About Steven case study addresses:

  • Adolescent depression.
  • School mental health.
  • Rural mental health services.
  • Social/emotional development.

The Brianna and Tanya case study reflects themes of:

  • Infant and early childhood mental health.
  • Educational disparities.
  • Trauma and toxic stress.
  • Financial insecurity.
  • Intergenerational issues.

The case studies are designed with many audiences in mind:

Practitioners from a variety of fields. This includes social work, education, nursing, public health, mental health, and others.

Professionals in training, including those attending graduate or undergraduate classes.

The broader community.

Each case is based on the research, theories, practices and perspectives of people in all these areas. The case studies emphasize the importance of considering an interdisciplinary framework. Children’s needs cannot be met within the perspective of a single discipline.

The complex problems children face need solutions that integrate many and diverse ways of knowing. The case studies also help everyone better understand the mental health needs of children. We all have a role to play.

These case has been piloted within:

Graduate and undergraduate courses.

Discipline-specific and interdisciplinary settings.

Professional organizations.

Currently, the case studies are being offered to instructors and their staff and students in graduate and undergraduate level courses. They are designed to supplement existing course curricula.

Instructors have used the case study effectively by:

  • Assigning the entire case at one time as homework. This is followed by in-class discussion or a reflective writing assignment relevant to a course.
  • Assigning sections of the case throughout the course. Instructors then require students to prepare for in-class discussion pertinent to that section.
  • Creating writing, research or presentation assignments based on specific sections of course content.
  • Focusing on a specific theme present in the case that is pertinent to the course. Instructors use this as a launching point for deeper study.
  • Constructing other in-class creative experiences with the case.
  • Collaborating with other instructors to hold interdisciplinary discussions about the case.

To get started with a particular case, visit the related web page and follow the instructions to register. Once you register as an instructor, you will receive information for your co-instructors, teaching assistants and students. Get more information on the following web pages.

  • Brianna and Tanya: A case study about infant and early childhood mental health
  • About Steven: A children’s mental health case study about depression

Cari Michaels, Extension educator

Reviewed in 2023

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128 Case Studies: Real Stories Of People Overcoming Struggles of Mental Health

At Tracking Happiness, we’re dedicated to helping others around the world overcome struggles of mental health.

In 2022, we published a survey of 5,521 respondents and found:

  • 88% of our respondents experienced mental health issues in the past year.
  • 25% of people don’t feel comfortable sharing their struggles with anyone, not even their closest friends.

In order to break the stigma that surrounds mental health struggles, we’re looking to share your stories.

Overcoming struggles

They say that everyone you meet is engaged in a great struggle. No matter how well someone manages to hide it, there’s always something to overcome, a struggle to deal with, an obstacle to climb.

And when someone is engaged in a struggle, that person is looking for others to join him. Because we, as human beings, don’t thrive when we feel alone in facing a struggle.

Let’s throw rocks together

Overcoming your struggles is like defeating an angry giant. You try to throw rocks at it, but how much damage is one little rock gonna do?

Tracking Happiness can become your partner in facing this giant. We are on a mission to share all your stories of overcoming mental health struggles. By doing so, we want to help inspire you to overcome the things that you’re struggling with, while also breaking the stigma of mental health.

Which explains the phrase: “Let’s throw rocks together”.

Let’s throw rocks together, and become better at overcoming our struggles collectively. If you’re interested in becoming a part of this and sharing your story, click this link!

Anabel Munoz Featured Image

Case studies

February 22, 2024

How Journaling and Regulating Emotions Helps Me Deal With Depression and Anxiety

“Sometimes I look back and think about all the years I spent crying and thinking about how to end the pain, which made me believe that’s how life is. I got to the point where I had no idea what it felt like to feel a little bit of joy or happiness.”

Struggled with: Anxiety Depression Feeling lost

Helped by: Journaling Self-acceptance Self-improvement Therapy

Erika Sinner Featured Image

February 17, 2024

Navigating Pet Grief With EMDR Therapy and Vulnerability to Come Out Stronger Than Ever

“We’re all comfortable with sharing cute photos and stories about our pets, but do we feel equally comfortable sharing the depth of our grief when we lose them? My personal experience challenged me to reevaluate my own understanding and openness to discussing the hard things too. It doesn’t always have to be sunshine and rainbows.”

Struggled with: Grief Stress

Helped by: Reinventing yourself Social support Therapy

Aidan Pilet Featured Image

February 15, 2024

How I’m Navigating Lifelong Anxiety With Breathwork and Better Boundaries

“I found that practicing breathwork and working on my breathing was more than 50% of my battle. Not breathing correctly caused my anxiety to be triggered easier and with my breathing being shallow, it made it hard to talk at length. I believe this kept me in fight, flight, freeze mode for prolonged periods of time.”

Struggled with: Anxiety Depression Stress

Helped by: Mindfulness Self-Care Self-improvement

examples of case studies for mental health

February 10, 2024

How I Successfully Battled Perimenopause and Hormonal Imbalance

“Menopause remains one of those delicate topics that rarely finds its way into everyday conversation, especially during dinner. Women are woefully unprepared by the healthcare industry for this stage of their lives, so when something like this strikes you simply feel crazy. I hope to help change that.”

Struggled with: Menopause Stress

Helped by: Self-acceptance Self-improvement Treatment

Rachel Miller Featured Image

February 8, 2024

My Journey to Get Back on My Feet After Alcoholism and an Ischemic Stroke

“The dual journey of recovering from a traumatic neurological event while also protecting my sobriety has felt daunting, perilous, and isolating. It felt like I’d been just practicing recovery from alcoholism for the past seven years just so that I’d be ready for the big test this year.”

Struggled with: Addiction Depression Stress Stroke

Helped by: Reinventing yourself Self-Care Self-improvement Social support

Rachel Eileen Featured Image

February 4, 2024

Dealing With ADHD and Anxiety And Becoming a Happier Me

“My immune system became very weak and I was sick nearly every week. Then, when I did feel better, my resting heart rate was so high I could hardly workout without worrying about my safety. On top of that, I started having issues with anxiety around people and new situations and began having panic attacks at night.”

Struggled with: ADHD Anxiety Panic attacks

Helped by: Journaling Meditation Self-Care Self-improvement

Luke Jones Featured Image

February 1, 2024

Recovering From Chronic Pain and Long-COVID With Emotional Healing Movement

“At my lowest points, I was bedbound, completely reliant on loved ones, and unable to perform basic tasks. Too fatigued to walk, make myself food, or do simple jobs around the house. I was heavily medicated and for the most part, in too much mental and physical pain to properly rest or sleep.”

Struggled with: Anxiety Chronic pain

Helped by: Exercise Journaling Self-improvement Therapy

Tim Lee Featured Image

January 30, 2024

Navigating Loneliness and Unfamiliarity in the Buzz of London and Overcoming It

“Closing yourself doesn’t help in such situations. It took a lot of effort to get out of my comfort zone, but I’m glad I did it. I consider myself an introvert, but you do find like-minded people in group events. You just have to push yourself, get out of your room, and be part of these meetings.”

Struggled with: Loneliness Stress

Helped by: Self-improvement Social support

Summer Willis Featured Image

January 25, 2024

Overcoming Grief and Assault With 29 Marathons and Now Helping Others Do the Same

“A man spiked my drink and assaulted me, leading to a diagnosis of PTSD and depression. This event fundamentally changed my life, leading me into a violent relationship and a period of repression and struggle. Despite these challenges, life moved on. I got married, and had two beautiful boys, but then faced another intense period of grief, losing seven loved ones in just a few months.”

Struggled with: Abuse Assault Depression Grief PTSD

Helped by: Exercise Medication Religion Self-Care Self-improvement

Susan Gold Featured Image

January 23, 2024

Breaking Free from Abuse and a Toxic Family to find Self-Love and Authentic Happiness

“The abuse expanded over time. My mother could be incredibly kind and would have given Martha Stewart a run for her money. The problem came when her mood and personality would flip on a dime, her eyes in slits, and I would be beaten, almost to the point of blacking out, for what reason I couldn’t understand.”

Struggled with: Abuse Childhood Depression PTSD Suicidal

Helped by: Meditation Self-acceptance Self-improvement Social support Therapy

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Mental health case studies

Driving up quality in mental health care.

Mental health care across the NHS in England is changing to improve the experiences of the people who use them. In many areas, a transformation is already under way, offering people better and earlier access as well as more personalised care, whilst building partnerships which reach beyond the NHS to create integrated and innovative approaches to mental health care and support.

Find out more through our case studies and films about how mental health care across the NHS is changing and developing to better meet people’s needs.

  • Children and young people (CYP)
  • Community mental health
  • Crisis mental health
  • Early intervention in psychosis (EIP)
  • Improving access to psychological therapies (IAPT)
  • Perinatal mental health
  • Severe mental illness (SMI)
  • Staff mental health and wellbeing
  • Other mental health case studies
  • Archived mental health case studies

Perspective for infant mental health

Perspectives

World Association for Infant Mental Health

A Case Study of the Early Childhood Mental Health Therapeutic Consultation Protocol within a Specialty Multidisciplinary Pediatric Clinic for Adopted and Foster Care Children

examples of case studies for mental health

Experiences of maltreatment, caregiver transitions, and other forms of chronic stress in early childhood have been related to an increased likelihood of health and mental health disorders. Despite having a number of well-developed and validated therapeutic options for fostered and adopted children, families are often overwhelmed by their child’s multiple health needs and have a difficult time accessing care. This case report describes a 2-year old female child in foster care who took part in a multidisciplinary program for fostered and adopted children ages 0 to 5 years old. This family’s experience highlights that patients can receive streamlined evaluations, short-term therapeutic interventions, and long-term service recommendations by providing families with a single point of contact in an integrated care setting. This approach decreases the time burden placed on parents, increases the effectiveness in understanding and addressing a child’s needs, and improves family and provider collaboration. Further, models of integrated care reduce the likelihood of misdiagnosis. Many symptoms of early childhood adversity and attachment disorders can present like other common mental (i.e., Autism Spectrum Disorder) and physical disorders (i.e., motor delays). Misdiagnosis can lead to recommendations that are ineffective or ultimately harmful to children with experiences of trauma. Given the range of general and mental health effects of multiple housing transitions, maltreatment, and/or neglect, this case underscores how a team approach is invaluable for promoting at-risk young children’s wellbeing and development.

Keywords: Foster Care; Adoption; Mental Health; Early Childhood; Integrated Care

Introduction

Over 443,000 children were involved in the foster care system in the United States during 2017 (Child Trends Databank, 2019). Children under the age of five are the largest group within foster care (~41%, N = 183,959; Child Trends Databank, 2019). Almost all children involved in these systems have experienced multiple transitions, maltreatment, and/or neglect. Many have also experienced malnourishment, pre-and post-natal substance exposure, premature birth, and exposure to infectious diseases. Environmental stress, bodily harm, and illness in early childhood can carry consequences for physical and mental health functioning across the lifespan (Cicchetti & Handley, 2019; Malionsky-Rummel & Hansen, 1993; Smith & Thornberry, 1995; Vachon, Krueger, Rogosch, & Cicchetti, 2015; Anda et al., 2006). Given the medical complexity of foster children, multi-disciplinary care models, including medical providers, mental health specialists, public health nurses, social workers, and occupational therapists (OT), are essential.

The purpose of this paper is to highlight the experience of a 2-year old female in foster care with a program that integrates early childhood mental health therapeutic consultation with a unique multidisciplinary medicine program for fostered and adopted children. We will, 1) illuminate the need for new ways for fostered and adoptive children under five to engage with health, mental health and other services, and 2) highlight an early mental health therapeutic consultation protocol within a pediatric setting. Ultimately we aim to motivate the development of this and similar programs across the United States to better serve young children facing threats to their life long trajectories of mental and physical illness due to early experiences of adversity.

Early Childhood Mental Health Evaluation in an Interdisciplinary Pediatric Team

Multiple housing transitions, maltreatment and/or neglect can be related to a range of medical, developmental, and emotional symptoms, with treatments located outside of the sphere of early childhood psychological intervention. Early childhood experiences of abuse and neglect have been linked to cardiovascular concerns, sensory processing disorders, failure to thrive, and chronic infections associate with immune system dysfunction (Anda et al., 2006; Felitti et al., 1998). Malnutrition, often associated with experiences of neglect, can have a detrimental impact on a child’s development trajectory if left unaddressed – including an increased risk for cardiovascular and metabolic disease in adulthood (Campbell et al., 2014), lower IQ scores in early adolescents (Liu et al., 2003), and micronutrient deficiencies that cause irreversible alterations to brain development (Monk et al., 2013).

While physicians in the United States are typically underprepared to address mental health ramifications of early childhood trauma, mental health providers similarly lack the training to fully conceptualize a child’s necessary medical interventions for their physical health needs. Due to this increased medical complexity for children who have faced early adverse experiences, it is invaluable to have a team approach that addresses concerns and efficiently rules out multiple etiologies for symptoms.

Further, many mental health symptoms related to trauma or attachment disorders can present like other common early childhood disorders. This may be difficult for providers without specialized training in early childhood trauma and attachment disorders to accurately determine the appropriate diagnosis. Misdiagnosis can lead to recommendations that are ineffective or ultimately harmful to children with experiences of trauma. For example, Autism Spectrum Disorder (ASD), trauma-related disorders, and attachment disorders have a similar profile of symptoms in early childhood. This includes delayed speech, delayed social cueing, difficulties with attention, and self-harm behaviors. However, for children with experiences of neglect, clinicians would recommend trauma-informed treatments focused on building attachment relationships and stability. For children with ASD, more behavioral oriented approaches would be recommended to target the growth of specific social skills. An ASD diagnosis for children with a trauma-related or attachment disorder could further disturb the child’s developmental trajectory by delaying appropriate services that focus on bolstering the child’s relational needs.

Access to Care and Therapeutic Consultation

Early childhood interventions that address parent-child attachment for children who have experienced early trauma have shown efficacy in reducing children’s negative behavioral and emotional outcomes (Reyes et al., 2017; Dozier et al., 2017; Cohen et al., 2000). However, a large number of children facing adversity do not ever receive the benefits of early interventions (Hartinger-Saunders et al., 2019). Specialty pediatric care settings that work with early mental health providers and their state’s department of human services have the unique opportunity to dramatically increase the likelihood that children who are at risk are identified and receive evidence-based interventions. However, to our knowledge, there are no standardized protocols, on how to incorporate early mental health and relationship-based evaluations into pediatric specialty care. This paper aims to highlight the benefits of a cross-systems integrated care model for addressing mental health concerns among young children in foster and adoptive care.

In the United States, foster care and adoption legislation is determined by the State. In Minnesota, children in foster care have a case review hearing 90 days after a child’s removal from parental care. After the court reviews the parent’s progress on their case plan, there may be a 6-month extension on the child’s foster care placement. Once a child has been in foster care for 12 months, the court will file a petition to decide on a permanency plan. Children in foster care can be adopted when their birth parents sign a voluntary consent, after which they have a ten-day period to change their mind. Children may also be made available for adoption through a court procedure to end parent rights. Birth parents have 20 days to appeal the court’s order.

The Adoption Medicine Clinic (AMC) at the University of Minnesota has been evaluating internationally adopted children since 1986 and in the past decade has focused on providing more services for children who have been domestically adopted or are in foster care. Funded by a grant from the Minnesota Department of Human Services the clinic has incorporated specialists into pediatrician visits, including psychology, OT, pediatric/public health nurses, and genetic counseling to address the far-reaching effects of early childhood adversity on physical and psychological functioning.

In 2019, approximately 48% (N = 188) of the population seen by AMC were children 5 years old or younger and were noted to have high rates of behavioral and emotional difficulties. Throughout 2019 and the beginning of 2020, the program spent large amounts of time doing community outreach to create partnerships and referral pathways. The program encouraged social workers across the state to refer young children and their foster families to the AMC for integrated care. All data and the case review were collected via chart review and approved by the University of Minnesota Institutional Review Board. At the onset of visits to the AMC, foster parents were provided with consents by check-in staff to choose to include their clinical information in research.

Early Childhood Mental Health Therapeutic Consultation Program Description

The over-arching goal of integrating the Early Childhood Mental Health Evaluation Protocol into AMC was to identify young children who are at high risk for long term mental health difficulties and displacement from their current foster or adoptive home. The mental health portion of the evaluation protocol consists of three components by which children are screened for (1) prenatal and postnatal experiences of trauma, (2) current behavioral, social, cognitive, and emotional concerns, as well as (3) current service access. In addition to the evaluation, the service includes referrals and a tailored psychoeducational intervention.

The first component of the evaluation consists of collecting information on pre and post-natal experiences of adversity. Prenatal risk factors can include the biological parent’s level of stress, access to prenatal care, prenatal substance use, and genetic liability for psychopathology. Postnatal risk factors for this population often include neglect, abuse, chronic mobility, food insecurity, and multiple separations or transitions from primary caregivers. We identify the duration and age of these experiences in order to integrate a developmental framework that considers how the developmental timing and duration of these experiences could affect functioning. The clinician utilizes a standardized traumatic event screening form to identify risk for post-traumatic stress disorder as well as the Disturbances of Attachment Interview (Smyke & Zeenah, 1999) which inquiries about symptoms of Reactive Attachment Disorder and Disinhibited Social Approach Disorder (DC:0-5; Klaehn, 2018).

The second component of the evaluation is collecting information on the child’s mental and behavioral health difficulties. Information is gathered via medical chart review, foster parent interview, and behavioral observations in the clinical setting. Providers review the child’s previous psychological evaluations and diagnoses. Clinicians complete a foster parent interview assessing the child’s developmental trajectory and the formation of their current attachment relationship using the Disturbances of Attachment Interview (Smyke & Zeanahm, 1999).

Mental health providers then observe child behavior in the context of a medical and occupational therapy exam. The observation protocol is designed to help mental health providers identify children’s difficulties in cueing distress elicited by the exam, using foster or adoptive parents for emotion regulation and support, as well as indiscriminate friendliness with unfamiliar medical staff. Mental health providers observe the parent-child relationship (Crowell, 2003; Cooper, Hoffman, Powell, & Marvin, 2011). The observation protocol captures a snapshot of how foster and/or adoptive parents attend to children’s distress and how, they provide structure, guidance and direction to their children. Children lacking a caregiver with these skills are the most likely to experience high levels of maladjustment related to early experiences of risk. Consistent and responsive caregiving has been shown to act as a buffer between young children and their environment, preventing the negative consequences of stress on mental and physical health (Johnson et al., 2018; Measelle & Albow, 2018; Liberman et al., 2004).

At the end of the exam, mental health providers review the foster parent and/or adoptive parents’ concerns and goals for the child’s mental health, and evaluate if there are any risks for these foster/adoptive parents requesting the child be removed from their current placements. Child placement instability has been related to a host of emotional, behavioral and developmental difficulties in children (Fisher et al., 2016). Unfortunately, many states have a high rate of foster care placement instability (U.S. Department of Health and Human Services, 2014). Foster parents who are at risk for requesting that children be moved to a different placement often have young children with high medical, behavioral, and emotional needs. Research suggests that children with more trauma symptoms are at an increased risk for foster care displacement (Clark et al., 2020). During the interview, foster/adoptive parents at risk often highlighted feeling exhausted by the child’s needs, feeling as if they do not have the skill set to help the child, and feeling like they don’t have the resources to identify those skills. Through our work, we have found it to be really important and impactful to have a candid discussion with foster parents about any of these concerns. Many foster parents were very grateful to have a space to talk through these concerns without judgement.

The third component of the evaluation consists of reviewing the child and their foster/adoptive family’s current service utilization and needs. This involves reviewing if full developmental assessments using the DC:0–5™ Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood have been completed as well as what mental health services the families may be using. In evaluating current mental health services, we review families’ satisfaction with those services as well as provide recommendations for evidence-based interventions and providers with whom those interventions can be accessed. Families then receive a brief educational therapeutic consultation, based on our conceptualization of the child’s current functioning and history. Foster/adoptive parents are provided with information on how to best emotionally and behaviorally support children’s development in the context of their early adverse experiences. Most foster/adoptive parents receive educational information based on the Circle of Security (Zanetti et al., 2011) as well as in the moment feedback during the end of the session based on the Attachment Biobehavioral Catch-Up protocol (Dozier et al., 2017). We also discuss ways young children signal distress and ways foster/adoptive can help buffer those responses.

Young children who are identified as high-risk for placement disruption or long-term mental health difficulties are referred for a full mental health evaluation (using the DC:0–5™) and trauma-informed as well as relationship-centered evidence-based treatment. Children that need immediate intervention and care because their current level of dysfunction is a risk for their wellbeing receive rapid access to a one to three session brief intervention while they wait for longer-term therapeutic options to become available.

Rationale for a Case Study

We chose to highlight Anna’s* participation in our program as a case study for multiple reasons. First, there is limited knowledge on the feasibility of integrated care consultation models for young children in foster care. We will highlight how a common point of contact can increase high-risk children’s access to appropriate and timely early intervention services. Relatedly, we hope to use this case to highlight the medical complexity of these young foster care children and hope to support program and policy development. Third, many of these children are at risk for experiencing multiple foster-care placements. Multiple placements have been related to increased maladaptive functioning (Lloyd & Barth, 2011). We hope to use this case to highlight how providing consultations services, short term emergency care, and facilitating the prioritization and referrals to community services, integrated care settings like these may decrease the likelihood of multiple placements.

Case Background

Anna is a 2-year 8-month-old Black female who presented to the AMC. Anna was accompanied by her foster mother Rachel*, who was interested in gaining a better understanding of Anna’s behaviors and wanted to learn additional techniques to help support her development. Rachel described Anna as bold, talkative, active, and loving. Rachel had an initial interest in adopting Anna, but had concerns about her ability to provide long term care due to Anna’s many medical and emotional needs.

Based on a medical record review and foster/adoptive parent interview, Anna was prenatally exposed to marijuana, cocaine, and alcohol. Anna’s biological mother experienced homelessness and engaged in sex work while pregnant. Anna’s biological mother has a history of substance use, an anxiety disorder, and depression. Anna was born at 36 weeks gestation via cesarean section due to maternal preeclampsia. At birth Anna weighed 3 lbs. and spent one week in the neo-natal intensive care unit due to her low birth weight. At birth, she had Δ9-tetrahydrocannabinol (THC) in her system and was potentially exposed to a Sexually Transmitted Disease. As a young infant, Anna was reported to have spent time with various caregivers for extended periods of time while under her biological mother’s care and experienced residential mobility. At 10 months, Anna had a documented emergency room visit after reportedly being dropped by her biological mother. At 11 months, she was removed from her biological mother’s care due to concerns for neglect and placed with her current foster family. At placement, Anna was malnourished – weighing only 11 lbs. – and was diagnosed with failure to thrive. Since being placed with her foster parent, Rachel reported multiple ear infections but otherwise noted that Anna had appeared to be medically healthy. At the time of the AMC visit Anna was living with her two foster parents, her biological sister (1-year-old), and three foster siblings (9, 5, and 2 years old). Anna did not have any contact with her biological mother or father since being in foster care.

At the initial foster care placement, Anna displayed flat affect and was socially uninhibited. At the time of evaluation, Anna displayed extreme difficulties with separating from her foster parents, often refused food, and had no independent self-soothing behaviors. Anna and Rachel had previously engaged with play therapy, but Rachel reported that it seemed to make Anna’s symptoms worse. Rachel noted high levels of intense meltdowns after play therapy sessions as well as regression in her toileting abilities. Due to these symptoms, they ceased services. Over the few months leading up to the appointment, Anna displayed high-intensity distress and anger at home and appeared inconsolable. In order to manage Anna’s emotional and behavior needs, Rachel took 6 months off of work and sent Anna’s 1-year old biological sister and foster siblings to daycare. This was a challenging experience financially and emotionally for Rachel and the other children. Additionally, there were concerns with sensory processing, speech development, and muscle reflex issues. Anna covered her ears during loud noises, displayed freezing behaviors in new or unfamiliar situations, and had a hard time with zippers and putting clothes on.

Implementing the Early Childhood Mental Health Therapeutic Consultation Protocol

Anna and her foster mother spent an hour with our multi-disciplinary team of occupational therapist, nurses, medical doctors and psychologists. All team members were present for the duration of the visit. Results of the medical exam noted generalized muscular weakness, vitamin D insufficiency, iron deficiency, and tonsillar hypertrophy. Anna was prescribed a series of vitamin supplements. The experience of traumatic stress and micro-nutritional deficit prenatally and in early childhood may cause an altered vitamin D metabolism in children (Terock et al., 2020). Further, iron deficiency – also related to micro-nutritional deficits – can worsen for children directly in proportion to the amount of rapid post-placement growth (Fugelstad et al., 2008). Both nutritional issues have been related to numerous long-lasting developmental and cognitive deficits (Doom et al. 2014; Terock et al., 2020).

Due to prenatal exposure to substances, the medical team assessed Anna for the facial features of prenatal alcohol exposure. Her facial feature measurements were not consistent with those seen in children with Fetal Alcohol Spectrum Disorder. The occupational therapy team noted a speech delay and slight sensory processing difficulties on their developmental screening. They recommended a full assessment with a speech language therapist.

In Visit Observations

The mental health team observed Anna’s interactions with her primary caregiver, Rachel, and her emotional reactivity/regulation during novel situations. During the visit, Anna started by cuddling into her foster mother and was not interested in exploring the toys in the room. Throughout the hour Anna became increasingly more interested in the toys and displayed more positive emotions. Anna looked to her foster mother for support when she was unsure of toys or new people. Her mother provided comfort as well as acknowledged and validated her emotional expressions (both positive and negative). Anna appeared to experience her foster mother as an emergent secure attachment figure. However, Anna appears to have a difficult time relying on Rachel to provide support when she became distressed. At those moments Anna would appear to freeze in the middle of the room. Anna appeared to become particularly distressed and cover her ears if she believed something would make a loud noise. Observations of Anna suggested that she was developmentally delayed in her fine motor movements, and speech. Anna also demonstrated potential delays in social-emotional development.

Mental Health Treatment and Therapeutic Outcomes

At the end of the initial visit, the mental health provider engaged in a short educational intervention, using augmented protocols from the circle of security program (Zanetti et al., 2011). We described the impact of children’s trauma on development and highlighted the ways Anna’s trauma was playing out in her relationship with Rachel. Trained Circle of Security providers ( https://www.circleofsecurityinternational.com/trainings/about-trainings/ ) introduced the circle and being with Anna on the circle. The provider and Rachel practiced identifying when Anna was on the top or bottom of the circle over the course of the medical exam. The mental health team referred Anna to receive a full DC-0-5 screening from our team and engaged with two brief emergency intervention sessions to build Rachel’s skills on identifying when Anna was experiencing distress and how to help soothe that distress. The team also assisted Rachel in setting up respite caregiving services. Anna was referred to and subsequently engaged in early childhood day-treatment therapy services. Rachel also engaged with a circle of security group through our partner community clinics. Outside of the mental health and medical interventions described above, Anna received OT services for her speech and sensory concerns. At a follow-up appointment approximately one year later with AMC, Anna was still placed with the same foster family. They reported that many of the interventions helped reduce Anna’s symptoms and that they are hoping to move forward with adoption.

Piloting the Early Childhood Mental Health Evaluation Protocol

In the pilot of the evaluation protocol that Anna took part in at the AMC, there were 105 children like Anna seen by the clinic team in the span of ten months. Children ranged from 0.7 to 71 months of age and were 41.38 months on average. They were 43.3% female and 72% (n = 75) of the children were in foster care. There were thirty-one domestically adopted children and twenty children adopted internationally. Of those adopted internationally, fourteen had experiences of institutional care. On average children experienced 2.35 transitions, but this ranged from one transition to seven. Children were 10.61 months old on average at their first primary caregiver transition, and children were 24.49 months at their most recent transition. All children had experienced some form of neglect or abuse, with the most common experience being parental drug use (n = 49 parental drug use; n = 64 prenatal drug exposure; n = 43 prenatal alcohol exposure). Of the children seen at the clinic, 21 experienced physical abuse, 19 witnessed domestic violence, and 36 experienced neglect.

Approximately 68% (n =71) of primary caregivers noted behavioral, social, or emotional concerns for their children at the onset of the visit. Concerns included failure to thrive, broad developmental delays, sleep difficulties, feeding difficulties, high amounts of emotional distress and difficulty soothing. Clinical observations noted that 24% (n = 25) of children exhibited maladaptive stress behaviors. However, the vast majority of children sought and received comfort from their caregivers effectively (n = 82; 79%). There were five children who exhibited significant levels of indiscriminate friendliness by clinician observation.

Only 32% (n = 23) of these children were accessing psychological services at the time of their visit, and 29% (n = 30) of all children had seen a neuropsychologist. Three of those receiving neuropsychological evaluations were based in DC:0-5 protocols (2016). DC:0-5 evaluations review the development and functioning of young children in the context of their relationship with caretakers and other environmental inputs such as traumatic events. Of the children who had caregiver reported emotional and behavioral concerns or exhibited difficulties in the clinic, six were referred for an immediate consultation or brief therapeutic interventions with the early childhood mental health team.

At the time of this manuscript, four of those referrals have been fulfilled. Of the two whose referral has not been fulfilled, one lived out of state and the other is unknown. Further, twenty-six individuals were referred for a full mental health assessment with our team and eleven of those have been fulfilled. Many families traveled to the clinic from multiple hours away and either preferred to see a provider closer to them and/or we also recommended they could receive services from a member of the community closer to their homes. We recommended that forty-eight children (46.7%) receive a trauma-informed diagnostic assessment and pursue evidence-based therapeutic treatment.

Conclusions and Clinical Recommendations

We found that social, emotional, and behavioral concerns are highly prevalent and a central concern for foster care and adopted children (Measelle & Ablow, 2018; Shonkoff et al., 2012). These concerns often present in addition to the many medical symptoms’ that foster children are experiencing. Working with an interdisciplinary collaborative team can offer the opportunity for an efficient consideration of other etiologies for behavior and intervention programs to address sensory, physical, genetic, or neurodevelopmental issues. In Anna’s case, she was able to benefit from all aspects of these interventions including medical interventions for micronutrient deficiencies, as well as OT services. Collaborative consultation programs lower the amount of time families spend going to appointments as well as the time demands on providers. This is particularly a positive for families who live in rural communities, who have to travel far distances to receive care. It is essential to not only provide recommendations but also explicitly state how families should prioritize these recommendations. Anna needed help to first address her emerging attachment relationship with Rachel in addition to her immediate medical concerns. Following these services, additional pediatric rehabilitation and sensory-based interventions were effectively introduced.

Collaborative environments should create access points to care while also decreasing the strain of accessing care on families who are balancing the many needs of their children. Potential community mental health referrals should be located in a convenient location for families and operate under a developmental and trauma-informed lens and offer evidence-based treatment. Creating referral lines and professional relationships with community clinics that provide this care was an element central to this program’s success.

However, we also found that for cases like Anna’s it is essential to have opportunities for immediate longer therapeutic sessions with a mental health provider. Many families seeking our care are families currently in crisis where children are facing potential long-term harm to their developmental trajectory. This includes highly distressing child symptoms such as self-harm behaviors or those that are highly challenging for caregivers to manage and who are at risk for placement disruption due to these symptoms.

Integrated care settings that specialize in foster and adoptive care experiences in early childhood could greatly reduce the probability that children will sustain long term consequences of early childhood stress. This case study demonstrated the feasibility and need for these services. Future work should evaluate if access to multiple service providers in one meeting decreased the number of appointments for those children and if it increased knowledge, and access to appropriate therapeutic care for families. Further, studies should evaluate if access to therapeutic care reduces the child’s likelihood of foster care displacement.

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Palmer, Alyssa R., Institute of Child Development, University of Minnesota

Dahl, Claire, Department of Pediatrics, University of Minnesota

Eckerle, Judith K., Department of Pediatrics, University of Minnesota

Spencer, MaryJo, Department of Pediatrics, University of Minnesota

Gustafson, Kimara, Department of Pediatrics, University of Minnesota

Kroupina, Maria, Department of Pediatrics, University of Minnesota

Author Note:

Corresponding author is Maria Kroupina, PhD, LP. Department of Pediatrics, University of Minnesota, 717 Delaware St SE, Minneapolis, MN 55414; e-mail: [email protected]

This work was supported by the Minnesota Department of Human Services [1501MNAIPP-75-1516-1536]; The National Institute of Health [T32 MH015755] and the University of Minnesota Interdisciplinary Fellowship to the first author.

We thank the children and families who participated in our services and the work of Amina Qureshi for data processing.

Ethics Statement: The case study and descriptive pilot data provided were approved by the BLINDED Institutional Review Board. All participants provided consent for their data to be included in scientific research and their related products.

*All names presented in this publication have been changed for privacy.

Data Availability: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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How to Write a Case Conceptualization: 10 Examples (+ PDF)

Case Conceptualization Examples

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

Case Formulation

  • Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
  • Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
  • Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

  • A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

  • Client’s gender, age, level of education, vocational status, marital status
  • Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
  • In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
  • Consider the full range of positive factors supporting the client.
  • Physical health
  • Family support
  • Financial resources
  • Capacity to work
  • Resilience or other positive personality traits
  • Emotional stability
  • Cognitive strengths, per history and testing
  • The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
  • Medical conditions affecting daily functioning
  • Lack of family or other social support
  • Limited financial resources
  • Inability to find or hold suitable employment
  • Substance abuse or dependence
  • Proneness to interpersonal conflict
  • Emotional–behavioral problems, including anxious or depressive symptoms
  • Cognitive deficits, per history and testing
  • Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
  • There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
  • The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
  • Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

  • Decide which events or factors are significant enough to include in a case conceptualization.
  • When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
  • A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Case Formulation Samples

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

  • Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
  • Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
  • Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
  • Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
  • Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
  • Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

The following resources can be found in the Positive Psychology Toolkit© , and their full versions can be accessed by a subscription.

Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners . Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

  • Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
  • May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
  • Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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  • Open access
  • Published: 12 February 2024

Experiences of delivering and receiving mental healthcare in the acute hospital setting: a qualitative study

  • Daniel Romeu   ORCID: orcid.org/0000-0002-2417-0202 1 , 2 ,
  • Elspeth Guthrie   ORCID: orcid.org/0000-0002-5834-6616 1 ,
  • Sonia Saraiva   ORCID: orcid.org/0000-0002-2305-9246 1 ,
  • Carolyn Czoski-Murray   ORCID: orcid.org/0000-0001-7742-2883 1 ,
  • Jenny Hewison   ORCID: orcid.org/0000-0003-3026-3250 1 &
  • Allan House   ORCID: orcid.org/0000-0001-8721-8026 1  

BMC Health Services Research volume  24 , Article number:  191 ( 2024 ) Cite this article

373 Accesses

Metrics details

Recent investment in UK liaison psychiatry services has focused on expanding provision for acute and emergency referrals. Little is known about the experiences of users and providers of these services. The aim of this study was to explore the experiences of users of acute liaison mental health services (LMHS) and those of NHS staff working within LMHS or referring to LMHS. A secondary aim was to explore the potential impact of a one-hour service access target on service delivery.

Cross-sectional qualitative study. Individual interviews were audio-recorded, transcribed verbatim and interpreted using framework analysis.

Service users reported mixed experiences of LMHS, with some reporting positive experiences and some reporting poor care. Most service users described the emergency department (ED) environment as extremely stressful and wished to be seen as quickly as possible. Staff described positive benefits of the one-hour access target but identified unintended consequences and trade-offs that affected other parts of the liaison service.

Conclusions

The assessment and treatment of people who attend ED with mental health problems needs to improve and particular attention should be given to the stressful nature of the ED environment for those who are extremely agitated or distressed.

Peer Review reports

The number of people attending emergency departments (EDs) in England has continued to rise, aside from the COVID-19 period. In 2019/20, there were 25.0 million ED attendances compared to 21.5 million in 2011/12 1 . In April 2022, waiting time performance in EDs was the worst recorded in modern data collections [ 1 ], and people with mental health problems had to wait substantially longer than those with physical health problems. Although mental health presentations decreased during lockdown, there was a bounce back post-lockdown with even greater numbers attending ED than before [ 2 ].

There are relatively few studies of people’s experiences of liaison mental health services (LMHS) in the UK. A recent internet survey of respondents’ experiences of LMHS in England showed that only 31% of service users found their contact with such services helpful [ 3 ]. Latent class analysis identified three types of experience; those who had a positive experience, those who reported a negative experience and those who were non-committal. Suggestions for improvement included the provision of a 24/7 service, reduced waiting times for assessment, and clearer communication about treatment or care post-assessment.

Prior studies of user satisfaction of LMHS in the UK have also been mixed [ 4 ]. One previous study which involved in-depth qualitative interviews with service users found that people complained about long waiting times before being able to access liaison services [ 5 ]. Some service users reported good experiences characterised by close collaboration between the service user and liaison practitioner whilst others described po or experiences.

In contrast with the UK, studies from Australia have reported positive service user experiences of LMHS with high levels of service user satisfaction [ 6 , 7 , 8 ]. In one study, service users reported timely access to being seen by a liaison practitioner and reported feeling listened to, understood and helped in a positive fashion, with an emphasis on problem solution [ 6 ].

All 170 hospitals in England with an ED now have at least a rudimentary LMHS [ 9 ]. These services have undergone substantial growth in the last seven years following significant investment from NHS England [ 10 ]. There has been particular expansion in acute services, and a “Core-24” service model has been developed, with staffing ratios based upon hospital size in terms of bed numbers [ 11 ]. These Core-24 teams usually consist of at least one liaison psychiatrist and several liaison mental health nurses. They focus on emergency work, providing 24-hour cover for EDs and acute ward referrals, with an emphasis on one-off assessments followed by signposting.

These new developments have been accompanied by rigorous performance targets for response times and throughput. In 2016, NHS guidance stated that a person experiencing a mental health crisis should receive a response from a LMHS within a maximum of 1 h of receipt of referral, and within 4 h the person should have received: “ a full biopsychosocial assessment if appropriate, and have an urgent and emergency mental health care plan in place, and as a minimum, be en route to their next location if geographically different, or have been accepted and scheduled for follow-up care by a responding service, or have been discharged because the crisis has resolved” [ 11 ]. Further review of access standards for mental health services in 2021 maintained the 1-hour target [ 9 ], although waiting time targets for all patients attending EDs are under review due to consistent and increasing failures to meet them.

While many hospitals have benefitted from the introduction of Core-24, especially where there were no or only rudimentary services previously, other established liaison services have had to change or modify their ways of working to meet targets. In addition to acute cover, these established services previously offered lower volume, higher intensity work involving the assessment, treatment and co-management of patients with complex physical and mental health problems seen in either inpatient or outpatient settings.

We previously completed interviews with 73 NHS staff from 11 hospital trusts in England who were either LMHS staff or worked closely with them and found that interviewees most valued being able to spend time with patients to carry out therapeutic interventions [ 12 ]. Some staff provided continued treatment for patients admitted to acute hospitals over several weeks. For example, in one service mental health nurses regularly visiting older adult patients or those on stroke wards to provide encouragement with eating and rehabilitation, both vital components of ensuring recovery. Teams with psychologists, therapists or mental health nurses trained in specific interventions (like cognitive behavioural therapy) offered brief interventions while the patient was admitted to an acute hospital bed, or a follow-up appointment after discharge. Staff reported problems with continuity of care across the secondary-primary interface; a lack of mental health resources in primary care to support discharge; a lack of shared information systems; a disproportionate length of time spent recording information instead of face-to-face patient contact; and a lack of a shared vision of care. Similar issues were identified across different liaison service types.

The aim of the present study was to better understand the experiences of users and providers of LMHS, and to explore hospital staff’s experiences of the changes brought about by the NHS England’s investment in Core-24 and any impact on patient care. We were particularly interested in improving our understanding of the mechanisms and trade-offs involved in relation to meeting one key performance target, the one-hour response time set by NHS England for LMHS. Recent programme theory suggests that the imposition of such fixed targets may have unintended consequences for liaison services and other parts of the health care system [ 13 ].

This work formed part of the first phase of a programme funded through the NIHR Health Services and Delivery Research scheme to evaluate the cost-effectiveness and efficiency of different configurations of liaison psychiatry services in England (LP-MAESTRO) [ 14 ]. The Consolidating Criteria for Reporting Qualitative Research (COREQ) guidelines [ 15 ] have been followed.

This was a cross-sectional qualitative study with service users of hospital-based LMHS and hospital staff with either experience of working in, or working closely with, LMHS.

Setting and sample

Service users were recruited from two Northern cities in England. We aimed to recruit 8–10 service user participants and developed a purposive sampling frame to ensure maximum variation. Potential participants were approached by either LMHS staff to determine their interest, or by local service user organisations who were invited to identify participants for the project through their own contacts. Once consent to contact had been provided by the service users, they were contacted directly by a member of the research team, who explained the study and provided a study information sheet. The potential participant was given at least 48 h to decide whether to participate. All participants provided written informed consent and there were no dropouts. No relationship was established with participants prior to study commencement. Participants were not informed of any of the interviewers’ personal goals for conducting the research.

Hospital staff were recruited from two hospitals in Northern England, both with EDs and within the same city. A maximum-divergence sampling frame was developed to maximise diversity according to professional background, sub-specialism within the LMHS, clinical or managerial focus and whether liaison team member or referrer to the service. Overall, we planned to recruit 8–10 staff participants. All staff participants provided written informed consent and there were no dropouts.

Data collection

Service users.

Nine service users were individually interviewed using a semi-structured topic guide. The service user topic guide was developed for this study (LP MAESTRO) and not published elsewhere (see Additional file 1 ). It consisted of a list of key topic areas with open-ended questions and additional prompts covering the following areas: introductory questions identifying the contact the participant had had with acute care; experiences of the acute care received from acute hospital staff; accounts of care received from LMHS staff; and views on desirable changes and ways to achieve them. They were not asked specifically about Core-24 developments, as it was unlikely that they would be familiar with such policy and staffing changes. However, staffing and waiting times were included as part of the topic guide.

Hospital Staff

Eight hospital staff were individually interviewed using a semi-structured topic guide. The hospital staff topic guide was adapted from an earlier topic guide used in the LP-MAESTRO study in relation to a previous investigation of liaison psychiatry and hospital staff experiences of liaison services [ 12 ]. The adapted topic guide, which focuses primarily on staff experiences of CORE-24 is provided in Additional file 2 . The following key topic areas were covered: introductory questions about the staff member’s work history and the nature of their involvement with LMHS; experiences of LMHS prior to introduction of Core-24; description of any changes resulting from Core-24; impact of these changes on the service; impact on patient care; and views on how the service could be improved.

Interviews lasted 30–90 min and took place via telephone between September 2017 and February 2019. Participant interviews were conducted first, followed by interviews with hospital staff. With permission all interviews were audio-recorded and transcribed verbatim. There were no repeat interviews. Transcripts were not returned to participants for comment or correction. Only the interviewer and participant were present at each interview. No field notes were recorded.

Interviews were conducted by three researchers, all from the Leeds Institute of Health Sciences and qualified by experience and training (CCG, SS, EG). None were involved in the delivery of acute LMHS at the time of the study. EG is a female Professor of Psychological Medicine and Consultant Psychiatrist. CCM is a female Senior Research Fellow and SS is a female Research Fellow. EG had previously worked in an acute liaison mental health team and was generally supportive of the Core-24 developments prior to the study. Neither SS nor CCM had a priori views or identified biases. The form and content of the topic guides were developed in collaboration with people with personal experience of mental health problems and accessing LMHS.

Data analysis

The semi-structured interviews were interpreted independently by DR and EG using framework analysis [ 16 ]. This is a qualitative method that is useful in research that has specific questions, a limited time frame and a pre-determined sample; it is therefore well-suited to applied policy research. First, DR and EG independently read all transcripts with the study’s aim in mind. Each then independently reviewed all transcripts line by line identifying relevant experiences, opinions, descriptions of incidents and emotions (codes). DR collated codes into a draft theoretical framework which was refined through discussion with EG. It became apparent to base several framework categories around the key areas of interest in the interview schedule as we wanted to be open to issues arising from the data. DR then matched the data to the provisional framework. Each example was independently included under one or more theme in the thematic chart by DR and EG who then met to resolve any disparities. In the final stage, findings were reviewed by AH. Relevant supporting quotations were then extracted from interview transcripts to illustrate each theme and sub-theme. Data from service users and staff were analysed separately but are presented together if relevant to the theme or sub-theme. Participants were not asked to provide feedback on the findings.

Sample characteristics

Seventeen in-depth interviews were conducted, nine with LMHS users and eight with healthcare professionals. Service user participants consisted of 3 men and 6 women with varying age ranges (Table  1 ). Presenting problems included self-harm, psychosis, mania, long-term physical health problems and medically unexplained symptoms. The interviewed professionals were mental health liaison nurses ( n  = 3), consultant liaison psychiatrists ( n  = 2), general nurses ( n  = 2) and one consultant in emergency medicine.

Main findings

Participants discussed a range of topics surrounding the provision and experience of mental healthcare in general hospitals. They illustrated the complexity involved in meeting mental health needs in this setting. Below we outline our findings in terms of themes and sub-themes that emerged from the interviews; the four themes and their constituent subthemes are summarised in Table  2 . The staff topic guide included specific questions about Core-24 that were not included in the service users’ topic guide, so most of the sub-themes around the Core-24 service standard are only relevant to staff participants.

Theme one: the emergency department (ED)

Healthcare professionals and service users discussed their views of the ED as a site for mental healthcare provision. The content of their discourse comprised the sub-themes of ED staff, physical environment, appropriateness for mental health problems and desired characteristics.

Service users recounted highly variable experiences of ED staff when seeking help for their mental health problems. Some were described as kind and compassionate people who acknowledged distress and evoked feelings of validation:

“ They recognised I wasn’t putting things on, that I did feel acutely suicidal as I was saying ” – Participant 1.

Others disclosed negative views of ED staff, describing them as unpleasant and harsh. Three participants reported that ED staff withheld treatment that they thought was needed. Others reported that staff did not allow the service user to speak and failed to provide any guidance or support on discharge.

“The GP referred me to A&E and when I arrived there, they were very very harsh” – Participant 6.

LMHS professionals generally had negative perceptions of ED staff, reporting that they had poor psychiatric knowledge and skills. Several felt that ED staff did not appreciate the role of LMHS and frequently made inappropriate referrals. Some suggested that ED staff had little interest in mental health problems:

“I think sometimes they don’t ask more questions about mental health, and I don’t know if that is because they don’t feel confident to, or they just don’t want to” – Participant 13.

Physical environment

The ED environment was discussed exclusively by service users, and their opinions were overwhelmingly negative. Common issues were that the assessment room was uncomfortable and small:

“You’re brought into this really small room with no windows, it was tiny, it was also not necessarily painted, it was very scruffy ” – Participant 5.

A lack of provision of refreshments contributed to a sense of discomfort. The privacy of the assessment environment varied; two individuals reported that they were assessed in a private space, and one was not:

“In the department with just a curtain pulled around, so it wasn’t very private” – Participant 1.

Appropriateness for mental health problems

Both service users and providers questioned the appropriateness of the ED for people with mental health needs. No participants felt that the ED was an appropriate place for these needs.

“A lot of them are quite vulnerable, and more at risk of accidental self-harm or sort of vulnerable from other people in the department and it’s A&E isn’t it, I wouldn’t it consider a very nice environment for people that are experiencing psychosis” – Participant 13.

Service users described their experiences of seeking care in the ED as anxiety-provoking and lonely. They acknowledged that attending the department was an undesirable last resort, only done when other services and professionals could not be accessed in the community.

“It’s not the best solution by any stretch of the imagination but, but it’s the only place that’s available” – Participant 8.

Desired characteristics

Participants suggested ways that the ED could be improved to better care for those with mental health needs. These included a more comfortable environment, the option to wait outside, better communication of next steps and knowledge of community-based support. One participant suggested the provision of company while awaiting input from the mental health team.

“I don’t know what else they could do apart from have somebody sit with you all the time until the psychiatrist came or somebody to assess you” – Participant 7.

Liaison practitioners also felt that the ED could be improved by providing more staff training in mental health assessments and improving referrals to the LMHS. This could reduce the volume of referrals and facilitate referral triage while reducing wait times for service users.

“If you upskill the ED people to even basic then liaison psychiatry should be able to turn down referrals… And we have to remember in the middle of all of this is a patient” – Participant 15.

Theme two: Liaison mental health services (LMHS)

The second theme refers to participants’ views and experiences of liaison mental health services (LMHS). There are three sub-themes: experiences of LMHS, barriers to contact and desired characteristics.

Service users described variable experiences of the help they received from LMHS. Contact with LMHS helped some individuals to feel more comfortable and to understand the next steps. Some described a therapeutic benefit of talking in depth about their issues:

“It helps me mental health, being able to talk about it and stuff” – Participant 3.

Others voiced that LMHS were either unhelpful or contributed to them feeling worse. This was related to the feeling of not being listened to and the perception that no tangible help or support was offered.

“ I’ve not got time for them as they do nothing for me” – Participant 9.

Some service users held the view that LMHS complete little more than a “box-ticking” exercise that offers little benefit to the service user. This was echoed by one of the physical healthcare professionals.

Common problems were that the professionals seemed rushed and incompetent. Three participants shared the view that LMHS staff were dismissive or disinterested. This led them to feel guilty and as though they had wasted the professional’s time.

“Sometimes the mental health staff can be very dismissive and treat me like I’ve just wasted everybody’s time, and I should have just looked after myself at home” – Participant 8.

Others described LMHS staff in a more positive light, reflecting that they allowed them to speak freely while listening carefully and acknowledging their needs. In some interviews, LMHS staff were described as caring and comforting. One participant felt that LMHS staff are underappreciated:

“I know with my experiences with liaison psychiatry that they do a lot more than people may think” – Participant 4.

Generally, interviewed professionals were complimentary towards LMHS staff, describing them as hard-working, knowledgeable, experienced, accessible, and committed to high-quality patient care. Participants had conflicting views on whether LMHS staff have a good relationship with the ward teams and whether they meet their expectations, although this was often attributed to a rise in demand for the service.

Barriers to contact

Participants discussed barriers to accessing LMHS. Some service users recounted how input from LMHS was postponed or withheld because they were under the care of a community mental health team. This sometimes resulted in interactions with a “diversion team”, which was described as a frustrating, obstructive experience.

“You just can’t get past diversion because they’ve been put in place to stop people like me who are known to the system… They’re basically there to go, ‘there, there, you’re ok, you go home and speak to your care coordinator tomorrow.’” – Participant 8.

Staff felt that significant barriers to contact with LMHS included insufficient staffing levels, particularly out of hours, and a seemingly excessive amount of time completing documentation.

“The [LMHS] team spend a long time writing things up and reporting… If we do make a referral for later in the evening or overnight, I don’t work nights, but they’re often told, ‘oh we can’t come and see the patient because we’re writing up our reports!’” – Participant 12.

Service users outlined factors that would improve their experience of receiving care from LMHS. Several participants described dissatisfaction with being discharged without a clear treatment plan and called for the provision of aftercare and more information about third sector organisations.

“If someone’s self-harming or whatever they shouldn’t just be discharged. They need aftercare and everything. It should be in their care plan.” – Participant 2.

Some described desirable characteristics of LMHS staff, which included compassion, knowledge, and clearer communication of delays and anticipated next steps. Service users expressed a desire to be treated as an individual and to be listened to attentively.

“You need front-line staff who have the personal interactive skills to acknowledge, to offer comfort and explain what is going to happen, not front-line staff who make you more agitated or that they are confused” – Participant 5.

Other desirable characteristics of the service identified include universal service provision across the country, a switch of focus from medications to psychosocial interventions, and a separate service for those who do not meet the criteria for admission but who feel unsafe to return home. Some service users voiced support for an acute mental health service separate from the ED.

Theme three: core-24 service standard

This theme encapsulates views towards the Core-24 service standard and the subthemes are the 1-hour wait, perceived benefits, unintended consequences , and policymaker detachment.

1-hour wait

Although professionals acknowledged the importance of targets, many felt that the one-hour target was unattainable, particularly for those with complex presentations or substance issues. Some felt that it was inappropriate to assume that service users’ needs are constant throughout the day. There was a consensus that immediacy was prioritised over clinical importance, which manifests as brief introductions within the hour instead of careful, comprehensive assessments.

“It’s not about how quickly you are seen, it’s about the quality of the interaction and I think if you are having to respond to patients in an hour that can sometimes compromise the quality” – Participant 16.

In contrast, service users almost universally expressed a wish to receive contact from the LMHS as soon as possible, and even a one hour wait felt too long to wait if someone was very distressed.

“When you are thinking of taking your own life, an hour is a lifetime” – Participant 1.

Perceived benefits (staff only)

The most salient benefit reported by the healthcare professionals was investment in the LMHS. They described more financial investment into the service, and the creation of staff posts to expand the workforce, contributing to feelings of reassurance and comfort. Although participants acknowledged the associated challenges of training new staff, overall, this change was perceived as positive.

“The investment within the services has enabled us to, erm you know, to broaden out what we do” – Participant 17.

Generally, professionals explained that the service standard improved patient flow. They felt that one-hour reviews were conducive to faster discharges and the prevention of unnecessary hospital admissions. They also reported a greater focus on the service user experience and acknowledged the target as an opportunity to improve the service further.

“I think that’s been a huge positive for the team because it’s made them think, actually, okay, we need to do this. How are we going to do it in the best way possible to get the service users experience and the standard of care for them as best as we can?” – Participant 14.

Unintended consequences (staff only)

Professionals also reported numerous undesired sequelae to the Core-24 one hour target. The first was that the target acted as an incentive for people to use the ED for their mental health needs in the knowledge that they would be seen quickly. This contributed to a rise in the clinical workload for both ED and LMHS staff.

“It was an odd thing to do when you’re trying to decrease attendances, it’s like a bit of an incentive to [attend the ED]” – Participant 11.

Some explained that the target had a detrimental impact on servicing providing ward cover, as LMHS staff are diverted from wards to the ED for initial reviews for new presentations. This results in delays on the wards and subsequently prolongs admissions.

“They used to see people who were in the beds before the parvolex (a treatment following a paracetamol overdose) ended, but they’re just unable to do that now because of the amount of people in A&E to be seen” – Participant 10.

The target has also had ramifications on working hours, with some participants reporting that their shifts were extended from eight to twelve hours, resulting in more lone working and reduced staff morale. This was identified as the reason for some staff members deciding to leave their jobs.

Policymaker detachment (staff only)

Generally, professionals felt that Core-24 was implemented poorly by policymakers and commissioners who were disconnected from the service. They described that no attempts were made to seek the views of clinicians, and that it was delivered as a compulsory change.

“The way that this change was brought in was very top-down, there was very little engagement with the team” – Participant 16.

One professional reported that they were informed with little notice that older people would be included in the remit of LMHS following the standard, and they received no formal training for this. The disconnect between policymakers and clinicians resulted in resentment among staff.

Service users echoed this idea by suggesting that policymakers were detached from the views and priorities of those seeking care. Some mentioned that these should be incorporated into decisions about LMHS provision:

“I think that the service should get more involvement from the service user’s experience” – Participant 6.

Theme four: stigma of mental illness

The final theme describes the stigma associated with mental health problems. The subthemes were discrimination and the mental-physical dichotomy .

Discrimination

Service users commonly felt discriminated against for having mental health problems. They described being treated differently to those with physical health problems, with their issues not being taken as seriously. Some recalled being dismissed and feeling guilty for accessing services.

“If you’re physically ill that counts, it’s given a higher priority over mental illness” – Participant 4.

Professionals also acknowledged the discrimination against those with mental health problems in the general hospital setting. They commented that service users with mental health needs are generally perceived as problematic and unwanted in the ED.

“Patients with mental health difficulties in the emergency department are the difficult ones, the bad ones, the ones that upset the data, or the ones that don’t move out quick enough” – Participant 15.

The mental-physical dichotomy

This subtheme describes the clear delineation between physical and mental health in the context of healthcare services. Both professionals and service users commented that mental health needs are frequently neglected in physical healthcare settings. This is attributed to a perceived unwillingness to enquire about psychiatric symptoms and a tendency to ignore biopsychosocial determinants of health.

“If I was to mention mental state, your consultants turn their faces away from me” – Participant 9.
“The traditional method of dealing with a lack of liaison psychiatry in the general hospital is to ignore the problem and just pretend it’s not there, to not notice that the patient is sad, not notice that they are anxious, to blame the patient, to discharge them early, to not take care of the wider side of psychosis difficulties that have prompted this admission” – Participant 15.

Clinicians also perceived a divide between mental and physical healthcare professionals. Some LMHS staff felt that ED clinicians had poor psychiatric knowledge and skills, that they often made inappropriate referrals with minimal information, and that their service was not understood or appreciated.

“I don’t think mental health is respected within the A&E department as a proper profession” – Participant 13.

Final analysis

The final stage of analysis is summarised in Table  3 , which shows comparisons across the service user and staff groups whilst also reflecting the strength of the signals from the data (determined by the proportion of participants who voiced these opinions). It shows some striking differences in patterns but also several areas of agreement. The one-hour access target is seen differently by service users and staff whilst issues related to stigma are perceived as important by both groups.

How our results compare

There are relatively few qualitative studies of LMHS, so this study is an important addition to the field. The variable experiences of LMHS users in this study are similar to those described by Eales and colleagues [ 5 ] and consistent with the recently published online survey of LMHS users [ 3 ]; some people reported good treatment and care from LMHS, whilst others report poor care and an unhelpful experience. Despite the increased funding for LMHS in recent years, people’s experiences remain patchy and well below the satisfaction levels reported by users of services in Australia [ 7 , 17 , 18 , 19 ]. However, it is difficult to compare services between countries with different healthcare systems.

Most service users felt that the ED environment contributed to additional stress and was an inappropriate place for people with acute mental health problems. This is consistent with previous studies [ 20 , 21 ], which have highlighted the negative and stressful aspects of the ED for people with mental health issues and described the ED as overstimulating and lacking in comfort and privacy. This is set against a backdrop of a recent survey carried out by the Royal College of Psychiatrists which reported that more than three quarters of people referred to mental health services resort to using emergency services because their mental health deteriorates whilst waiting for an initial assessment [ 22 ].

Wait-time targets

Opinions about the appropriateness and helpfulness of the one-hour performance target for LMHS varied between service users and staff. Service users highlighted the importance of being seen as quickly as possible in ED, particularly because the environment was stressful, but also because they were in a heightened state of distress and needed urgent relief. Some staff, however, believed the one-hour target distorted clinical practice with performance taking precedence over clinical need. This resulted in many unintended consequences including encouraging an increase in mental health ED attendances and a detrimental effect on other parts of the liaison service.

These findings support a logic model we previously developed to explain the impact an increase in liaison mental health provision may have on specific target response times [ 13 ]. Increased staffing levels initially enable LMHS to see more service users within the designated response target time, but various tensions and trade-offs within the system become apparent over time. If more service users attend ED due to the quicker response time, coupled with long waits in the community, pressure on the system increases again. This pressure causes a tension between the balance of ED work and the needs of patients with severe mental health problems who are inpatients in the acute hospital. The focus on ED and meeting the response target may result in potential disruptions to the care of hospital inpatients with deleterious clinical consequences and increased length of hospital stays. The introduction of a response target inevitably leads to unintended consequences in other parts of the healthcare system; the balance of advantages and disadvantages of the target across the whole system needs to be considered.

Public stigma and discrimination against people with mental illness is not a new phenomenon and is still widespread in society [ 23 ]. A review of 42 studies of ED staff attitudes towards service users presenting with mental health problems, 14 of which were conducted in the UK, reported widespread perceived negativity, although positive experiences were also acknowledged [ 24 ]. The findings from our study suggests negative attitudes towards people with mental health problems are still problematic in the ED setting. A recent qualitative systematic review exploring stigma and discrimination experienced by mentally ill individuals seeking care for physical and mental health concerns suggests that stigma and discrimination significantly compromise the quality of healthcare relationships with services users [ 25 ].

What can be done?

The Royal College of Emergence Medicine has produced a useful toolkit for improving care of people with mental health problems whilst in the ED, which stresses that all people with either a physical or mental health problem should have access to ED staff that understand and can address their condition [ 21 ]. There is a clear driver from both the Royal College of Emergency Medicine and the Royal College of Psychiatrists to improve the care of people with mental health problems who attend ED. There has also been recognition of this problem by NHS England with funding in 2017–2018 of £18 million for 234 winter mental health schemes to help alleviate pressures in ED for people with mental health problems [ 26 ]. Most of the funding was allocated to mental health liaison schemes, community crisis resolution and discharge and step-down schemes. Although many individual schemes reported local positive benefits, there were no robust evaluations which would support national rollout of any of these schemes.

There is some evidence that small positive attitude changes towards people with mental illness can be achieved by specific stigma reduction interventions [ 27 ], although relatively few interventions have been evaluated in the ED. Most educational interventions have focused solely on knowledge acquisition for specific conditions such as substance misuse disorders [ 28 ]. However, the endemic nature of stigma towards mental illness suggests that multi-level changes are required at organisational and personal levels. The Lancet Commission on ending discrimination in mental health included a review of all forms of stigma and discrimination against people with mental health conditions in all settings and societies globally [ 23 ]. The authors made several recommendations including policy and societal changes and workplace changes. Of relevance to the ED setting, they recommend that all healthcare staff receive mandatory training on the needs and rights of people with mental conditions, co-delivered by people with lived experience of mental health issues.

The staffing recommendations for Core-24 LMHS were largely based upon the size of hospital and the knowledge that mental health issues account for 4% of ED attendances. However, recent work suggests a further 4% of ED attendances consist of people attending with a physical health problem but who also have significant mental health issues [ 2 ]. This suggests that current LMHS staffing levels need to be reviewed, as Core-24 guidance may have underestimated the workload demands on LMHS, and workload is better estimated by patient throughput than the size of the hospital in terms of bed numbers or the presumed percentage of people in ED who may require liaison services [ 29 ].

Strengths and limitations

This study has several strengths. First, we met our recruitment targets, although, recruitment of service users took longer than we anticipated. There are no patient organisations that represent liaison service users, so recruitment can be challenging. However, we achieved a wide diversity of service user participants in terms of demographic characteristics and clinical problem areas. The most common clinical problems seen by liaison services in England are co-morbid physical and mental health problems, self-harm and cognitive problems [ 29 ]. Participants with co-morbid physical and mental health problems were represented in our participant sample. However, service users with cognitive problems were excluded from this study due to the inability to provide informed consent to participate. Second, the staff participants came from a range of professional backgrounds, including those who worked within LMHS and those who referred to LMHS. Third, we were able to explore both service user and staff perspectives about an important aspect of current service provision – the one-hour access target.

There were several limitations to the study. First, our sample size was relatively small and service user participants were only recruited from two geographical areas, and hospital staff from only two hospitals. We required members of staff who had experience of LMHS both prior to and subsequent to the introduction of Core-24, which limited the number of staff who we could interview and were willing to participate in the study. This also limited our ability to interview to the point of saturation. A larger staff sample may have resulted in other themes emerging so the findings of this study cannot therefore be generalised to other services in England, although many of the findings do accord with previous work in this area. Second, as discussed above, we were unable to recruit people with cognitive problems, making findings less relevant to liaison services for older adults. Third, interviews with participants and staff were conducted before the COVID-19 pandemic and its impact upon healthcare delivery. There was a marked drop-off in ED attendances during lockdown and the many liaison ED services were moved to other parts of the hospital to minimise spread of infection. Although there has been a clear bounce back in ED attendances among people with mental health problems post-pandemic [ 2 ], it is unclear to what extent services and service users have changed.

This study provides compelling evidence that the assessment and treatment of people who attend ED with mental health problems needs to further improve. The negative staff attitudes described are unacceptable, services for aftercare following assessment are inadequate, and the immediate experience in ED is often negative.

Particular attention should also be given to the stressful nature of the ED environment for those who are agitated or distressed. It can be argued that the ED is not the most appropriate place for people with acute mental health needs, but at present, there is often no clear alternative. Diversion schemes are under development in some areas. However, there will always be a need for many people with mental health problems to attend ED, as people with mental health issues commonly also have physical health problems, which require investigation and management in parallel with their mental health difficulties. Whilst ED service users emphatically support the one-hour response target, the imposition of such targets can have unintended consequences on other parts of the liaison service which need to be balanced to ensure parity for LMHS users in ED and those admitted in the acute hospital as inpatients.

Availability of data and materials

Data from this study are not available due to the qualitative nature of the study.

Abbreviations

Liaison Mental Health Service

Emergency Department

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This project is funded by the National Institute for Health Research (NIHR) HS&DR programme (project reference 13/58/08). The work was also supported by a legacy provided by the family of Dr James Haigh. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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AH, JH and EG conceived of the research. AH was the programme lead. CCM, SS and EG conducted the interviews. DR and EG conducted the analysis. DR and EG wrote the first draft of the manuscript. All authors (DR, EG, SS, CCM, JH, AH) contributed to the manuscript. All authors have read and approved the final manuscript.

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This research was conducted in accordance with the Declaration of Helsinki [ 30 ]. NHS ethical permission was obtained from the North of Scotland Research Ethics Service (REC reference: 15/NS/0025) and NHS Trust level approvals were obtained. All participants provided written informed consent to participate and there were no dropouts.

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Romeu, D., Guthrie, E., Saraiva, S. et al. Experiences of delivering and receiving mental healthcare in the acute hospital setting: a qualitative study. BMC Health Serv Res 24 , 191 (2024). https://doi.org/10.1186/s12913-024-10662-4

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Received : 24 August 2023

Accepted : 30 January 2024

Published : 12 February 2024

DOI : https://doi.org/10.1186/s12913-024-10662-4

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  • Liaison psychiatry
  • Mental health liaison services
  • Qualitative
  • Experiences of care

BMC Health Services Research

ISSN: 1472-6963

examples of case studies for mental health

Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

  • Identify disorders of childhood and adolescence in case studies

Case Study: Jake

A young boy making an angry face at the camera.

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

A girl sitting with a book open in front of her. She wears a frustrated expression.

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

  • Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
  • Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
  • A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
  • Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
  • Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright

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