Work Site Case Study
Samuel Law
Nov 22nd, 2000
Introduction:
Physical locale of
Encounter:
Walk-in clinic at the
Gouverneur Hospital, where a patient sees a nurse first, for triage (usual
wait: approx. 20 min to 3 hours). After triage, persons requiring further care
are to register at the cashier (usual wait: 5 to 30 min for revisit, 40 to 90
min for new patients), in order to see a physician or supervised physician aid
(usual wait: 1 to 4 hours). Further waiting time required if labs involved.
Case Presentation:
August, 2000
Mr. Z was referred from the
triage nurse of the walk-in clinic for psychiatric assessment. I took the call.
Mr. Z. is an unilingual 30 year-old patient of Chinese descent. His main
language is Fu-Zhounese, a dialect from the southern Fujian province of China.
He spoke some limited Mandarin for the purpose of the assessment. He presented
to the hospital accompanied by his older sister, who reported that Mr. Z was
having problems sleeping and displayed increasing unusual behaviour - calling
her incessantly at all hours, complaining that the police are chasing after
him, and that he is worried about their parents in China, his arranged
marriage, and money.
He stated that he was
stressed, and that he did not understand why he is having such unwanted
thoughts. He denied any unusual activities or any abuse of substances. He could
not comment on whether he was suffering from auditory hallucination, but denied
visual hallucination more unequivocally. He did not seem to understand
questions on thought broadcast/thought withdrawal/thought insertion. He had no
reported or observed manic symptoms such as increased energy, talkativeness, or
pressured speech. He seemed genuinely disturbed at the sight of uniformed
officers at the hospital.
His sister could not comment
further on his symptoms beyond that he was acting bizarrely. She reported no
protracted period of mood disturbances, and noting no clear precipitant. She
gave a history that Mr. Z has had a previous episode of similar bizarre
behaviour, but he had been ok since discharge from hospital and was in his
usual/baseline level just a few days ago. She has been worried for her brother,
however, who was a isolated man, worked at a restaurant 6-7 days a week, all
over the country. Both he and his sister denied any use or knowledge of any
substance abuse.
Past Psychiatric
History:
During assessment, we
requested information from Bellevue Hospital via the psychiatric crisis service
where a psychiatry resident is on-call. Faxed copies of the following
collateral information arrived within 15 min.
Mr. Z.’s first psychiatric
admission was in Jan - Feb 99, at Bellevue. lasting 3 weeks. He was brought to
Bellevue by NYPD after a bystander called the police for he was “running in
Chinatown in his pajamas (winter), screaming that he was crazy”. Mr. Z.
reported at the time that he was feeling increasingly confused after returning
from a job as a cook in Connecticut. He reported throwing away his belongings,
including his C8 Visa and $900 cash. He also admitted to command auditory
hallucinations to hurt himself and paranoid delusions that the government
(immigration) was out to get him because his C8 Visa was due to expire in 7/99.
He also later admitted to
sleepless nights for two weeks prior to admission, coinciding with starting new
job. He denied other manic symptoms, denied substance use, and denied family
history.
Mr. Z’s social history at the
time was that of a single person, living mostly in restaurants where he worked.
He came to visit his sister during days off. His parents were in Fu Zhou. He
had been in the U.S for five years, having worked in 20 different places.
His past medical history from
Bellevue showed some WBC elevation. Further work up, including a lumbar tap,
and CT of head, were negative. He received Haldol 5 mg IV twice, Valium 10 mg
IV, twice, and Versed 2 mg IV.
While on the in-patient unit,
he was under the care of a Mandarin-speaking psychiatrist. He gradually
responded to treatment, with Haldol 4 mg qd, and Benedryl 50 mg for sleep. At
the time of discharge, his paranoid delusions, auditory hallucination,
insomnia, and thought disorganization were “completely resolved”. He was
interacting in a meaningful way in groups and in sessions and showed no
suicidal or homicidal ideation. His insight and judgment improved.
Mr. Z was diagnosed with
Psychosis NOS, most probably schizophreniform disorder. His Axis IV was noted
“stress at work, loss of job, impending loss of legal status”. His Axis V was
20 on admission, 75 on discharge.
Mr. Z’s discharge medications
were Haldol 4 mg qhs, Cogentin 1mg qhs, Benedryl 50 mg, qhs. He was given a
month’s supply and was instructed by a Chinese speaking social worker to follow
up at a local psychiatrist’s office. He was to return home to live with his
sister, who was aware of and agreed to implement the treatment plan.
Past Medical History:
No known acute illness. No
current medication.
Family Psychiatric
History:
No other known family
psychiatric history, according to sister.
Social History:
Isolated, worked at restaurants
all over the tri-state area and beyond. He “paid off” his
“immigration”(smuggling) debt about a year ago. As an illegal immigrant, Mr.
Z’s social history is integrally related to the onset and on-going stressors
contributing to his illness and inability to seek treatment. His story warrants
a closer look.
“Undocumented Alien”
and others:
Mr. Z. is one of the 300,000
people from Fu Zhou thought to have illegally left China over the last few
decades. A very large proportion of that group reside in the New York tri-state
area; their community’s life center is East Broadway, a recent extension of the
Manhattan Chinatown. Gouverneur Hospital is in the heart of this community.
We are probably familiar with
the recent sensational stories about immigrant smuggling, from the Golden
Venture (a dilapidated boat carrying hundreds ran aground with 10 deaths) in
1993, to the more recent 58 deaths by suffocation in a tomato container truck
in England in 2000. For the long periods before and in between, there has been
on-going smuggling of illegal immigrants form China. They are surprisingly
mostly from a small area of China – Fu Zhou, in Fujian province.
Mr. Z was born in a small
village near Fu Zhou. While illegal crossings from China to Hong Kong, or
Macao, or other more prosperous neighboring regions of China has always been a
known fact, for years the only way to come to the US directly was to become a
seaman and then jump ship. However, with widening economic inequity, political
oppression, lack of opportunity and jobs in China, and ties between the U.S and
China warming up - opening trade, travel, tour and study links – more people
have sought to escape from China to put roots in the U.S. They have achieved
this through various methods. For example, some go AWOL from a tour, marry an
American, seek political asylum, or refugee asylum; some use forged State or
Business visitor documents, etc. Once a group has established here, it becomes
the nucleus of a self-perpetuating flow of other compatriots to migrate to the
U.S, through legal and illegal sponsorships.
Traditionally, smugglers are
known as “snake heads” - with human cargo as the “snakes”. Typically snakeheads
use Latin America such as Mexico, Belize, and Guatemala as stepping-stones to
the U.S. More sophisticated operators provide forged papers such as Visas for
plane arrivals. They also bribe of corrupt immigration officials, tour
operators and other underground organizations, making this a multinational
business. Mr. Z. came on the more traditional, hardy, sea route, at a cost of
$US 35,000.
According to his sister, Mr.
Z came first by boat to Central America, then to Mexico, crossed over the U.S
border into Texas, then was driven to New York in a minivan. He had nothing but
debt and hope when he arrived.
Mr. Z. paid off most of his
debt after he came to the U.S. He obtained the down-payment from his family and
relatives in Fu Zhou. Smuggled immigrants are typically found jobs at
restaurants and factories upon arrival to pay for their remaining debts. Those
who could not afford down payments can borrow from the snakeheads at a
punishing 30% interest, effectively living an indentured life until they pay
off the debt.
Mr. Z. was lucky to have a
sister here in the U.S already to help out the first leg. Her role was typical
of many immigrants in catalyzing further smuggling; she tapped into an
extensive underground financial network. (Smugglers operate “bank services” in
Chinatown where people can wire money back to Fujian. Money is delivered in
hours and in U.S. cash, a superior choice over the poor exchange rate, 3-week
process at the official Bank of China who delivers in the Chinese currency
Yuan. This financial network was also instrumental in stimulating further
smuggling. The symbol of success in Fu Zhou has become “who can get to the U.S
and who can send more money home.” Money was Mr. Z’s major worries through out,
and most likely a major precipitator of his illness.) Today, the smuggling fees
to the U.S have soured to about $60-70,000.
For the community as a whole,
there has been a major boom in the “undocumented community” after the amnesty
granted by President Bush in 1989 after the Tiananmen Square massacre. The
amnesty created a major base of legal immigrants who are able to sponsor their
family from overseas, and/or afford the smuggling fees.
In the U.S., Mr. Z usually
made around $1500 a month, and spent very little. He lived in single room
apartments with other workers. He paid off his debt in about three years. This
apparently is the norm if everything goes well and as planned. A booming U.S.
economy meant plentiful jobs in restaurants and garment factories, further
strengthening the conviction that there is sufficient opportunity in the U.S.
to risk the process. After paying off the debt, Mr. Z. was thrilled to be able
to start sending home money. He became preoccupied with it. Another stressor
was his desperate wish to arrange for a female friend to come to join him,
although it was also a source of purpose and hope. Mr. Z had some pre-existing
friendship with a woman in China whom he envisioned joining him in the U.S. Of
course, he would need to arrange for her smuggling – at least to pay for her
down-payment. Then the illness started
Mr. Z tried to learn some
English while in China. However, he never mastered much of the language even
after a few years in the U.S., severely restricting his opportunities for
employment and education.
Mr. Z had hopes to move up in
the restaurant world. He wished to open or become a partner of his own place if
possible. His future long-term plan also includes hiring a lawyer to seek
asylum for him as a Falun Gong member, or for any other available and feasible
reason. The legal fee may be as high as $4000 and the chance of success very
low. At this point, in his view, he cannot afford to be too concerned about his
illegal status. In his world, everybody is in the same situation – living on
the margin of the society. He is not alone.
Family History:
Mr. Z’s only relative in the
U.S. is his sister who came before Mr. Z to join her husband. She knows quite
well the hardship involved when she prepared Mr. Z to come. She helped out with
the down payment and once arrived, helped him to find a job. With the
decompensation, she has felt guilty for bringing him here. She wondered if he
would have been better off staying in China. Their parents are working on a
farm in China.
“Undocumented” economy. Paid
“under the table”. Public assistance available in the forms of shelters, soup
kitchen, etc.
Current exact legal status
unknown. Was on a C8 visa, issued to those who are awaiting asylum or
immigration hearing. After the onset of his illness, he missed his hearing,
thus currently a “underground” or “undocumented” alien.
None. Emergency Medicaid
only, under the “don’t ask, don’t tell” rule. Basic care dependent on City
Hospital system, community services, and traditional services in Chinatown.
Mental Status:
(At the walk-in Clinic) Mr. Z
was a 30 year-old slim man who stood about 5’5”, reasonably groomed and
appropriately dressed for the weather, and appeared younger than his age. His
features were on the delicate side, suggesting that he was not used to hard
labour. He started out looking quiet and apprehensive, with some psychomotor
retardation. During the course of the assessment and administrative
registration, he became increasingly agitated, with pacing, self-directed
yelling, and later, an attempt to harm himself. He was guarded throughout, and
suspicious of the hospital police, but more readily cooperated with the
interview once we started speaking Mandarin. His affect was initially
restricted, and anxious; his mood was “confused” - deteriorating later to
agitation and gross confusion. He had some apparent thought blocking,
disorganization, and delayed responses; he was unable to express himself
clearly, which worsened over time. His thought content reflected delusions of
persecution by the police, great concerns about his family in China, and
desperation about the hopelessness of his arranged marriage. He reported that
these thoughts were intrusive and debilitating. He uttered words of guilt and
regret, as if he was tormented by his own failure (vis a vis his family,
marriage), and he expressed expectation and willingness to be punished. This
progressed to biting his own tongue in an attempt to punish or kill himself. He
had no expressed intention or plan for suicide prior to this overt act. There
was no homicidal ideation or plan. He did not report any auditory or visual
hallucination, but he appeared to be preoccupied with internal stimuli. His
insight was poor, with no understanding of his situation, and he drew no
connection to his previous hospitalization. His judgment and behavior was
disordered, but cooperative with assessment and appeared to be receptive to
help initially. Ultimately, he was unable to carry out these initial intentions
given his gradual descend into dyscontrol / decompensation. His cognitive
ability was limited at the time, predominantly focused on his internal turmoil.
No formal testing was done. His competence to make treatment decisions was
severely questionable as the assessment processed.
Psychiatric Diagnoses:
Axis I Schizophrenia -
paranoid type
R/O
Schizoaffective disorder
R/O
Bipolar disorder
R/O
Acute distress disorder
R/O
Psychosis secondary to general medical condition or substance
Axis II Deferred
Axis III Unknown; non observed
Axis IV Major
social economical stressors: illegal immigrant, no English language skill,
social isolation, financial hardship, lack of follow-up of illness, etc.
Axis V 20
Treatment Plan after
Initial Assessment:
1. Crisis management of agitation and confusion - IM
medications given (Haldol and lorazepam)
2. Emergency admission to Bellevue Hospital CPEP unit -
with the assistance of hospital police and ambulance (usual procedure to call
911).
3. Facilitate follow up by Asian Bicultural Clinic (ABC)
for intake upon discharge from Bellevue.
4. Psychoeducation and support for patient’s family.
Course in Hospital at
Bellevue:
Mr. Z. was treated by his
previous psychiatrist who speaks Mandarin. He became reasonably calm and
oriented, after the emergency treatment with IM medication at Gouverneur. He
felt safe in the Unit. A medical work-up showed elevated CPK and urine
myoglobin, but no clinical evidence of extra pyramidal signs or neuroleptic
malignant syndrome. Lab abnormalities were thought to be isolated findings,
associated with physical struggle during his agitated state. He was medically
cleared a day later. Psychiatrically, he revealed that he believed the police
was chasing after him and that his father was sick in China because of him. He
wanted to die, by biting his tongue, to make things better for himself and for
his family.
He responded to his previous
medications (Haldol) gradually. Clinicians learned that he has been under
tremendous pressure to make money to send home, having worked in a few States,
ranging from Indiana, to Florida in the last few months. He came back to
Brooklyn with a few thousand dollars, hoping to be closer to his sister as his
fear of the police and loneliness intensified. He was unable to find other
employment in New York. A few weeks after his return, he decompensated to the
point he was willing to come to hospital.
After three weeks in
hospital, his intrusive thoughts and delusions lessened in intensity and he was
no longer suicidal. He was discharged, on his previous medications, to the ABC
clinic at Gouverneur.
Sept, 2000
The ABC, part of the
Department of Behaviour Health, is an out-patient mental health clinic serving
Asians, but predominantly Chinese, regardless of immigration status, in Lower
Manhattan. It has three part-time psychiatrists, two full-time psychologists,
and two social workers – probably the largest and more comprehensive and
independent Asian services in New York. It uses an interdisciplinary approach.
The clinic typically assigns a clinician and a psychiatrist for each patient,
handling individual, group, and psychoeducation needs, as well as
psychopharmacology. It also provides community education, and family support
programs. It uses a sliding scale for fees, usually $10 to $40, a payment that
would entitle patients to obtain medications (that are on the Hospital
formulary) if prescribed.
The clinician and
psychiatrist at ABC saw Mr. Z twice, from Sept to Oct, 2000. He appeared calm
and cooperative during the visits, but had constricted affect. He had no
hallucination or suicidal ideation. His medication remained the same as per
Bellevue’s discharge plan. He found a job at a local restaurant and was to
return for F/U in 4 weeks. But two weeks after his last appointment, he was
readmitted to Bellevue.
Late Oct, 2000
Brought to Bellevue directly
by sister, who reported that Mr. Z was suffering decreased sleep, decreased
appetite, increased agitation, and worsening paranoia about Immigration and
police over the previous two days. This occurred despite having been seen and
followed up at the ABC clinic, reportedly on regular medications. He related
that he was feeling very guilty about lending $2000 to a friend a few years
ago, and that he gambled and lost a little bit of money (new information). No
other obvious precipitant otherwise. No suicidal or homicidal ideation
reported. No manic symptoms observed.
Medical work up was normal.
The impression was
questionable compliance with medication and treatment. He had a history of
believing that he was cured once he was well. He was placed on Haldol again,
and responded in a few days, supporting the hypothesis that his deterioration
was related to poor compliance. He was switched to Haldol Decanoate 150 mg IM q
4wks upon D/C. He tolerated the new medication well.
Notable points of this
Admission:
¨
Social worker notes
indicate that there was a communication problem, for patient spoke limited
Mandarin and social worker was Cantonese speaking.
¨
There was
miscommunication between ABC and Bellevue as ABC did not have record of patient
when Bellevue initially called to enquire Mr. Z’s out-patient follow up status.
Bellevue therefore operated under the assumption that patient had no F/U, or
his medication had been reduced or changed.
¨
There was difficulty
arranging F/U given that patient and his sister lived in Brooklyn, which is out
of catchment area of Gouverneur, Bellevue’s usual choice. ABC clinic made an
exception to continue to care for patient.
Current Clinical
Situation:
Nov, 2000
Since discharge, Mr. Z has
moved in with his sister, his primary care-giver at this point. There are some
tension as his sister is working long hours and has to look after her child.
Mr. Z. has come to two F/U sessions at the ABC so far. He appears more
dysphoric, but mostly constricted in affect. His insight has improved slightly,
and he has resigned to treatment and IM injection. He finds his daily routing
boring and depressing, ashamed that he is unable to work or contribute to his
sister’s and his parents. He is eager to find a job soon.
Last week
Mr. Z’s sister called ABC
that he was again not sleeping well, having arguments with her. She wondered if
she should bring him to the hospital. Mobile Crisis was called (where I also
work, but not at ABC directly). I talked to his sister who the next day. She
reported that he is doing better after taking an extra pill of this oral
Haldol.
Some Known Barriers for
Mr. Z to Access Services:
¨
Basic fear of as an
illegal immigrant - “As illegal immigrants, they live in fear, often afraid to
enroll children in school or visit a hospital”, reports E. Rosenthal of the NY
Times. Mr. Z. is one of them. He came to the hospital only after great
encouragement from the sister. His delusions have incorporated his fear of the
police, fear of being sent home. When at Gouverneur, he was visibly disturbed
when the Hospital Police walked by.
¨
Lack of knowledge of
services and support - Mr. Z did not
know the difference between Bellevue and Gouverneur, or what services there is
in Chinatown for mental health. For example, he did not know the ABC clinic at
Gouverneur.
¨
Language – lack of
English and other main Chinese dialects (e.g. Mandarin, Cantonese) skills
dictate Mr. Z and other patients like him go for help in Chinatown, within his
own community, which is relatively new and in great transition, often paying
what ever the shop/doctor demanded.
¨
Cost – Mr. Z’s discharge
plan in 1999 included a doctor whose fee was $200/visit. He never went.
¨
Lack of knowledge in
mental health – mostly poorly educated individuals from a farming communities.
A stoic disposition prevent many of them from recognizing illness and seeking
help.
Other Resources /
Services for Unilingual Chinese Immigrants:
(mostly Mandarin and
Cantonese speaking, rare Fu Zhounese speaking staff in the City at this point)
¨
Henry Street Settlement
Mental Health Clinic (out patient treatment for individuals and family,
day-treatment, services in Chinese available) Accepts all Immigration status.
¨
Lower East Side Service
Center, Mental Health Clinic ( for mental health and substance abusers,
day-treatment, therapy)
¨
Hamilton-Madison House
Mental Health Clinics (psychiatric consultation and counseling)
¨
University Settlement
Consultation Center (individual and group therapy. Chinese and Spanish speaking
staff )
¨
Chinatown Family
Consultation Center (general counseling
services, no psychiatrist)
¨
Lutheran Medical Center
Mental Health Clinic, Brooklyn
(comprehensive out-patient treatment; some Chinese speaking staff
available)
¨
Fort Hamilton Mental
Health, Brooklyn (out-patient services
with Chinese speaking staff available)
¨
Elmhurst Hospital
Center, Asian Mental Health Clinic, Elmhurst ( comprehensive in and out-patient
services with some Chinese speaking staff, city wide acceptance)
¨
Other private practice
providers (charges ranging from $120 to $200, some with sliding scale.)
Some Relevant Questions:
1. What is the responsibility and role of the “system”
toward the caring of the “undocumented immigrants”?
2. What is the role of “Public Psychiatry” toward this
population?
3. How to appreciate the mental health needs of this
population?
4. How to deliver mental health services to this
population?
5. What do we learn from this population in terms of
public psychiatry at large? (of course, Chinese illegal immigrants are not
unique, which leads to: )
6. What can we learn from the experiences of other
“undocumented” populations (e.g. Latinos, Canadians...?)