Changing the Role of Case Management

Peter Zook
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When I became a case manager at a community mental health agency in Cincinnati, Ohio, I had a bachelor’s degree in journalism, 11 months of experience working in the advertising world, and 10 months of serving with AmeriCorps under my belt. I was not the most qualified person for the position, but I was hungry for experience in the mental health field, and I was determined to be good at the job. My supervisor said he hired me because he knew I had the interpersonal skills to do the work, and that he could teach me the rest. Two of the main axioms I learned as a case manager were that mental illnesses are due to chemical imbalances, and psychotropic medications are the solution. As a result, I spent an abundance of energy negotiating with my clients to take their meds or try new ones that the pharma reps encouraged us to promote.

I did witness experiences like a client on the verge of going to jail for unknowingly defacing public property and slandering the police become organized and respectful on a regimen of Zyprexa Relprevv. Conversely, this same client became complacent, gained 30 pounds in two weeks, and grew fearful of ever going off his medications, his quality of life diminished. While I continued to believe and trust in the efficacy of medications, it did not take long for me to realize I was maintaining a bleak status quo for my clients. For many of them, status quo was $710 in SSI, Medicaid spend-downs exceeding $200, food stamps, cramped apartments with smoke-stained walls, and isolation maintained with a cocktail of psychotropic drugs, anti-side-effect meds, sleep aids and pain management pills. One of my clients may have stayed out of jail and the hospital for over a year, and additionally the voices she heard were quieter, but she slept almost 18 hours a day and clenched her fists as a result of her Geodon. Her ex-husband would not allow her to see their 14-year-old son, and her 22-year-old son’s girlfriend refused to let her meet her new granddaughter because she could not take care of herself and needed reminders to shower. Where I wondered, is the quality of life in that? Who would want that to be their status quo?

The challenge of being a case manager is that the above situation is not an extreme scenario; it is the norm, and there are sometimes 40 other clients in similar situations. Combine that with an agency mindset that puts increasing demands on productivity, stressing the use of medication as the first step to recovery, and it is easy to default to the supposed quickest, best “fix.” I was eager to go to graduate school, but anxious about what would happen to my clients. If I left, who would replace me? I knew I needed to gain more knowledge to figure out how to properly address the dysfunctional state of our current mental health system, which would be at the expense of my clients.

After one year of graduate school in social work at Temple University I am a lot more aware of what’s out there, but I’m also keenly aware that I still have a great deal of learning to do. There’s no clear answer, no fast solution, and that’s part of what’s so frustrating. But that challenge should not stop us. There are ways to get involved in policy and affect legislation. There are ways to educate mental health agencies, doctors, nurses and social workers to begin to consider new approaches to treatment. Sure, America is much larger than Finland and may not have the time, resources or buy-in to implement Open Dialogue Therapy treatment, but why should we let that stop us from trying? When will we stop demanding a new normal, and actually create one?

One possible factor to consider could be standardizing education and training requirements for case managers. We would not let just anyone with a random bachelor’s degree, and in some instances a high school diploma, deal with the health care of our children, so why is this acceptable for the mental health population? After one, short year of graduate school I have a clearer understanding of policy and theories that explain social and individual behaviors. I can not only identify the systemic injustices that create pervasive disparities and inequities, but I can explain how they began and why they continue. I have access and exposure to ground-breaking research that is reshaping and informing the way we look at the medical model. If I were not in graduate school I may not have discovered Anatomy of an Epidemic, met Robert at Temple’s psychiatric grand rounds and started contributing to this website. Demanding graduate degrees may be unrealistic and unnecessary. We all have unique experiences, and different careers prepare us for what’s next, but I believe we should set higher, more uniform qualifications for case managers. They are at the vanguard of health care with ample opportunity to be the story-tellers challenging old paradigms. Better quality case management and respect for the position will result in better health care outcomes. To attract better case managers, we will need to pay them more, and that’s a whole other subject.

24 COMMENTS

  1. I actually think you were lucky to have your on the ground experience before your training. I was in the same position, and it helped me learn to smell a rat and not be afraid of calling it what it was. A lot of training is indoctrination into exactly what they told you at your job (which is a lot of why they told it to you). I’m glad to see that Temple is having the sense to have RW and other more provocative presentations, but I’m not sure that’s the case everywhere. Most psych students I’ve talked to tell me they spend an inordinate amount of time on how to do DSM diagnosis, and very little on creating new alternatives.

    Glad you’re out there pitching a new game!

    — Steve

    • Good point. I think going the standard way – being “educated” (read: indoctrinated) and then moving on to work in mental health system usually turns people into unthinking drones disposing drugs few of whom ever stop and ponder if what they are doing is actually helpful and ethical.

  2. My daughter and I now know that case workers, especially social workers, hold a lot of the cards as it regards the fate of people stuck in the mental health system. They can find ‘placements’ in the community to ‘step-down’ facilities which can make the difference between long, illegal hospital incarcerations v.s. discharge.

    They are often hacks. Once a social worker at the private hospital where my daughter was involuntarily held for three months before being shipped off to a state hospital, told my husband that my daughter had a chemical brain imbalance and she would have to take meds for life, like diabetes. I complained about her to her supervisor, but to my knowledge she is still employed by the hospital giving out misinformation to other hapless parents. At the Oregon State Hospital, ditto. Our daughter’s case worker was a hack; never did anything to stand up to the psychiatrist to protect my daughter from over drugging

    Even though many social workers are arguably learning about alternative modalities at a faster rate than MD’s, they generally lack backbone, especially in hospital settings; they usually don’t go out on a limb for their clients or go toe to toe with psychiatrists who are treated like Gods, which they certainly are not, judging by psychiatrists rack record of stupidity, arrogance, and cruelty. The psychiatrist always has the last word in a court of law when it comes to commitment and that word in our experience has had devastating effect on our daughter’s civil rights and mental health and recovery.

    Unless social workers develop enough backbone, as a profession to stand up against MD’s and stem the flow of misinformation and despair flowing from the biological model of mental health, I will generally hold a low opinion case workers and social workers.

  3. Glad you saw it for what it was, (shameful!) because, according to pharma, this woman is one a pharma’s success stories: “One of my clients may have stayed out of jail and the hospital for over a year, and additionally the voices she heard were quieter, but she slept almost 18 hours a day and clenched her fists as a result of her Geodon. Her ex-husband would not allow her to see their 14-year-old son, and her 22-year-old son’s girlfriend refused to let her meet her new granddaughter because she could not take care of herself and needed reminders to shower.”

    • Yup. This is what success looks like from the psychiatric viewpoint. Client on medication, not being jailed or hospitalized, “symptoms” less than what they were or “under control” (not necessarily relieved or resolved.) The quality of life for the patient is not something that is even measured or considered a priority.

      — Steve

  4. Thanks for this post, Peter. Welcome. I’d like to respond to your suggestion; “One possible factor to consider could be standardizing education and training requirements for case managers.” The key question for me is what would they be taught? Education or indoctrination? I’m glad to hear of RW’s visit to your campus, but not aware of his info getting into graduate curriculums much.
    I generally haven’t found a strong relationship between the level of education and the quality of “case-m’gmt” (BTW – people aren’t cases and don’t want to be managed). I’ve seen many people w/ life experience & HS diplomas excel at providing recovery support, often being preferred to their better educated colleagues.

    • Thanks, Wayne! You ask a really important question that we all should be thinking about. I know I certainly don’t have the answer right now, but I believe it starts with an interdisciplinary approach of various professions and schools of thought coalescing to begin discussing best practices of prevention and treatment. By prevention I am referring mainly to larger, macro-level issues like trauma-informed care, in which I see you specialize.

      To your other point, there are some really excellent paraprofessionals. I think people should always be questioning and seeking more information, especially in a field related to people’s health and well-being.

      • Wayne raises good points. I’ve found that advanced degrees in the mental health field tends to equal indoctrination into the medical model. And I’m glad he raised the issue that we are not “cases” and don’t need to be “managed.” So for me the question is not what kind of standardized training should a “case manager” have, but how can we create alternatives to the existing mental health system to provide voluntary support to people in emotional distress that they will find helpful? The existing system pretty much does everything wrong. It takes distressed people who are mostly trauma survivors and subjects them to the very things that make trauma survivors feel worse – forced drugging and attempts to control their daily lives. And Peter, I wonder what you mean when you talk about “prevention” and “treatment”? I don’t have an illness, so I don’t need treatment. And what would have prevented a lifetime of emotional distress would have been stopping child abuse, and a safe caring place for an abused child to heal. The system offers nothing like that.

        • Hi Darby, appreciate what you’ve added to the discussion. By treatment I mean things like psychotherapy, recreational therapy to increase community participation, supportive employment, etc. I believe in taking a client-centered, individualistic approach working with an individual’s self-determined goals. The prevention part is trickier, and I agree, some systems are negligent in that regard. I want to believe there are ways to work towards a more caring society and informed parenting/family-focused style that breaks cycles of abuse.

        • “I don’t have an illness, so don’t need treatment. What would have prevented a lifetime of emotional distress would have been stopping child abuse, and a safe caring place for an abused child to heal. The system offers nothing like that.”

          I’m sorry you were abused as a child, Darby. My child, too, was abused, and it makes me sick child abuse is so prevalent. And you are right, the current system offers no help when it comes to child abuse concerns. To the contrary, when I went in to talk to a psychologist, so I could overcome my denial of the abuse, I ended up being railroaded into the mental health system. According to my medical records, based upon a list of lies and gossip from the alleged child abusers.

          And the current psychiatric system is actually set up to ignore and cover up child abuse by stigmatizing and tranquilizing the victims. This, in turn, keeps the child molesters on the streets raping more and more children. Which brings in more clients to the psychiatric practitioners. And, I’ve learned that the psychiatric industry has been systematically coving up child abuse since Freud.

          We need to get rid of our current system, that blames the brains of victims of crimes and further tortures them with tranquilizers, while aiding and abetting the child molesters. And set up a system of caring for the victims, and punishing the criminals instead.

          And you are correct, child abuse can be overcome when the child has a safe and loving place to heal. My child went from the “school for gifted children,” where we had the misfortune of meeting the child molesters, to remedial reading in the public school in first grade. But since he had a loving place to heal, he ended up getting 100% on his state standardized tests by eighth grade. This greatly confused the school social worker, who wanted to get her hands on him. But I personally knew that the system was upside down and backwards at that point, so found a nice prep school for him to go to for high school. He graduated as the valedictorian.

          Child abuse is NOT a “life long, incurable, mental illness,” and it is sad to see the psychiatric industry now trying to claim it is. And it’s sick the well connected child molesters have the entire system set up to protect them, while further torturing their victims. Our society, from the DCFS to the police to the religions, is way too paternalistic. We do not need an entire faction of the medical community set up to cover up sexual abuse of children for the men.

          Please work towards ending this appalling aspect of the system. Six stigmatized children in the neighborhood that protected the rapist of my child, ended up violently killing themselves while my child was in high school. And no one “in the system” ever bothered to find out whether the children were stigmatized due to child abuse originally. The child suicides were all just “okay, because he was mentally ill.” It makes me sick.

    • Took the words right out of my mouth (typing fingers), Wayne. Judging by the quality of the critical thinking I see at my university, I would suggest that mere credentials don’t equal knowledge, intelligence and understanding. In fact, more education can just lead to more confidence in one’s incorrect assumptions. Seriously, I doubt I will continue my studies for exactly this reason. Regurgitating what one’s told doesn’t seem a likely route to intellectual enlightenment.

  5. Peter, I am glad to hear a voice from the case management perspective. Most case managers are too busy keeping their records in order to even begin to be aware of the problems of the current medical management model. If you happen to take a Social Work History class you will hear the story of Dorthea Dix who was an extremely strong voice for those of us who were institutionalized in the past in horrible conditions. When I went to graduate school it was in Washington D.C where Family Therapy was considered cutting edge and the DSM II was merely a small tool. Saul Alinsky was championed as a role model.There was going to be Social Workers in parishes and in all aspects of the community. Instead Reagan became president and the money stopped flowing into agencies so that innovative programs were stopped and innovative thinking was actively sidelined.Many excellent Social Workers fled the field ( I among them) or went into private practice where they helped middle class people solve middle class problems.
    The underclass was left with – if they were lucky folks like you-or those who could copy an treatment plan from one of the many treatment planning book factories and had little to no clinical skill, talent, or expertise.
    In the 1960’s young people like yourself flocked to Social Work. But the trend has been away from SW as a profession and really who would want to with the huge graduate fee and such piddly community mental health salaries. Even the profession of medicine has lost new talent to Wall Street. This is an unspoken issue the flow of the best and brightest to business.
    Your ideas are good but you still need to cross the divide between us versus them. Why have programs that separate? Inclusion is not part of Mental Health treatment. The treatment programs are virtual Aparthied. The Developmentally Disabled Community has long worked with the inclusion model and push for client independence.

    My county board of Mental Health has knowledge of a alternative treatment model that is based on a private non for profit agency that provides alternative therapies to those undergoing (and those friends and families )chronic and or terminal illness. It could be used for folks and families undergoing stress but no – in the mental health professional community everything has to be tied to medicine.
    We have no quilt for our fallen. There is no make a wish foundation for us. There are no blankets for Mental Illness. In my area NAMI’s walk is picayune compared to that of Race for the Cure and that despite major medical support.
    Professionals need to replicate the studies where people went undercover in hospitals. NAMI members need to spend 3 days on a secured floor. Docs need to sit for 15 minutes in seclusion.
    Social Work used to have a great reputation for being at the cutting edge of social movements. I hope you become one of the old social workers and not the ones who just play the game. Sounds like you have potential. BTW Maryland used to have a non for profit agency that would team a Social Worker and a Attorney to work with a family mainly to fight school issues. That would be another paradigm to think about.
    Good luck.

      • Hi Peter, I am not comfortable at this point in naming the county and or state. I could email you. It’s my idea formed from an agency that offers Reiki, Massage, Art Therapy, Tai Chi, Yoga, Music Therapy., The agency provides group and individual support along with a library and librarian. Medical treatments are up to the client . They make their own personal decision. so you can have non compliant folks who refuse treatment along with those who follow every detail of every medical protocol. The model has been copied several times for various medical concerns. Theses activities are all provided at no cost. My mental health board and the head of the peer support coalition in my state have my business plan but have never responded.Some peer supporters involved with NAMI have seen it as well. Private practice professionals have read through it and have found it a sound and worthwhile project. I developed the idea of helping any family deal with over the top stress. All humans suffer from stress and those who deal with hard stress could benefit from alternative therapies before a mental health crisis occurs. Medication could possibly be avoided.
        I could give your more details privately if you wanted. Not ready to out my county and state and thus myself at this point. I also feel a great responsibility to the agency itself. It offered a great service to my family in a time of great crisis. I don’t want them sullied because of the MH politics of my county.Let me know how you want to approach this!

          • Thanks. One important fact I forget to mention is that friends and family members and or professionals are also invited to partake of the services. This means there is no labeling of patient or caretaker. You take a yoga class and you may be doing a downward dog with a physical therapist or a mother of an end staged young son. There are no labels!!!
            I think this is huge!
            The doctor/patient relationship is kept out of the picture and left to the private and personal realm.
            What a difference this makes!!!!!!!!
            Patients dictate what support and kind of support groups are needed. This allows for those who have chosen to follow medical regimes to have support as well as those who are trying to follow say a homeopath method of treatment. Medical professionals are invited to come and talk when the interest arises.
            This is what healthy supportive help looks like. I strongly feel case management is a form of institutional codependency leading to many folks living lives of quiet desperation having their case manager their only nonfamily – non peer involvement in their lives. Their ability to engage in independence is thwarted by the system. This type organized suppport would be a quiet but strong game changer for all involved in the MH system.

    • “Professionals need to replicate the studies where people went undercover in hospitals. NAMI members need to spend 3 days on a secured floor. Docs need to sit for 15 minutes in seclusion.”
      Excellent suggestion. Actually I’d make it mandatory for every future psychiatrist to undergo a standard “treatment” of being taken to hospital by police (snatched from home or university for everyone to see), forced on the ground and injected with neuroleptics, spend at least one day strapped to the bed and pissing/shitting under him/herself and then being washed by other people including members of the opposite sex. Followed by 24h seclusion (I’d throw in a straightjacket, why not – it’s still being used in some places). At a bare minimum. I wonder how many of them would then be defending the forced treatment. If they still do – I have some ECT therapy for them, if it doesn’t teach them humanity then at least there is a chance they are going to end up so brain-damaged that they never finish school anyway.

  6. Hi Peter – Thank you for this interesting article. Could you explain more about what a case manager does? I guess my question is, what is a case manager, exactly? (Also, I am confused. Are you still working as a case manager?) Good luck with your studies and career.

    • Hi Cataract, great question! Case manager is simply a professional title that various social service agencies began using to open the pool of hirable candidates who were not licensed social workers, and therefore could not be called social workers because of Title Act accountability. Case managers are also sometimes called paraprofessionals. I should note, many case managers do have master’s and/or licenses from different professional disciplines. There are all kinds of case managers who work in hospitals, mental health agencies, foster care agencies, shelters and other professional settings. Their responsibilities vary depending on the location, but mainly they work with a caseload of clients to connect them to resources, help them maintain benefits, and lead successful lives in the community. As a case manager I did everything from create hospital discharge plans, find housing, medication management, make referrals, go for walks and hang out with clients in the community to feel more socially comfortable, plus many other things. It was a very enriching job that taught me a lot. I am no longer a case manager. I am full-time student and research assistant at Temple University.

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