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.

    • 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.

    • “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.