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.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.