Meds, Money, and Manners

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MEDS, MONEY, AN D

MANNERS

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MEDS, MONEY, AN D

MANNERS THE CASE MANAGEMENT OF SEVERE MENTAL ILLNESS

JERRY FLOERSCH

C

COLUMBIA UNIVERSITY PRESS NEW YORK

C

Columbia University Press Publishers Since 1893 New York

Chichester, West Sussex

An earlier version of chapter 6 appeared as “Reading the Case Record: The Oral and Written Narratives of Social Workers,” Social Service Review 74 (2): 169-192. Copyright © 2000 by the University of Chicago. All rights reserved. Copyright © 2002 Columbia University Press All rights reserved Library of Congress Cataloging-in-Publication Data Floersch, Jerry. Meds, money, and manners : the case management of severe mental illness / Jerry Floersch. p. cm. Includes bibliographical references and index. ISBN 0-231-12272-1 (alk. paper) — ISBN 0-231-12273-X (alk. paper) 1. Mentally ill—Care. 2. Mentally ill—Rehabilitation. 3. Mental illness—Treatment. I. Title. RC480.5 .F564 2002 362.2—dc21 2001047740 I Columbia University Press books are printed on permanent and durable acid-free paper. Printed in the United States of America c 10 9 8 7 6 5 4 3 2 1 p 10 9 8 7 6 5 4 3 2 1

For Jeffrey Longhofer

This violent contradiction between the data of experience, from which he could not liberate himself, and which, of course, all his life he knew alone to be real, and his deeply metaphysical belief in the existence of a system to which they must belong, whether they appear to do so or not, this conﬂict between instinctive judgement and theoretical conviction-between his gifts and his opinions-mirrors the unresolved conﬂict between the reality of the moral life, with its sense of responsibility, joys, sorrows, sense of guilt and sense of achievement-all of which is nevertheless illusion-and the laws which govern everything, although we cannot know more than a negligible portion of them-so that all scientists and historians who say that they do know them and are guided by them are lying and deceiving-but which nevertheless alone are real. —Isaiah Berlin, The Hedgehog and the Fox

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Contents

Tables ix Acknowledgments xi CHAPTER 1

Introduction 1 CHAPTER 2

The Formation of Community Support Services 17 CHAPTER 3

The Rise of the Case Manager 42 CHAPTER 4

Strengths Case Management 61 CHAPTER 5

Landscape for a Case Manager: The Carless Mentally Ill 83 CHAPTER 6

Oral and Written Narratives of Case Managers 108 CHAPTER 7

Money 125

viii

CONTENTS

CHAPTER 8

Meds 150 CHAPTER 9

The Helper Habitus: Situated Knowledge and Case Management 180 CHAPTER 10

Conclusion 202 Appendix A. Methods, Data, and Analysis: A Critical-Realist Perspective 215 Appendix B. Continuum of Services 221 Appendix C. Interview Schedule 223 Notes 227 References 235 Index 249

List of Tables

1.1 Six Elements of Helping Social Fields 9 3.1 Client Activity, 1983–1989 46 3.2 Staff Time, 1983–1989 47 3.3 Client Age Distribution, 1983–1989 48 3.4 Four Client Domains 50 4.1 Consumer Strengths Assessment 76 5.1 High County, Kansas: Median Household Income (1989) 101 6.1 February Monthly Goal Plan 113 7.1 Team Flexible Fund Expenditures 142 8.1 Drug Categories and Target Symptoms 152 8.2 Medication Trade Name and Prescription Frequency 154 8.3 Frequency Medication Category 156 8.4 Frequency of Medications per Consumer 157 8.5 Medication Category by Type of Drug User 158 8.6 Double Medication Combination by High and Low User 159 9.1 A Case Manager’s Day 184 9.2 CSS Employee Demographics 197 9.3 Case Managers’ Education 199

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Acknowledgments

I

cannot adequately express my deep gratitude to the case managers, staff, and consumers at High County Mental Health Center. They allowed me into their lives, public and private, often while they faced pressing deadlines and intractable problems. And, unfortunately, because I must protect their privacy, they cannot be personally acknowledged for their many insights and sacriﬁces. I owe a great deal to the faculty and students at the University of Chicago and the School of Social Service Administration (SSA) for creating an intellectual environment that allowed me to explore the broader historical, sociological, and anthropological implications of social work practice. In particular, I wish to thank Leora Auslander, Evelyn Brodkin, Larry Cohen, Elizabeth Durkin, Sarah Gehlert, Penny Johnson, Susan Lambert, Martha Nussbaum, Elsie Pinkston, William Pollak, Melissa Roderick, Margaret Rosenheim, Pat Selmi, Kristi Shook, William Sites, Brenda Smith, George Steinmetz, Michael Sosin, Susan Stone, and Jane Yamaguchi. I am especially grateful to Jeanne Marsh, Sharon Berlin, and Andrew Apter for their encouragement and their thoughtful and timely comments on my evolving project. I am also deeply indebted to the many friends and colleagues who have provided constant advice and encouragement over many years, most especially Morteza Ardebili, Barbara Levy Simon, Ilga Svechs, Donald Stull, Janis Jenkins, Ann Kuckelman Cobb, Steve Koester, and Rush Rankin. In particular, Morteza Ardebili introduced me to critical realism ﬁfteen years ago.

xii

AC KNOWLEDGMENTS

I have consulted my good friend Robert Gross many times, and I thank him for an inspiring and truly interdisciplinary mind. I have greatly beneﬁted from the work of Philippe Bourgois, whose commitment to understanding street-level and local knowledge is original and remarkable. I want to thank my mother, Rita Wietharn Floersch, and my father, Raymond Floersch, for encouraging me to follow my desires; they also contributed much toward meeting my most basic needs. And I owe a special thanks to my colleagues at the Mandel School for Applied Social Sciences, Case Western Reserve University, and to John Michel and Sabine Seiler at Columbia University Press. Finally, Jeffrey Longhofer, my lifelong partner, has made an inestimable difference in my ideas and life by bringing speciﬁcity to my thought, depth to my theorizing, and curiosity to my world. I am indebted to his intellectual spirit, grateful for his kindness, and thankful for our everyday mutuality.

MEDS, MONEY, AN D

MANNERS

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C HAPTER 1

Introduction

I

worked with and studied case managers while they mobilized resources in a mental health organization to enable former hospital patients to continue living in communities. In this book I am primarily concerned with the ways managers use case management theory to produce apartment-dwelling consumers of mental health services. The policy is deinstitutionalization and the practice is case management. Sometimes called “continuum-of-care” or “community reintegration,” case management depends heavily on the policy emphasis given to short stays in hospitals. And successful programs are measured by their capacity to divert patients from hospitals to community resources. Researchers, policy advocates, and practitioners persuasively argue that case management, the linchpin of deinstitutionalization, is effective in linking clients to social, mental, and medical services; it increases functioning, diminishes residential mobility, promotes independent living, and reduces hospitalizations. Practitioners are inundated with books and scholarly articles describing case management models and corresponding outcome and evaluation studies. Encouraged by this accumulation of knowledge, policymakers and scholars now talk about “best practices,” especially those shown to measure up to empirical scientiﬁc standards.1 I add to the case management literature by studying the work of a speciﬁc practice model, and when it fails I ask what the case manager faces. My study of case managers’ daily work explores not only how the policy of deinstitutionalization, community support service, and strengths case management

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I NTRODUCTION

determines practice. I also examine how practitioners produce effects that are of their own making. Yet I am fully aware that policy inﬂuences social work practice. Managed care, for example, has transformed the nature of our practice, just as the politics and economics of liberal social welfare states shape practitioners’ actions (Chatterjee 1999; Handler and Hasenfeld 1991; Lipsky 1980). And the recent scholarly focus on the power to name, to classify, to survey, and to regulate behavior—what has been called discursive or disciplinary knowledge /power—reveals still more constraints on practice and practitioners (Chambon et al. 1999). The literature studying the conditions for practice raises signiﬁcant theoretical, practical, and research questions about the moments where case managers take the products of policy, welfare states, and discursive knowledge and make or do something tactical, personal, and new with them (de Certeau 1984:xii). Although I found the conditions for case management to be immensely constraining, by comparing oral and written narratives, I show that case managers create in ways not determined by or reducible to those conditions. I utilize a unique methodology for studying and writing social work practice, a multimethod, interdisciplinary and critical-realist perspective that will challenge current mental health policymakers and practitioners.

THEORETICAL AND METHODOLOGICAL CONSIDERATIONS

Social workers are often seen as occupying two positions, that of the omnipotent state agent, enforcing policy, rules, and conventions, and that of the oppressed worker, acquiescing to more powerful state structures and agents. Indeed, the criticism and study of social workers ﬂuctuates around these two poles. One practitioner is knowing and reﬂective, the other is dominated and at the same time dominating. I explore the practical and symbolic terrain between what Joel Handler once called the coercive social worker (1973) and Richard Cloward and Frances Fox Piven (1977) called the acquiescent one. Inﬂuenced by anthropological, historical, and interdisciplinary studies, I am reversing the typical way of thinking about and studying social workers. Michel de Certeau (1984) argues, for example, that television programs do not absolutely determine consumers’ taste and opinion. Likewise, subjects of colonial governments and economies are not mere copies of the colonizer (Apter 1992), nor are peasant farmers uniformly pawns of landlords (Scott 1990). Bourgois, in his study of poverty and drugs in Harlem, shows how dealers are agents in their own right (Bourgois 1995), with a full understanding of

I NTRODUCTION

3

the economic logic that shapes their lives and that they in turn use to shape their lives. Just as anthropologists, historians, and sociologists have recovered agency for marginal or oppressed groups—factory workers, women, peasant farmers, ethnic minorities, gays and lesbians, or drug dealers—I believe that the study of social work practice must include the practitioners and account for their agency. Thus we must carefully explore what effects managers produce that are outside the mere conditions of practice. A variety of methodological and theoretical works during the last decade have been aimed at the study of social workers.2 They examine the writings of practitioners to show how social workers dominate through their unmediated applying of policy and disciplinary knowledge/power. In part, this new interest in social work results from the availability of records; with the passage of time sticky conﬁdentiality questions are resolved, and scholars have access to case records from the early decades of the last century. Moreover, social workers are easy research targets as they are the authors of thousands of progress and case notes, treatment plans, social histories, and assessments (Prince 1996; Kagle 1991). Nothing is more seductive to the researcher or journalist than a professional paper trail; indeed, it is imagined that case records reach deep like taproots into a social worker’s subjectivity. For more than a generation now critics have argued that social workers police the masses. The liberal welfare state, according to this view, is a proxy for capitalists who use social workers to manipulate, control, and regulate the unwanted workforce. For scholars critical or unsympathetic to the politicaleconomic argument, Michel Foucault offered a radical alternative account. Foucault’s signature concept, biopower, provided a point of departure for the more recent sociological, anthropological, and historical accounts of practice. Government agents, the theory suggests, use biopower to regulate and routinize everyday social relations; typically, however, this is not accomplished through techniques, knowledge, and classiﬁcatory schemes that give emphasis to the naked force of the state. In short, this is not simply power over. Biopower refers, instead, to the myriad ways that dominant discourses on gender, sexuality, ethnicity, and work, become taken for granted, normalized, and internalized; the individual becomes the subject dictated by the dominant discourse. And it is in this way that biopower includes practitioners’ “dividing practices” (e.g., assessment and diagnostic schemes) that work to place clients either inside a normal circle of behavior or outside, among the abnormal. Inﬂuenced by Foucault, researchers use case records to interrogate the malevolent worker; they produce the service recipient’s subjectivity: the

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I NTRODUCTION

“patient,” the “client,” or the “case.” Consequently, to the earlier political and economic criticisms of practice a new one is added: the social worker as disciplinary agent. Armed with psychological, behavioral, and psychodynamic practice theories, helpers defend the therapeutic state (Polsky 1991), produce tales of wayward girls (Tice 1998), invent kindness to mask the evils of home visits (Margolin 1997), and construct delinquent daughters (Odem 1995) and unwed mothers (Kunzel 1993). Through disciplinary knowledge and power, social workers are ﬁgured as regulators of castaways and their everyday lives. This generation of scholars has argued that the regulation of bodies—emotional, intellectual, and physical—in time and space is an effect of disciplinary knowledge /power (Foucault 1979; Chambon et al. 1999). Though Foucault rarely turned his gaze to the practices of social workers, about the generalized process of discipline and social regulation projecting outward from prisons, he wrote that “the second process is the growth of the disciplinary networks . . . as medicine, psychology, education, public assistance, and ‘social work’ assume an ever greater share of the powers of supervision and assessment” (Foucault 1979:306).3 In a recent application of Foucault to what many claim is the ever-widening sphere of social work, Leslie Margolin (1997) argues that social workers subversively use empathy and friendliness to gain entry into private homes and lives. In short, surveillance and disciplinary meetings, disguised as “home visits,” were “social work’s totem technique, corresponding to the psychometric test of the psychologist or the physician’s prescription” (Margolin 1997:26). I have argued that Margolin’s purblind use of written texts exaggerated the role of disciplinary knowledge in social work (Floersch 1999). About Margolin, Jerome Wakeﬁeld adds, “he eliminates from consideration what social workers actually say to one another or to themselves and focuses instead on examples presented in textbooks and articles, where social workers—as do other professionals—tend to present the most successful examples of practice” (Wakeﬁeld 1998:567).4 In this study, I avoid this by now conventional temptation to reduce social workers and their practices to the disciplinary power of theory (Kunzel 1993; Gordon 1994; Odem 1995; Tice 1998). Although theories and models of practice constitute a basic component of the conditions for practice, without individual actors there can be no practice (Collier 1994). In short, by arguing that case managers make a difference—not as minions of disciplinary knowledge—in the everyday work that produces the effects of deinstitutionalization, I offer a corrective to accounts of social work that reduce practice to theory or disciplinary knowledge/power. I follow the work of those who have

I NTRODUCTION

5

argued that the ideas, cognitive processes, meanings, and experience of social workers generate speciﬁc practices (Berlin and Marsh 1993:11). I started with Michel Foucault’s concepts of biopower and disciplinary schemes and looked at how scholars apply them to the study of social work. The result was my use of the concept disciplinary knowledge/power, which refers in this study to strengths case management. This I did in order to highlight that strengths theory has an inherent quality to produce helping effects; its property to produce effects is denoted by placing a forward slash (/) between knowledge and power (i.e., strengths disciplinary knowledge/power). Most Foucauldian studies of social workers see disciplinary knowledge/power as regulating, controlling, and shaping the behavior and thoughts of clients (i.e., the making of a “case” of mental illness). In order to avoid reducing all practice effects to the disciplinary knowledge/power, I needed a companion concept to capture the case manager’s speciﬁc, contextual, or strategic efforts. In this search, I found Foucault’s discussion of the “speciﬁc”intellectual potentially useful (Rabinow 1984:67–75). Similar to Antonio Gramsci’s organic intellectual, Foucault’s speciﬁc intellectual identiﬁes the knowledge of the particular; that is, knowledge that is grounded in everyday action and is not mediated by a dominant theory or ideology or, in my case, strengths case management. However, in addition to Foucault’s idea of the speciﬁc intellectual, I trace my adoption of situated knowledge/power to a further synthesis of several professional and scholarly works. First, there is the cognitive and learning literature on situated learning; here, learning is contextual, intersubjective, relational, and speciﬁc, not the single or direct extension of intrinsic capacity or teaching theory (Lave 1988; Lave and Chaiklin 1993; Rogoff 1990). Second, professional literature has used the following concepts to denote a practice reality that is separate from theory: practice wisdom (Klein and Bloom 1995); tacit knowledge (Zeira and Rosen 2000; Sternberg and Horvath 1999; Imre 1985); personal practice models (Mullen 1983); reﬂective practitioner (Berlin and Marsh 1993; Schön 1983), deliberative practitioner (Forester 1999), and practitioner-researcher (Hess and Mullen 1995). And third, anthropologists use the terms “local knowledge” (Geertz 1983) and “situated lives” (Lamphere et al. 1997) to refer to particular cultural knowledge, and the feminist philosopher Donna Haraway (1988) calls for an understanding of women’s situated knowledge. Examining how these conceptualizations variously name personal knowledge, I saw agreement that situated knowledge/power pointed to realities disciplinary knowledge/power could not capture or represent; that is, practitioners produce local, speciﬁc, contextual, or situated knowledge in practice. Moreover, in contradistinction to the a priori disciplinary knowl-

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I NTRODUCTION

edge, these various conceptualizations see situated knowledge as dependent on activities or as knowledge in action. I have not operationalized, according to positivist methods, the terms disciplinary and situated knowledge/power. Like others, I am using these in a heuristic description of the holistic work of practicing professionals. Nor am I referring with these concepts to a strict polarity between two powers, theories, or logics; instead, I show that case managers use both types of knowledge/power. I use historical data in chapter 3 to argue that an early form of case managers’ situated knowledge was absorbed by the scientiﬁc community and then transformed into strengths case management disciplinary knowledge. Thus, disciplinary and situated practices are often integrally related. It is in this manner that I show that case managers can be viewed as Foucauldian “speciﬁc” and “universal” intellectuals (Rabinow 1984:67–75). By using ethnographic methods, I demonstrate that Foucault’s speciﬁc intellectual uses situated knowledge/power, while the universal employs the disciplinary. And most important, I show that situated knowledge/power is found in the oral narratives of case managers. I will show that while disciplinary knowledge/power tends to absorb indeterminacy into universal categories, social workers also use situated knowledge/power. Moreover, the multiple (and often indeterminate) causes of mental illness make responses to it continually negotiable. Situated practices may complement disciplinary ones, or it may resist them; it may be consciously or unconsciously deployed; alternatively, it may be subsumed by the disciplinary. Situated and disciplinary practices are both constraining and productive forces, controlling and also caring (Wakeﬁeld 1998). I show not only how these combined knowledge/power systems produce the same controlling and caring outcome. I also show their distinct conceptual signiﬁcance and usefulness. None of the effects of disciplinary or situated practices, however, can be known a priori (Apter 1992:213–226). Situated knowledge /power must be empirically studied; it could be different from and contrary to the disciplinary—in this case it might resist the desired outcome. Or it could be different from but complementary to the disciplinary—in this case it has a neutral or supporting inﬂuence upon the desired outcome. A third possibility is that situated knowledge /power could be a copy of the disciplinary—in this case both work together to achieve the desired outcome, that is, where policies, organizations, and the disciplinary practice produce all desired effects, practitioners have no reason to create or invent. I will show that case managers used situated knowledge/power and acted in the manner of the second possibility. The study of situated knowledge has been overshadowed by sole interest in the Foucauldian idea of an omnipotent disciplinary gaze. Yet, even the hospi-

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7

tal nurse, psychiatrist, and social worker were incapable of ﬁnding a single standpoint (the panopticon) that provided absolute insight, monitoring, and assessment. Susanna Kaysen, in Girl Interrupted, nicely illustrates how she acted as an adolescent patient to checkmate the gaze of the nurse. She writes, “We were sitting on the ﬂoor in front of the nursing station having a smoke. We liked sitting there. We could keep an eye on the nurses that way” (1993:65). Patients secretly passed notes and hid medications in the cheeks of their mouths. Similarly, social workers escape the gaze of the administration, policy, and disciplinary knowledge/power. I show that when strengths case management fails to produce effects, situated practices make up for the model’s limitations. Scholars, neglecting to see the obscured oral narrative, the empirical site of situated knowledge/power, miss its signiﬁcance by studying only the written texts, the empirical site of the disciplinary knowledge/power. I will show that oral situated practices are not just a shadow of the written disciplinary powers, and although situated practices are difﬁcult to research, they have unique powers with corresponding effects. In sum, I use a variety of qualitative methods and a critical-realist perspective5 to show that case managers use two types of practice power: disciplinary and situated. Together they form a totality of practice. I challenge scholars of practice to calibrate their conclusions to both the readily seen (written text) and the less visible (oral narrative) facets of social work power. I have placed the disciplinary practices of case managers within social ﬁelds; this provides for a more nuanced treatment of the systemic cultural and political features of strengths case management (see ﬁgure 1, appendix A).

SOCIAL FIELD

Knowledge/power schemes are not ahistorical, nor are they independent of society. I use Pierre Bourdieu’s concept of the social ﬁeld to understand the history and sociological production of knowledge/power. Social work practice is inextricably connected to national, state, and local policy. Mental health policies create boundaries that constitute a ﬁeld of practice that ﬁlls up with unique kinds of knowledge/power schemes. And the latter deﬁnes who the helpers and recipients will be. For example, the mental hospital was a unique social ﬁeld formed with nineteenth-century understandings and policies. Accordingly, the medical model deﬁned the power relationship between the psychiatrist and the patient (Braslow 1997). During the last forty years, however, a new social ﬁeld gradually replaced the hospital: community support services (CSS). This ﬁeld deploys case management as a knowledge/power

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I NTRODUCTION

scheme and deﬁnes a new social relationship, that between case manager and consumer. Although case managers are brought into the project of deinstitutionalization, it is not a project of their own choosing. A social ﬁeld called CSS structures the conditions for case management. For Pierre Bourdieu, a ﬁeld may be deﬁned as a network, or a conﬁguration, of objective relations between positions. These positions are objectively deﬁned, in their existence and in the determinations they impose upon their occupants, agents, or institutions, by their present and potential situation (situs) in the structure of the distribution of species of power (or capital) whose possession commands access to the speciﬁc proﬁts that are at stake in the ﬁeld, as well as by their objective relation to other positions. (Bourdieu and Wacquant 1992:97)

Bourdieu identiﬁes religious, artistic, educational, and economic social ﬁelds, among others. To this list I add community support services. The network of power relations that organize and reproduce community support services bind the disciplinary and situated practices of case managers; these relations have juridical force—in my study this force derives from the Kansas 1990 Mental Health Act—and they are also administratively determined by the mandated use of strengths case management. The CSS ﬁeld is ﬁlled with practice theories (disciplinary) as well as with local (situated) meaning and experience. Here I am cautious not to use social ﬁeld as a conceptual receptacle for the purpose of reducing disciplinary and situated practices, that is, these practices have relative autonomy from a social ﬁeld’s policy and administrative power. The relationship between case managers and service recipients is thus conﬁgured by national and state mental health networks that name the problem (e.g., patients’ dependency on hospitals), create systems of organizations, and employ speciﬁc kinds of workers. Case managers’ practices only make sense—and can only be made sense of— when placed in a sociohistorical relation to the CSS social ﬁeld. I argue that state mental hospitals and community support services uniquely combined six elements of helping social ﬁelds; in table 1.1, I compare these elements. Spatially, hospitals were organized as laboratories; in the clinical environment patients were conﬁned, studied, diagnosed, and, one hopes, cured (Foucault 1973). Here, as Foucault describes in regard to prisons, there is “uninterrupted, constant coercion, supervising the processes of the activity rather than its result and it is exercised according to a codiﬁcation that partitions as

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TABLE 1.1 SIX ELEMENTS OF HELPING SOCIAL FIELDS ELEMENTS

1. 2. 3. 4. 5.

Space Time Mobility Economic Disciplinary knowledge

6. Helper and service recipient

MENTAL HOSPITAL

COMMU N ITY SU PPORT

SOCIAL FIELD

S E RV I C E S S O C I A L F I E L D

Closed clinic Institutional Bodies ﬁxed Socialized economy Medical/psychiatric Doctor and patient

Open community Personal and private Bodies in motion Commodity, market economy Pharmacological-medical and strengths case management Case manager and consumer

closely as possible time, space, and movement” (Foucault 1979:137). Indeed, hospitals were designed to remove patients from the pathologies and stresses of urban life or the hazards of living in communities (Grob 1994). In the hospital space, a closed therapeutic environment, patients moved through institutional time, not personal or private time. Moreover, patients gained access to daily necessities—shelter, food, and medicines—through a centralized, socialized, hospital economy, where needs were met at a single and uniﬁed site. Medical and psychiatric knowledge was aimed at underlying pathologies; the helper was named doctor and the service recipient was known as patient. In the CSS social ﬁeld, space, time, mobility, and economics were so radically reorganized and reconstituted that new disciplinary knowledge and practitioners became necessary. Deinstitutionalization loosened the patient’s ties to the closed system of the hospital, and policy advocates believed that the open system of the community was good for personal growth. In addition, CSS advocates claimed that life regulated by personal time, as opposed to institutional time, was therapeutic. Once freed from the constraints of the hospital, former patients became “consumers” of commodities, including mental health services. And here was the rub: making patients into everyday consumers was not possible within the time frame of the ﬁfty-minute, clinicbased, psychotherapeutic hour. Many of the former patients required continual monitoring and assistance with paying bills, shopping for groceries, taking medications, and socializing. In this new and open environment practitioners, former patients, and families experienced the commodity and social service

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economies as fragmented, and by the end of the 1970s, together with the National Institute of Mental Health, all reached the same conclusion: a new practitioner and disciplinary knowledge was needed to screen, link, and monitor the consumers as they moved through the open systems of community life. With this sociological and historical understanding, I began my ethnographic study of case managers.

THE SETTING

High County Mental Health Center6 is located near the crossroads of the Oak Springs branch of the historic Santa Fe Trail and Fort Harrison and Fort Smith roads. In 1856 Oak Springs was renamed Oaklawn. Community Support Services (CSS), a branch of High County Mental Health Center, is located one mile south of Oaklawn, Kansas. The mission of CSS is to support and teach individuals in developing the skills and resources they need to be successful in the living, learning, working, and social environments they choose. The desires, goals, and aspirations of the people we serve are of paramount importance in guiding this process. (High County Mental Health Center 1997)

The mentally ill, put in motion by a policy called deinstitutionalization, negotiate the exurban world near the old Santa Fe Trail, from the state hospital to High County Community Support Services, then outward to homes, apartments, and center-operated residential facilities. Each client, with an assigned case manager, is linked to food, apartments, transportation, and health care. Advocates of deinstitutionalization claim that the journey from the hospital to the sprawling exurban spaces of High County is about the realization of unfulﬁlled dreams. At the national level, critics of the policy accuse it of having produced a lost population of underserved, neglected, jailed, and often homeless individuals (for a recent discussion, see Torrey 1997). Yet despite its detractors, deinstitutionalization in Kansas and most states is a reality. Indeed, on May 16, 1997, the Kansas Topeka State Hospital closed its doors, and the region’s only remaining state-run hospital allocated only ﬁfteen beds for the 400,000 residents of High County. Hospital closure and downsizing required Herculean efforts: 400 CSS clients, along with their thirty- ﬁve case managers, travel nearly 750,000 miles annually—thirty revolutions around the earth—to and from CSS, apartments, grocery stores, banks, welfare ofﬁces, and numerous other suburban locations. Little did the

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architects of deinstitutionalization realize that resettling the suburban mentally ill would become, de facto, a transportation policy. In the early 1980s Kansas community mental health centers provided few services for the “chronically mentally ill.” While High County Mental Health Center had a program for such clients, it was clearly peripheral. For example, in 1981 the center employed no case managers, it lacked a housing program, and psychosocial services amounted to little more than a few afternoon “talk groups.” High County made its ﬁrst serious overture to the ex-hospital population during the early Reagan years, when federal monies were sent directly to state treasuries via block grants. For ideological and political reasons, state administrators acknowledged that services to the most seriously mentally ill were underfunded and subordinate to “worried well” clinical services. Thus, Kansas ofﬁcials initiated pilot projects aimed at expanding the scope of community support services philosophy and practice. As a result, by 1987 High County had ﬁfteen case managers, had allocated ofﬁce space for services, and had established a rudimentary psychosocial program. Structural change was forthcoming in the form of the 1990 Kansas Mental Health Act. The latter mandated community support services, reoriented funding to assure its implementation, and empowered street-level workers. The new law, for example, gave social workers with master’s degrees along with psychiatrists authority over involuntary commitment procedures, something formerly granted only to psychiatrists. By 1997 High County had nearly 300 employees distributed among three programs: clinical services, medical services, and community support services. An executive director, appointed by the county commissioners, was accountable to a board of directors.7 Each of the three divisions had a director, and within CSS there were several programs: case management, vocational, psychosocial (a residential care facility was phased out in 1994), and a crisis case management team. Subprograms of CSS were supervised by social workers with masters’s degrees, and most case managers had bachelor’s degrees. I chose High County Mental Health Center as the site for my research for two reasons. First, in Kansas and High County ample resources and political will provided an optimal environment for case management. For example, common wisdom suggests that it is desirable for case managers to have no more than ﬁfteen clients. In High County, not only did the thirty-ﬁve CSS managers have the expected caseload, but their median salary ($35,000) was respectable enough to minimize burnout and discourage turnover. This assured that clients would have a continuous relationship, a variable considered crucial to successful case management (Axelrod and Wetzler 1989;

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Bigelow and Young 1991; Chamberlain and Rapp 1991; Dietzen and Bond 1993). Moreover, of the mental health center’s overall 1997 budget, a robust 39 percent (ﬁve million dollars) of the total (thirteen million dollars) was spent on community support services; the center’s clinical services allocation was 30 percent (four million dollars). This marked a dramatic turnabout; advocates for the mentally ill had been critical of the national tendency to provide clinical services primarily to the “worried well” as opposed to those with chronic mental illness (Torrey 1988:228–232). At High County the three requirements of successful case management were satisﬁed: (1) reasonable caseload, (2) staff continuity, and (3) adequate community resources. In this organizational environment, rich in resources and unhampered by contradictory funding policies, I did not have to concern myself with how an underfunded project constrained practitioners. In short, High County had produced optimal conditions for case management. There was a second reason for my choice of this site. I had worked as an emergency crisis counselor and housing supervisor—from 1981 to 1994—in building crucial components of High County Community Support Services. In my work as a case manager I was enmeshed in the practices that shaped the everyday lives of workers. But perhaps most important, I was a familiar face; I had earned the respect of clients and staff; and mutual respect produced a curiosity about my research. For these reasons I was easily absorbed into the life at CSS.

DEVELOPMENT OF THE CSS SOCIAL FIELD

Displacing the hospital as a social ﬁeld in Kansas and replacing it with community support services required top-down (national and state bureaucracies) and bottom-up (ﬁeld practitioners) efforts. As policymaking goes, deinstitutionalization covers everything: from the idea to empty beds, from debate to agenda setting, from legislative action to implementation (Kingdon 1984). I do not, however, marshal historical data on CSS, Kansas, High County Mental Health Center, and the National Institute of Mental Health (NIMH) in chapters 2 and 3 to conﬁrm or negate any particular theory about policymaking. In these chapters it is my purpose to show that once the CSS social ﬁeld was formed, disciplinary knowledge necessarily followed. In chapter 2 I argue that the “principle of normalization” and the fragmentation of mental health services are among the primary historical roots of CSS and case managers’s roles.

I NTRODUCTION

13

RISE OF THE CASE MANAGER

Once CSS was conceptualized, NIMH and Kansas built organizational capacity. In chapter 3 I describe the bottom-up effort to build a viable county program, especially through the incremental rise of the case manager. Although the central ﬁgures of hospital care—the nurse and psychiatrist—were not altogether displaced in the new social ﬁeld, their ruling and pivotal positions gave way to that of case managers and their advocates, policymakers, and related practitioners. In this chapter I describe how High County (in the 1980s) used ofﬁce-based partial hospital program monies to surreptitiously support individual case management in the community. A “learning by doing” practice emerged; the ﬁrst case managers were not trained in any speciﬁc disciplinary knowledge. And the early period marked the simultaneous use of “client” and “consumer” to name service recipients, a dualism that persists to the present day.

STRENGTHS CASE MANAGEMENT

Together with colleagues, Charles Rapp, a professor of social work at the University of Kansas, created a veritable cottage industry for the testing, formulation, and dissemination of strengths case management. Through scientiﬁc production processes, he coded the situated practices of case managers in the 1980s to produce a model of practice named strengths. The acceptance and legitimation of the strengths model is indicated today by numerous national and international conferences and workshops where it has been discussed. In 1984 High County became one of Rapp’s research sites. It proved a fruitful and enduring relationship. Of the case managers I studied, 90 percent had attended strengths workshops sponsored by the University of Kansas School of Social Welfare. Only recent employees had not attended. Indeed, training in strengths management was the only common element in the work and educational histories of the case managers I studied. In chapter 4 I discuss strengths case management. Although in dozens of articles, research reports, and books (Rapp 1998) strengths management has been described and defended, none use ethnography to understand its application. Thus I began my research by attending a “Basic Strengths Workshop.” Here my aim was to develop from the outset an ethnographic understanding of the normative tenets and language of strengths management.

14

I NTRODUCTION

LANDSCAPE FOR A CASE MANAGER

Kansas state hospitals, like many, were bounded by pastoral grounds and treelined drives and had a central admission ofﬁce, ward walls, corridors, and locked doors. Wards were locked to keep those inside from getting out. The use of space to segregate patients from communities was consistent with the nineteenth-century romantic notion that isolation from dirty, noisy, and crowded industrial landscapes fostered well-being (Grob 1994). Today, in a complete reversal, CSS’s doors are locked at night, not to keep consumers from getting out but to keep those outside from getting in. The use of suburban space now complements the idea that communities are healthy and that segregated hospitals foster dependency. In chapter 5 I describe case managers’ experiences with an eye toward understanding the unique conﬁgurations of time and space and the physicality of suburban High County. With respect to studies of deinstitutionalization and, perhaps, social work practice more generally, I bring a novel perspective to the study of the work of helping. Discussions of space and landscapes—as opposed to the concept policy environment—are borrowed from recent literature in social geography and sociology of space (Soja 1996; Zukin 1991; Jackson 1984). In the production of space we reproduce social relations. Space, in short, is not a mere abstraction that we work around and through; indeed, spatial arrangements help deﬁne the nature of practice. Case managers must move in and out of suburban space in order to fulﬁll the mission of CSS and the strengths model to discover “naturally occurring resources.” Negotiating space is also a source of irritation for the situated practitioner; by staying within the boundaries imposed by geopolitical landscapes, strengths management must absorb and deﬁne as “natural” what situated practice ﬁnds unnatural—the time it takes to drive (annually, nearly 12,000 miles per case manager) from home visit to grocery store to pharmacy to endless destinations. It is in this way that the suburban landscape uniquely marks case management.

MEDS, MONEY, AND MANNERS

To better understand the relationship between disciplinary and situated knowledge /power I draw in chapter 6 on the work of the anthropologist Victor Turner (1974). He argues that in moments of crisis social structure is revealed and social drama unfolds. When case management did not produce the hoped-for effects, I investigated the responses of practitioners. I present

I NTRODUCTION

15

an unfolding crisis and social drama in one intensive case study as an instance where medicine, CSS, and strengths case management fail to produce the desired effect of an independent, apartment-dwelling consumer. It is in crisis and social drama that the structure of the relationship between disciplinary and situated practice is most transparent. Two types of data were used in chapter 6. First, I examine the written texts produced by case managers. Here, I explore the kind of textual subject produced in the recording of a case. Second, I use ethnography to capture the spoken language of the case managers. By combining the written and spoken narratives I produce a narrative that represents how case management is actually produced. And of this I asked: had one narrative been subtracted, what part of the analysis would have been silenced? In answering this question I point toward a critique of the sociological and historical literature that depends solely on the written texts of practitioners. The strengths disciplinary scheme identiﬁes seven primary functions of management—engagement, assessment, planning, implementation, collaboration, counseling, and graduated disengagement. In addition, situated practice functions to support three life domains: medications (meds), money, and manners. In chapters 7 (“Money”) and 8 (“Meds”) I describe how the social ﬁeld and strengths bind case managers to service recipients. In the unending delivery and monitoring of medications and in the daily, weekly, and monthly supervision of spending, the case manager’s body is subject to the very same patterns of routinization and regularization as are the bodies of service recipients. Strengths management, however, ﬁnds itself conspicuously empty-handed when medication does not work or consumers do not live within their ﬁnancial means. It seems the situated knowledge/power is pressed into action when strengths case management is ineffective. Thus, the day-to-day particulars of taking and administering medications produce a situated practice I call “effect interpretation.” And with regard to money, a situated moral economy of case management works to produce “real” consumer identities, especially ones that recognize a good shopping bargain.

THE HELPER HABITUS

Strengths case management is derived from administrative mandates, state policy and law, and academic professionals. But what is the source of situated practice? Does the idea of a speciﬁc and situated practice mean that every case manager is unique in his or her practice? The specter of the independent

16

I NTRODUCTION

actor, voluntarism, or methodological individualism—actions without conditions for action—seems unavoidable. Contrariwise, in chapter 9 I will show that case managers shared a situated language and practice. I posit that a case manager helper habitus and the time and space constraints of the CSS social ﬁeld account for their tactical language. In chapter 9 I use Pierre Bourdieu’s mediating concept of habitus to revisit an old problem that the case managers situated practice posed: the “friendly visitor.” The earliest social work academicians appropriated the term “friendly visitor” from the precursors of nineteenth-century social workers. The term helped deﬁne the project of professional education by separating the untrained (family visitor) from the college-educated (Lubove 1965). The dispositions, or habitus, of the nineteenth-century friendly visitor—practical taxonomies, for example—are not unlike those of late twentieth-century case managers. Often, different epochs present unique helping projects that uniquely reconﬁgure the friendly visitor or helper habitus. For Bourdieu, a habitus is an embodied set of dispositions produced in social ﬁelds. Most important, the dispositions, through the habitus, are transposable to other ﬁelds. Bourdieu writes that the habitus continuously generates practical metaphors, or, more precisely, systematic transpositions required by the particular conditions in which the habitus is ‘put into practice’ (so that, for example, the ascetic ethos which might be expected always to express itself in saving may, in a given context, express itself in a particular way of using credit). The practices of the same agent, and, more generally, the practices of all agents of the same class, owe the stylistic afﬁnity which makes them a metaphor of any of the others to the fact that they are the product of transfers of the same schemes of action from one ﬁeld to another. (Bourdieu 1984:173)

With interview data, I show that case managers transpose teacher/student and parent/child dispositions to the CSS ﬁeld. Moreover, from their middleclass backgrounds and the surrounding suburban landscape, they transpose ideas of progress, goal-oriented achievement, and ideas about “living by the rules.” These concepts—habitus, disposition, and transposability—would not be so compelling to me if it had not been for Bourdieu’s understanding that through the habitus dispositions affect and are affected by the contexts where they are “put into practice” (Jenkins 1992:78). Practitioners make something new because the social ﬁeld of community support services requires case managers to put helping theory into practice.

C HAPTER 2

The Formation of Community Support Services

S

ocial work has long had an interest in challenging and dismantling congregated care or residential institutions. Among the names given to such projects are “placing out,” “aftercare,” and “community support services.” Social work carved out of the liberal welfare projects of the late nineteenth century a workplace between the surrogate home—the residential institution—and the “real” home, the one of “person-in-community.” Deinstitutionalization is not new to the profession of social work; indeed, the project to empty institutions has deﬁned the profession for a long time. The eighteenth-century almshouse was a universal institution; it clustered the aged, the physically and mentally disabled, and the poor as well as other outsiders at one site. The project of reclassifying and then separating out the disparate groups of the elderly, inﬁrm, and mentally ill began in the early nineteenth century and was largely completed by the 1920s. The breakdown of the almshouse, the ﬁrst project of deinstitutionalization, produced categorical institutions: the orphanage, the home for the aged, the charity organization society, the house of refuge, the home for unwed mothers, the boys’ and girls’ home, and the mental hospital (Trattner 1999; Katz 1986; Patterson 1994; Lubove 1965). With each emerging institution there developed unique locations, spatial arrangements, and practitioners, each with professional languages to classify and control its particular inmates. Recent research shows that of the professions coming to the fore during the Progressive era, social work crossed most institutional boundaries. For example, in Andrew Polsky’s work, The Rise of the Therapeutic State (1991), social workers helped deﬁne

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juvenile detention and related court services; in Regina Kunzel’s, Fallen Women, Problem Girls (1993), they counseled unwed, pregnant women; in Mary Odem’s, Delinquent Daughters (1995), social workers deﬁned and then managed female, juvenile correctional homes; in Elizabeth Lunbeck’s, Psychiatric Persuasion (1994), they helped construct one of the ﬁrst hospital-based, outpatient clinics; and ﬁnally, in Linda Gordon’s work, Pitied But Not Entitled (1994), social workers used Aid to Dependent Children to keep children and women at home. In sum, social work provided the disciplinary knowledge for the categorical social welfare institution. Andrew Abbott’s systemic theory of professions supports my thesis that nineteenth- and twentieth-century deinstitutionalization projects contributed to making social work a profession. For Abbott, professions emerge out of objective and subjective realities; in turn, the subjective has three modalities of action: diagnosis or classiﬁcation, inference or reasoning, and treatment or taking action (Abbott 1988:35–40). Colligation, the ﬁrst step in diagnosis, establishes the rules of evidence and the tools used to classify a problem or assemble a picture. The second step, classiﬁcation, is the profession’s own mapping of its jurisdiction; it represents a taxonomy or dictionary of the work items that professions see and recognize. Architects of strengths case management developed a unique classiﬁcation system of “wants.” Attaching action to diagnosis requires reasoning or inference, the second modality of work. What reasonable action produces change? An absolute one-to-one relationship between diagnosis and treatment is antithetical to professional expertise; if no reasoning (inference) is required to identify the appropriate treatment, then administrative standards lead to routinization and deprofessionalization (Abbott 1988:45–48). If mental health problems had straightforward textbook and formulaic solutions, no inference would be required. For the professions, human problems are not easily treated and many seem intractable; thus, an important step toward treatment is inference (Abbott 1988:49–52). Theorists of strengths management accordingly reason that change is mostly a product of identifying agreed upon positive abilities and competencies in communities. Treatment, the third subjective property of social work, requires taking action to resolve problems. Depopulating mental hospitals has required the creation of a new social ﬁeld within which professional work is conducted and legitimated. Community support services became the new social ﬁeld incorporating one or several theories of case management, which differ in their capacity to diagnose, infer, and treat. And it has largely been left to

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19

the profession of social work to train the workers that ﬁll the CSS social ﬁeld. Thus, for paradigms to become recognized, diagnosis, inference, and treatment practices must perform different kinds of work. Psychoanalysis, family systems therapy, cognitive psychology, behaviorism, task-centered approaches, and strengths case management each articulate a different combination of the subjective properties of work. To legitimate professional work, professional schools, according to Abbott, organize and teach standard paradigms: “Academic professionals demonstrate the rigor, the clarity, and the scientiﬁcally logical character of professional work, thereby legitimating that work in the context of larger values” (Abbott 1988:54). The early history of social work has been described as competing paradigms among professional schools: problem solving (University of Chicago), functional (University of Pennsylvania), and diagnostic (Columbia University). “In 1993, as part of the CSWE1 reaccreditation study,” the University of Kansas School of Social Welfare, “adopted the strengths perspective as one of its guiding curriculum themes” (Rapp 1998:xv). Establishing a claim or identifying the link between a profession and work—a link Abbott calls jurisdiction—is a crucial step in professional development. Public, legal, and workplace arenas are the sites where practitioners make such claims and in this chapter, I show how community support services were given jurisdictional rights to the workplace claim of depopulating hospitals. As a profession, then, social work was well-established to expand into and accommodate the second project of deinstitutionalization: the removal of residents from the categorical institution and their placement or return to families and communities of “origin.” And it is with this incomplete second project that I examine the formation of the social ﬁeld aimed at keeping the mentally ill out of hospitals and in communities. Though CSS in Kansas is an ongoing project of the policy to depopulate state mental hospitals, it is not my purpose—nor is it necessary—to weigh one theory of policymaking against another. Here, I am concerned solely with establishing that the policy of emptying hospital beds created the need for a new social ﬁeld. And this approach, conceiving of CSS as a social ﬁeld, is new to the study of deinstitutionalization. In this chapter I discuss the contribution a study of disciplinary and situated practice makes to our received understandings of deinstitutionalization, the social policy of deinstitutionalization and how it produced the conditions for community support services, and the rise of CSS in Kansas.

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DEINSTITUTIONALIZATION

Deinstitutionalization policy and practice offer a unique opportunity to examine how disciplinary and situated knowledge reproduce the community as a site of practice as opposed to a hospital social ﬁeld. Within the professional discourse, institutions and their agents come to imagine, regulate, and control behavior (Foucault 1965). Problem identiﬁcation requires the use of subject categories to name and classify the “it” that practitioners within a social ﬁeld seek to address. Barbara Nelson points out, for example, how the naming of child abuse as a medical problem was crucial to national agenda setting (Nelson 1984). William Graebner, in A History of Retirement (1980), shows how the subject categories “aging,” “elderly,” and “retired” effectively organized support in late nineteenth-century business, political, and popular culture. In short, categorical identiﬁcations are the syntax of political rhetoric (Stone 1988; Edelman 1988). Asylum policy coincided with the popular notion that mental illness was a kind of uncivilized madness. Segregated and residential treatment followed. However, most scholars have examined the disciplinary knowledge of the categorical institution, and though extremely useful and provocative, this body of work must be further developed by applying it to community support services. In fact, by focusing only on the residential institution, scholars have altogether missed the signiﬁcance of social work’s almost exclusive claim to the work of deinstitutionalization. Most studies of mental health policy have ignored the practices social workers use to assure implementation. The academic literature either extols the virtues of community support programs or discusses neglect of the mentally ill. Analysts fail to imagine how professional discourse and practice, at every level of the policy process, inﬂuence outcomes.2 Instead, studies of deinstitutionalization focus on (1) how a fragmented polity failed to set a coherent mental health agenda (Marmor and Gill 1989; Bloche and Cournos 1990), (2) how a fragmented delivery system (sometimes believed to be an outcome of the former) made it difﬁcult for clients to obtain services (Frank et al. 1988), (3) how historically (and currently) the system was biased toward hospital care (Grob 1991; Rochefort 1989:12), (4) how community mental health centers, as imagined by their creators, failed at the implementation of the 1963 legislation (Foley and Sharfstein 1983), and ﬁnally (5) how the right mix of ideas and inducements never produced a coherent and communitybased system (Weiss 1990). I review Weiss, Marmor and Gill, and Scull (1984)

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21

to demonstrate that analysis of disciplinary and situated practices will enrich the study of deinstitutionalization and related mental health policies. Janet Weiss has examined how the National Institute of Mental Health (NIMH) used ideas and inducements to encourage local and state ofﬁcials to switch from hospital to community care (Weiss 1990). In the absence of a federal bureaucracy—like the Department of Agriculture with regional and local ofﬁces to set and implement policy—she asked how, in 1948, NIMH initiated and implemented a mental health policy. Letters and records, according to Weiss, show that ofﬁcials used economic inducements to disseminate new ideas. Her analysis centers on institutional capacity: leadership politics, ideas among NIMH ofﬁcials, and ﬁnancial inducements (March and Olsen 1984; Robertson 1993). Together, policy instruments and the proper mix of institutional conditions at NIMH gradually led local and state ofﬁcials to new ways of thinking about mental health treatment. Though she describes the institutions and agents (NIMH and physicians), the disciplinary and situated practices used to advocate for community programs are missing from the analysis. In the same way that nineteenth-century mental hospitals were set in opposition to public neglect and the almshouse, in the 1960s organizations like Thresholds, Fountain House,3 and community mental health centers were constructed as alternatives to public hospitals. NIMH intentionally bypassed state governments in order to fund local notfor-proﬁt groups. Ofﬁcials feared that state legislators would continue to fund hospitals with NIMH money (Grob 1991:239–272). What would then happen to community programs? These newly created “oppositional” institutions provided practitioners with a structural means to launch a systematic attack on hospitals. Absent in Weiss’s account, community-based disciplinary knowledge (e.g., case management, medication groups, day programs, and supportive housing strategies) made competition with the hospital possible. Emerging community support services advocates reconceptualized and reorganized the six elements of the hospital social ﬁeld—space, time, mobility, relationship between helper and service recipient, economics, and disciplinary knowledge (see table 1.1). New understandings and associated languages emerged in the situated practices of spaces like Thresholds and Fountain House. Here, practice took place at community sites; it was calibrated to community time and was not predicated on immobility. Its service recipients’ became “members” of clubhouses, and as members they were responsible for meeting their daily living expenses. Although in their early history Thresholds and Fountain House

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had not formalized a new disciplinary knowledge, leaders envisioned practices that opposed the medical, psychodynamic, and institutional model (Jackson 2001; Dincin 1995). A second and well-known discussion of deinstitutionalization is Marmor and Gill’s fragmented polity thesis (Marmor and Gill 1989). Without a centralized mental health authority, policies are initiated and implemented by ﬁfty states and 3,000 counties. They argue that disjointed agenda setting and implementation produce slipshod community programs; in short, the mentally ill are neglected. Although I recognize that mental health policy arises from a fragmented bureaucratic system, my central question about this thesis is not an empirical one. Rather I ask why a decentralized polity would not produce a plurality of outcomes and problem deﬁnitions. In a piecemeal environment, why did some states, for example, not retain the hospital-centered organization of mental health care? Thus, one is left to wonder, given that mental health policy is produced by a fragmented polity without uniform standards: (1) why there was a national trend to close large state hospitals and shift the location of services to a fragmented system of communitybased organizations, (2) why cost-saving slogans were used so pervasively (among advocates for community care) when the “double funding” of hospitals and community support services actually increased state budgets,4 and ﬁnally (3) why case management services, medication groups, transitional housing programs, and rehabilitation models are used almost exclusively. In short, how does a fragmented polity produce national trends, namely, in this case the pervasive use of community support services? Andrew Scull (1984), in his explanation of deinstitutionalization or what he calls decarceration, argues that market economies require welfare states to cover labor costs ignored by capitalists. In turn, shifting the “costs of production” from capital to the state leads to a ﬁscal crisis (see also Block 1987). The state, therefore, is forced to limit spending. Thus, an unexpected alliance occurs between ﬁscal conservatives and liberals. Depopulating hospitals saves money. With the mentally ill in communities—supported with federal dollars from social security income and HUD—state and local governments shifted the ﬁscal burden to the federal treasury. Scull, however, hastily reduces deinstitutionalization to a mere ﬁscal crisis. Although ﬁscal conservatism is a major factor, we are left to wonder who persuades legislators that community support services are less expensive.5 And, moreover, what disciplinary knowledge is used? If case management is not imagined by a group of legislators or lobbyists, is it the creation of social workers and mental health practitioners? Legislators do not invent practice theories, social workers, however, do.

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23

Beginning in the late 1960s—with little funding but lots of energy and creativity—advocates for the mentally ill and social workers demonstrated in experimental programs that hospital patients could live outside the “totalizing institution” (Test 1979). But expansion of community services required a funding source. Advocates argued that hospital closings would eliminate institutional costs, and the savings could then be transferred to community programs. There was a belief that outpatient services were ﬁscally responsible; indeed, one could argue that a cost-savings logic was the sine qua non of the movement. But it also contained a paradox: double funding the old hospital (albeit reduced) along with community support services actually increased mental health budgets. Paul Lerman writes that although some legislators may have believed that actual state costs were being reduced, the fact is that state costs for the total mental health budget were increasing. . . . After a decade of sharp population reductions, actual cost savings had not yet materialized. (Lerman 1982:95)

In Kansas, for example, with the implementation (1985–1995) of mental health reform, funding for community support programs led to a doubling in the overall state mental health budget—from $71 to $151 million dollars.6 Still, policy advocates claimed to save money through closing hospitals. Decarceration movements, in Scull’s view (1984), encompass prison inmates, nursing home residents, and incarcerated juveniles. Unwittingly, his comparative method undermines the argument; if cost-conscious state ofﬁcials demand decarceration, then why build more prisons? Scull acknowledges that prisons are unique. Society viliﬁes the criminal to such a degree that deinstitutionalization is made politically impossible: “not in my backyard.” This exception needs to be accommodated by theory, and Scull’s response begs yet a further question. Why are mental patients not maligned? To answer this question, Scull must step outside the structuralist conception of the problem. If the nineteenth-century policy was, as Scull theorized, to segregate the unwanted, unemployed, and bizarre from the “normal” population, then the asylum clearly met those goals. To move from a centralized hospital to a decentralized community-based delivery system, however, meant the dissolution of the policy that had once provided both a livelihood and service at a single site. This required, as Scull and Lerman have argued, speciﬁc welfare policies—starting with social security—to provide for the expenses of daily life; once the policies were in place and the mentally ill made

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eligible, then service and subsistence could be severed from the hospital (Lerman 1985). I think the reorganized elements of the hospital social ﬁeld, especially the need for former patients to have money, established pragmatic conditions for the usefulness of “illness identities.” Sue Estroff notes the signiﬁcant difference between the claims, “I have an illness,” and “I am schizophrenic” (Estroff 1993). I argue that illness identities create a “worthy category” of welfare and social security recipient (Handler and Hasenfeld 1991); in contrast, criminality remains a moral and personal problem, one not worthy of community support services. “I am an ex-convict” does not have the same appeal to liberals as does “I am a manic-depressive.” The above questions cannot be addressed by a political theory that presupposes a “fragmented” polity. Nor can these questions be explained by simply positing the existence of NIMH as an instrument for system change. And Scull’s structuralist approach fails to account for the continued increase in mental health funding, despite a real or perceived ﬁscal crisis. A politics of categories focused attention on illness identities, creating a unifying effect where a fragmented polity could not do so. Moreover, an unintended consequence of the use of community space—politics of location—paradoxically contributed to a new system of politics, not unlike the one present in the asylum. Social workers monitor and assure that former patients occupy delimited community space. Advocates for community practice misunderstood that work in the community is de facto decentralized and fragmentary: a mobile, communitybased service recipient is by deﬁnition decentralized. In contrast, the hospital centralized service by combining all elements of a social ﬁeld at one site. The community support services politics of space and categories persuades me of the merits of Foucauldian skepticism about the progress inherent in liberal social projects (Hoy 1986). The substitution of the community for hospitals led to alternate disciplinary knowledge that had to contend with the reorganized elements of the hospital’s social ﬁeld. Here, Foucault’s pessimism about progress is most appropriate; after all, monitoring continues in the community. Hospital- or community-centered monitoring is part of mental health disciplinary knowledge /power schemes. Community advocates who thought monitoring would end with deinstitutionalization were naive. The objects of community-based mental health practice still needed classiﬁcation; inference still needed to reason how change would occur and how planned intervention would follow. This is the nature of disciplinary knowledge/power, and no liberal project can overcome the inherent properties of practice. Community support services produce different effects than hospitals, and outcomes might

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be measured along a continuum from good to better to best. The latter, however, would require that we engage in thoughtful moral and epistemological arguments, arguments that neither Foucault nor advocates of CSS seemed willing or able to engage in. Public policy combined with practice to relocate bodies. I use the term “body”7 to capture in the most abstract sense the objective of deinstitutionalization: the relocation of “mentally ill” bodies. How social workers and policy analysts construe the recipients’ subjectivity is central to community support services (Stone 1988; Edelman 1988). When practitioners identify individuals as “the chronically mentally ill,” the social relationships of caregiving are framed and ﬁgured in a unique way. Among other things, for example, the subject position “mentally ill” makes a person worthy or eligible for social security disability payments. Deinstitutionalization leaves us with crucial questions about how policy and practice contribute in historically particular ways to the creation of the “mentally ill” subject position, and relatedly, about what the limits and possibilities of this kind of activity are. In short, practitioners employ categories that frame the subject positions of helper and service recipient. With respect to the category “disability,” Deborah Stone writes in The Disabled State that “disability is a formal administrative category that determines the rights and privileges of a large number of people” (Stone 1984:27). Medical and clinical methods legitimate illness and resolve, for Stone, the need to reconcile a work-based distribution system with a needs-based one. An injured worker must be distinguished from workers who lack only employment, the former made worthy of state aid by an observable disability. With mental illness it was not uncommon to observe case managers explaining to clients that “like diabetes, the disease of schizophrenia requires daily medication to prevent relapses.” Lindsay Prior has observed that this emphasis on body—and especially the nervous system—was . . . characteristic of early twentieth-century psychiatry. And although, as the century progressed, numerous other objects of psychiatric work came into play, the body as a theatre of practice never truly lost its primary role. (Prior 1993:71)

Case managers claimed that individuals who acknowledged their illnesses were “easier to manage in the community.” Refusal to recognize that a “disease” inhabits the body resulted in the claim that “consumers resist or deny.” Once biomedical explanations were employed in everyday practice, decisions

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and actions were framed around and within them, leading to the politics and practice of diseased and mentally ill bodies. Had they not framed the problem as disability, illness, or disease, community support services advocates would have lost their constituency because released patients would have been expected to work and live in the community as “normal” people do. Most “normal” people rely upon earned income to purchase commodities that satisfy wants. Fortunately for those advocating for a new social ﬁeld, many former patients had difﬁculty ﬁnding jobs and staying employed; consequently, they relied upon social security monies and community support services as a substitute. In short, the disease model provided the rationale for worthy mental health services supported by federal, state, and local taxes. Thus, the disease model provided the community support services social ﬁeld with a discourse to capture a dependent constituency. Why have I emphasized space as a key factor in the understanding of deinstitutionalization? The social politics of space is not new to the study of welfare policy (Katz 1986). In the United States, alms, poor relief, and beneﬁts have always been subject to residency requirements. The dichotomy, real or imagined, used to characterize our welfare past—indoor and outdoor relief— is imbued with the notion that location is crucial to the success of policy implementation. Surely the attack on one of the more “totalizing” institutions, the hospital, was generated by the claim that hundreds of bodies cannot be salubriously conﬁned in one limited space. Deinstitutionalization, in policy and practice, sought foremost to desegregate, and it did so by shifting the site of service. Community-care establishes imaginary walls or boundaries sometimes called “catchment areas” and usually denoting a county or zone served by a local mental health center. Hospital patients are discharged to geopolitical units; service, however, can be refused and the subject be referred to original counties of residence, those within which he or she lived prior to hospitalization. Community support can be characterized as the mobilization of resources to coordinate the movement of individuals through variously organized spaces toward “higher levels of independent living” in “the least restrictive environment.” It is common for individuals to cycle through placement or residential sites. Recipients often relapse, return to the hospital for a few days or weeks, leave, return to their apartment—if their case manager was lucky enough to be able to pay the rent—or move into a group home and then into an apartment; consequently, the movement through space and time is cyclical. While asylums ﬁxed the patient to one service site, the closed system of

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the hospital, deinstitutionalization encourages mobility in the open system of the community. Homelessness highlights this point (Jencks 1994; Wagner 1993). Many discharged patients wander through streets and alleys refusing to acknowledge geopolitical boundaries; thus, extensive case management and mobile crisis units provide street-level services. The homeless mentally ill demonstrate how deinstitutionalization policy is implemented in an open as opposed to a closed system. But even in the community, practice must reestablish closure; that is, mobile case managers track the homeless and create boundaries where none exist. Indeed, homelessness poses a formidable challenge to deinstitutionalization (Mowbray and Bybee 1998; Schutt et al. 1997; Mowbray et al. 1996; Morse et al. 1996). By accentuating the beneﬁts of closing hospitals, policy scientists, in effect, may have narrowly focused our attention on the problem of location. For example, the University of Kansas Ofﬁce of Social Policy Analysis highlighted above all other goals: The chief ﬁnding of this evaluation is that the Kansas Mental Health Reform Act is legislation that is accomplishing its intended purpose. Substantial progress has been achieved: 1) State Hospital beds have decreased. (University of Kansas School of Social Welfare 1995:1, emphasis in original)

Practitioners and policymakers calibrated their narrative accounts of success based on the reduction of hospital utilization rather than on generous income maintenance programs. This narrow politics may have limited deinstitutionalization in the same way that according to Evelyn Brodkin’s argument, antipoverty Democrats “found themselves trapped by their own strategy—a strategy that depicted welfare as the critical national problem, more critical, it seemed, than the problem of poverty” (Brodkin 1995:219). Social workers framed hospitalization as the critical problem, and within this discourse they persuaded state policymakers that the hospital should become peripheral to policy. Practice and politics shifted the locus of treatment to new delivery sites and systems, not to the expansion of entitlement or economic rights (Rachlin 1983). Is deinstitutionalization, then, a de facto policy and politics of categories and space? The discourse on the body and illness privileged biological over social forces by dividing humans into two broad categories: the physically healthy majority and the mentally ill minority. Foucauldian dividing and biopower technologies are practices appropriately applied to instances where disease is

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invoked to legitimate categorical services (Chambon et al. 1999). As Deborah Stone has argued regarding disability in general, categories frame eligibility for government supports (Stone 1984). The meager welfare beneﬁts granted to the mentally ill require identiﬁcation with the emerging and acceptable categories describing biological or genetic bases for illness. Social workers and community support services advocates organize claims around the state’s responsibility to care for individuals afﬂicted with illness and who bear, then, no direct responsibility for their condition. As a consequence, the politics of deinstitutionalization becomes health care politics, which thus limits it to health care ﬁnancing. This may explain why lobbying is framed around health care issues. Moreover, the illness narrative, like identity politics, tends toward exclusion (Seidman 1993). Shifting the location of service to the community meant that the mentally ill had much in common with those in need of lowincome housing, mass transit, and perhaps most important, jobs that paid a living wage (Wagenaar and Lewis 1989). Yet I suspect that politically, advocates for community support services centered the mental illness experience and this elides the disadvantages community living may present to impoverished groups. Indeed, one Kansas CSS client remarked in a recent study, “There’s something that’s lacking in the community that the state hospital has and that’s housing—safe and affordable housing” (University of Kansas School of Social Welfare 1995:47). While it is ironic that the hospital provided, in the opinion of one client, “safe and affordable housing,” it is also unfortunate. This statement, moreover, captures the way an everyday need (shelter) became a practice problem for case managers.

NIMH REACTION TO DEINSTITUTIONALIZATION

Over twenty-ﬁve years (1955–1980) the national hospital census dropped by a remarkable 76 percent (Torrey 1997:100). By 1994 the Kansas Hospital population was down to 883, an 80-percent decline from its 1955 high of 4,420 (Torrey 1997:207). One might conclude from these dramatic statistics that the introduction of psychotropic drugs and innovative therapies combined with transitional or aftercare programs alleviated or ameliorated the worst effects of mental illness. This was not the case, however. By the early 1970s journalists, researchers, scholars, professionals, family members, and former patients raised the question whether deinstitutionalization was just a new version of nineteenth-century (prehospital) neglect and abandonment. NIMH joined others in criticizing the effects of deinstitution-

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alization (Grob 1994:249–279). In fact, ofﬁcials thought that the pre-1970s policy had produced a chaotic void that community-based services could ﬁll. In a summary article, two NIMH employees—hired in 1974 and 1976— retraced their early efforts to create a national system of community support programs: We regard this article as an opportunity to describe key features of the program and to present our interpretation of ways in which CSP holds promise as an approach to a complex service system problem. Our comments will be offered from the standpoint of two NIMH staff members who have been intimately involved in the program’s design and who now have a stake in its success. . . . Our purpose is to present the rationale for decisions reached so far. (Turner and TenHoor 1978:319)8

NIMH sought to shift the terms of the debate, whereas reform efforts of the 1950s and 1960s emphasized the inhumane conditions in large mental hospitals, in the current decade attention has shifted to problems connected with “community placement” of the same population. (Turner and TenHoor 1978:320)

Moreover, community programs would solve the myriad problems that the policy of emptying beds had caused. Between August 1975 and April 1977 NIMH hosted eight working conferences (referred to hereafter as NIMH-CSP Conferences) “to assist the Division of Mental Health Service Programs (DMHSP) design policies and programs to improve opportunities for adults with serious mental disabilities” (Turner and TenHoor 1978:345). Of the 140 invited guests, only 6 operated state hospitals: ﬁve represented St. Elizabeth’s in Washington, D.C., and the sixth was from the St. Louis State Hospital’s Community Homes Program. NIMH did not put the improvement of hospital programs on the agenda. Among the conference participants were eighteen ﬁeld practitioners, ten university professors, thirteen state-level mental health directors, ﬁfty-ﬁve NIMH and Health, Education, and Welfare ofﬁcials, and a long list of representatives from national mental health organizations (Turner and TenHoor 1978:345–348). Though many of the invitees were already staunch and prominent advocates of community support services, more important, they were to become the leading authors of various disciplinary approaches to case management. Leading ﬁgures included:

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• John Beard, founder of the famous Fountain House, New York • Jerry Dincin, founder of the equally famous Thresholds, Chicago, Illinois • Richard Lamb, professor of psychiatry, author of numerous articles and books on community treatment • Steven Segal, professor of social work, and author of a 1970s seminal article critical of California and its efforts to desegregate the mentally ill • Steven Sharfstein, then acting director of the Division of Mental Health Service Programs, NIMH (he later published a book that became a standard policy text for understanding the politics of deinstitutionalization) • Leonard Stein and Mary Ann Test pioneered research that “proved” community treatment was more cost-efﬁcient and effective. They founded the Assertive Community Treatment (ACT) model of case management • John Talbot, professor of psychiatry, became a key spokesman for community psychiatry, and ﬁnally, • Wolf Wolfensberger, professor of psychiatry, author of “The Principle of Normalization and Its Implications for Psychiatric Services.” The NIMH-CSP conferees interpreted the ﬁndings of the Senate Subcommittee on Long-term Care (1976) and the General Accounting Ofﬁce study (1977) on deinstitutionalization to mean that neither hospitals nor community programs had clear policy or administrative mandates to control mental health services. In sum, deinstitutionalization had occurred ad hoc and conferees concluded that the problem had become “community placement” (Turner and TenHoor 1978:323). Ofﬁcials sifted through the conference discussions and found consensus: fragmented service was the most critical factor contributing to numerous inadequacies and problems. For example, there were no clear legislative and administrative links between hospital discharge and community services. Although it was clear to NIMH by the mid-1970s that SSI (supplemental security income), SSDI (social security disability income), Medicaid, and Medicare had shifted the treatment cost from state to federal treasuries, it was not clear just how these resources were to be used. Hospitals had been funded almost exclusively with state monies; yet in the shift to federal programs no national policy had been formulated to assign responsibility at the local level. States, as a result, claimed no responsibility for disjointed services. Who would provide the link at the local level? Would the county welfare caseworker follow the discharged patient? Should hospitals be held account-

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able? Why weren’t community mental health centers providing programs and services for the individuals “placed” in the community? After all, ofﬁcials were quick to point out that the 1963 Community Mental Health Center Act specifically designated the CMHC the effective unit for community treatment. Paramount among concerns was the funding mechanism for communitybased programs. Even though thousands of hospital beds had been emptied, states continued allocating millions to hospitals. No one at the state or federal level had earmarked money speciﬁcally for community services. Thus, NIMH ofﬁcials concluded: All of these problems, although difﬁcult, are amenable to solution. What has been particularly lacking, however, is clarity about who should provide the necessary leadership at Federal, State, or local levels to move things forward. The need for such leadership has been a recurring theme. Although there are serious difﬁculties inherent in attempting to assure a full range of communitybased services for the mentally disabled, it would seem incumbent on the mental health system to assume a leadership role—particularly during the present period of major systems transition. (Turner and TenHoor 1978:326).

One obstacle remained: what to do with old initiatives that focused on hospital reform? Sometime in 1977 NIMH ofﬁcials buried reform. Frank Ochberg, director of the Division of Mental Health Service Programs, established the Hospital Improvement Task Force to consider the problem of state hospitals. With G. Bart Stone and his cochair William TenHoor, an advocate of community services, the group recommended a “phaseout of existing programs and the redirection of resources into a new CSP” (Turner and TenHoor 1978:326). Upon their recommendation, a new task force, the CSP (Community Support Program) Implementation Group, was formed. The NIMH-CSP conference produced a comprehensive reform agenda, and one proposal is of particular interest to my analysis: “To conceptualize and deﬁne goals, principles, and terminology to guide the planning of ‘comprehensive community support systems’ for adults with chronically disabling mental health problems” (Turner and TenHoor 1978:327). NIMH recognized the need for a new language to classify and manage the mentally ill placed in the community. Conferees persuaded ofﬁcials to clarify “goals and concepts before developing implementation initiatives” (Turner and TenHoor 1978:328). With the decentering of the hospital accomplished, the work of creating a new social ﬁeld with shared language and goals remained. NIMH eagerly accepted the challenge.

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NIMH, COMMUNITY SUPPORT SERVICES, AND CASE MANAGEMENT

NIMH envisioned a “core service agency,” something like a community mental health center, to implement the community support program initiative. And though the CMHC mandate (P.L. 94–63)—to provide former patients with follow-up care—was not contested, Turner and TenHoor questioned whether or not it should be interpreted narrowly as referring to clinical mental health aftercare only, or should a broader and more comprehensive “case management” responsibility be assumed? If CMHCs were not to assume case management responsibility, who should do so? (Turner and TenHoor 1978:328)

By contrasting “clinical” with “case management,” ofﬁcials decidedly placed management, the case manager, and associated practices at the center of community-based services. The consequences were far-reaching. As suggested in the passage above, the historical emphasis on the “clinical” presupposed two related and problematic practices, each of which community proponents derided and saw as vestiges of the hospital (Torrey 1988:220). First, for most, the term “clinical” connoted traditional psychotherapy and psychological assessment. Second, clinical treatment had particular spatial and temporal requirements—the clinic ofﬁce and the traditional ﬁfty-minute hour. The 1970s saw an unrelenting barrage of criticism aimed at the CMHCs’ emphasis on psychotherapy (Johnson 1990). The argument, then and now, was that the CMHCs had failed in their responsibility to the severely mentally ill. In short, CMHC practitioners remained safely ensconced in their private ofﬁces, committed to the sacrosanct ﬁfty-minute hour. Too much emphasis was given to the “worried well.” This became a mantra for community advocates and gave rise to a critical literature, even ideology, that continues into the present day.9 Mental health systems, critics claimed, needed new concepts and practices. In sum, at the heart of the federal CSP initiative was a stubborn antipsychotherapy sentiment, often taking on the features of a social movement. In place of psychotherapy NIMH suggested a community support program with fourteen case management services and functions. I list them here because they succinctly capture the social ﬁeld’s purpose and logic: • Identiﬁcation of the target population, whether in hospitals or in the community and outreach to offer appropriate services to those willing to participate.

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• Assistance in applying for entitlements. • Crisis stabilization services in the least restrictive setting possible, with hospitalization available when other options are insufﬁcient. • Psychosocial rehabilitation services, including but not limited to: goaloriented rehabilitation evaluation; training in community living skills, in the natural setting wherever possible; opportunities to improve employability; appropriate living arrangements in an atmosphere that encourages improvements in functioning; and opportunities to develop social skills, interests, and leisure time activities to provide a sense of participation and worth. • Supportive services of indeﬁnite duration, including supportive living and working arrangements, and other such services for as long as they are needed. • Medical and mental health care. • Backup support to families, friends, and community members. • Involvement of concerned community members in planning and offering housing or working opportunities. • Protection of client rights, both in hospitals and in the community. • Case management, to ensure continuous availability of appropriate forms of assistance. • The comprehensive need of the population at risk must be assessed. • There must be legislative, administrative, and ﬁnancial arrangements to guarantee that appropriate forms of assistance are available to meet needs. • There must be a core services agency within the community that is committed to helping severely mentally disabled people improve their lives [my emphasis]. • There must be a single person (or team) at the client level responsible [my emphasis] for remaining in touch with the client on a continuing basis, regardless of how many agencies get involved (Turner and TenHoor 1978:329–330). These services and functions underscored three community principles: “normative service methods and settings,” a focus on “in vivo” methods, and the “indeﬁnite duration”of mental illness (Turner and TenHoor 1978:330–331). Ofﬁcials understood the need to rename and reorganize the use of time and space. The ﬁrst principle referred to use of “least restrictive environments” or community placement, a spatial designation. The community support services social ﬁeld was set in opposition to the most restrictive environment: the hospital. The second principle, “in vivo,” concerned daily living skills and

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training in “real-life”settings, like apartments—not the clinic ofﬁce. The third, a temporal dimension, was most explicit in its recognition that community programs would continuously support the mentally ill. I will return to dimensions of time and space throughout this study of the case manager. Here it is only important to note that NIMH knew that replacing hospitals would require community monitoring and that such systems would be needed “indeﬁnitely.” In sum, by providing opportunities for clients to assume normal social roles, these approaches are in sharp contrast to programs—whether institutional or community—that perpetuate a passive “patient” role. (Turner and TenHoor 1978:332)

The ﬁnal NIMH initiative incorporated medical, rehabilitation, and social support services. In a prescient moment, Turner and TenHoor argued that “all three of these approaches have relevance; any one of them alone is inadequate to the needs of this population.” Indeed, meds (medical model), money (teaching life skills and rehabilitation model), and manners (social supports model) are client domains that case managers in 1997 ceaselessly focused on. Following the conceptualization of the community support services social ﬁeld, NIMH assisted states with implementation. The institute announced a new program in 1980: “Community Support Systems Strategy Development and Implementation.” With this new emphasis on implementation, the future direction of the community support services social ﬁeld had been decided: it was to be the responsibility of each state to construct a CSS social ﬁeld.

KANSAS AND COMMUNITY SUPPORT SERVICES

It had taken NIMH approximately seven years (1974–1980) to formalize community-based programs. Although not surprising—given the growing population of released patients—it is noteworthy that High County had introduced community services during the time of the NIMH-CSP conferences. Allen Street recounted the early history of CSS: The birth of CSS actually started in 1974. The Center had received a Comprehensive CMHC grant from the federal government, which in effect started the Center. It functioned as a stand-alone comprehensive MHC under the CMHC Board. I was named the Administrator of the Center and was responsible for

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putting together the components required for the Federal grant. One required component was Partial Hospitalization. In my mind it seemed like a nurse should head up that part of the program. We had a psychiatric nurse intern named Sally, whom I recruited to be the “Partial Hospitalization” director. Neither Sally nor I had much of an idea what to set up other than a traditional day program. Sally began investigating what was developing around the country in services for the SPMI [Severe Persistent Mentally Ill] population. She hooked up with the CSP branch of NIMH, and from there learned about the PACT [Program Assertive Case Management Treatment] program in Madison and Places for People in St. Louis. At her insistence we both visited these programs. This set the stage for a community-based approach. (Personal correspondence with author 1997)

NIMH provided technical assistance to High County but referred practice questions to ﬁeld practitioners, like those in Madison, Wisconsin, who had created model programs such as assertive case management (i.e., ACT). When Street learned in late 1980 that the Kansas Commissioner of Mental Health and Retardation Services, Dr. Jerry Hannah, was applying for a federal grant, he enthusiastically supported the effort: This letter is written in support of the state’s application for a Community Support Systems Strategy Development and Implementation Grant. As you know, this is an area I am highly invested in and feel strongly the state should exercise leadership to ensure that necessary resources are available, and that proper coordination takes place to guarantee the success of these programs on the local level. Any effort to improve the state’s capacity to provide such leadership will be extremely helpful. High County Mental Health Center, for the last four years, has been working toward the development of a community support program to serve the chronically mentally ill in our community. While progress has been made, it has been a frustrating process for at least two reasons. First, many of the service components of a community support program are not fundable through traditional sources. Secondly, the interagency coordination required to make such a program successful is virtually impossible without state level policy and initiatives supporting such coordinated efforts. The ﬂedgling Community Support Program developed by our Center has conclusively demonstrated to us its value in preventing unnecessary hospitalizations and maintaining chronic patients within the community. Even with these efforts, however, over 200 patients per year are admitted to the State Hospital from High County.

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With proper supportive services, I am convinced this admission rate could be reduced by at least one-half. (Kansas Department of Social Services, “Community Support Systems Grant,” letters of support, 1980)10

Jerry Hannah moved quickly to bring Kansas into the project of community support services. And the thirty-three-year-old commissioner had the credentials: bachelor’s and master’s degrees in social work, a Ph.D. in psychology, experience as chairman of the Community Mental Health Management Special Interest Group (a national group created to promote the development, reﬁnement, use, and dissemination of empirical, research-based technology), and experience as director of Vermont Community Mental Health Programs. State ofﬁcials faced a six-week deadline. Hannah’s assistant, G. C. Coniglio, then administrator of Community Mental Health Programs in Kansas, had a graduate degree in social work and had worked at Topeka State Hospital (1952–1955). With Coniglio’s hospital experience and his welfare and community mental health work (1961–1980), Hannah was prepared to think strategically about the gap between the hospital and community services. He sought federal funds to restructure the state mental health ofﬁce; he envisioned a state-level coordinator of community programs and support for the development of demonstration projects in “Community Mental Health Catchment Areas.” In general, Hannah wanted to restructure three sectors of the Kansas mental health system: (1) the public community mental health centers; (2) the public state hospitals, and (3) the private system of hospitals and practitioners. For the commissioner, two “philosophical principles” served as underpinnings for his CSS strategy. First, he turned to the famous Wyatt v. Stickey decision to ﬁnd juridical support for a “least restrictive individualized program of services based on assessment of the patient’s special needs.” For those “who can only be treated in an institution” he promised advocacy and adequate funding. Uppermost in his mind, however, was “the prevention of unnecessary [his emphasis] institutionalization of those persons believed to be mentally ill” (Kansas Community Support Systems Grant 1980:1). Second, Hannah pointed toward the principle of normalization. He believed that the mentally ill should have a lifestyle that would be considered normal for non-handicapped persons of similar ages. That is, handicapped persons who live and function in normal

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settings, which incorporate normal patterns and routines, thus enhancing their self-concepts, will develop behavior accepted by the mainstream of society and will be increasingly self-sufﬁcient. (Kansas Community Support Systems Grant 1980:1–2)

NIMH had borrowed from Wolf Wolfensberger (see Turner and TenHoor 1978) the principle of normalization, who had borrowed it from Swedish experiments with the developmentally disabled (Wolfensberger 1970). Hannah’s use of phrases like “mainstream of society” explains why in the construction of the Kansas CSS social ﬁeld, he borrowed a companion concept like normalization; that is, to be mainstream is to be “normal.” The CSS social ﬁeld, however, had to face its antagonist: the hospital. Early in the formation of Kansas CSS, ofﬁcials lacked the political clout to challenge the hospital; instead, it was seen as an important one-third of the system. Nevertheless, Hannah used a concept—the “continuum of care”—in his 1980 application that was, I argue, effective in politically subverting the hospital, while at the same time deﬁning and establishing the CSS boundaries. By incorporating the hospital into his continuum of care, Hannah absorbed the old into the new; he brought the past into the present. CSS brought the hospital into its ﬁeld and from there delimited the hospital’s role in the continuum of care. Hannah wrote: Functionally, the institutions and community-based service agencies are the providers of care to meet a broad array of needs for the mentally ill. . . . The rubric “Continuum of Care” is the concept which links all the divisions of the Department of Social and Rehabilitation Services together. . . . The concept begins with a state of equilibrium of the client, referred to as “independence or self-support.” Departure from the sense of “self-care” moves the individual out of the state of equilibrium into the context of services needed to restore him or at least move him toward the self-care state of equilibrium. When the individual moves into the context of services provided by the Mental Health Services, he is in the area of services provided by the community-based agencies or one of the institutions. (Kansas Community Support Systems Grant 1980:3)

This description captured the essence of the emerging social ﬁeld. Hannah included in the application the illustration reproduced in appendix B. I provide it to give emphasis to the conceptual signiﬁcance of the continuum of care. Hannah’s CSS language was borrowed from biology, ecology, and con-

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servation. Continuum of care suggests a “system” with interactive parts and equilibrium states. For the mentally ill, then, equilibrium was reached with self-support, self-care, and self-sufﬁciency. Crucial to the continuum concept was mobility. The illustration’s (appendix B) arrows imply that individuals move from one status to the next. Mobility and movement were at the heart of CSS. I am persuaded that the driving force of the CSS social ﬁeld, its law of motion, can be found in the constant movement of former patients along the continuum of services. I think of the hospital social ﬁeld, heuristically, as its opposite—stasis, ﬁxed subjectivities, minds locked, bodies suspended in space and time. Contrariwise, CSS was about client movement in and out of structured environments: ofﬁce buildings, apartments, the grocery store, the apartment complex ofﬁce, the Crisis Stabilization Unit, and, of course, the welfare ofﬁce. The Kansas CSP grant was designed to build capacity for the continuum of care system. The mental health system, according to Hannah, lacked coherency. He wrote that at present, no mechanism exists within the Mental Health System that is charged with the task of ﬁlling gaps, improving coordination, improving the use of currently available resources, and above all, identifying, overcoming and removing obstacles to provide comprehensive community services to clients. (Kansas Community Support Systems Grant 1980:8)

The ﬁrst task was to deﬁne the “target population.” This he accomplished by aligning Kansas with NIMH’s “operational deﬁnition” of the target population: Adults 18 and over, with a severe and/or persistent mental or emotional disorder that seriously impairs their functioning relative to such primary aspects of daily living as personal relations, living arrangements, or employment, but for whom long-term, 24-hour care in a hospital, nursing home or protective facility is unnecessary or inappropriate. (Kansas Community Support Systems Grant 1980:8)

Second, the grant tied the “target population” to the continuum of care, thereby relegating the hospital to the periphery. Notice (see appendix B) that Hannah’s illustration lacked an identiﬁable center. He suppressed the centrality of the hospital by using a second conservation concept: the “catchment area.” The federal 1963 Community Mental Health Center Act also used that

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term. In conservation, catchment areas refer to basins or reservoirs used for collecting or draining water. The metaphor was apt: former patients would be drained from hospitals and collected by community mental health centers. A mental health catchment area became a geopolitical region with a continuum of care system. For Hannah, such areas were found where there were Mutual understanding and sharing of economic problems through established “folkways”-patterns of trade, commerce, industry, transportation. Uniﬁcation of common bonds of homogeneous populations, hereditary traits, social mores, or philosophical attitudes. Arrangements that combine multiple county cooperation in political matters and utilize to best advantage existing transportation and communication networks. (Kansas Community Support Systems Grant 1980:11)

In short, the catchment area was substituted for the pastoral grounds, the ward, and the hospital keys. “Mutual understandings,” “homogeneous social mores,” and transportation networks were superimposed onto comparatively abstract and amorphous county political units. High County became a catchment area for those released from the state hospital and urban state hospital. The catchment area, unlike the hospital was more symbolic than real and provided a means to reestablish organizational accountability and responsibility for the now mobile patient. Each county or counties were to become service basins for released patients. And it was within each region that Hannah wanted to build capacity. He characterized the ﬁrst Kansas initiative, called Partnership Agreement for Continuity of Treatment, as embryonic. Hannah’s narrative account of High County’s early efforts is useful here. He eloquently framed why he thought these “embryonic beginnings” needed NIMH support: Another community support program in Kansas is afﬁliated with the High County Mental Health Center in Oaklawn. It has been titled,“Living, Inc.” The major focus of this program is to offer a structured support setting for chronic clients of the center. The program ﬁrst began with a therapeutic activity program for the clients; however, the staff became increasingly aware of additional services needed to help clients live successfully in the community, one of these being a residential program. Currently the program has a liaison relationship with a local SRS ofﬁce, The State Hospital, and Oak House (which is a local transitional living program in the community). It has become increas-

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ingly clear that social circumstances, i.e., housing and employment can play an integral part in the client’s level of emotional functioning. It is not uncommon, for example, for an event such as an apartment eviction to precipitate a psychiatric crisis resulting in hospitalization. Therefore, the concept of the program has been broadened to include efforts in the following speciﬁc areas: i.e., housing, vocational support, clinical intervention in case management. In order to tackle the very difﬁcult problem of housing for the chronically disabled, the staff ﬁrst negotiated with several landlords in the area to rent apartments to clients being served by the mental health center program. Under this agreement, the landlord notiﬁes the center of a ﬁrst option on the vacancy. In return, the mental health center assures the landlord that the apartment will be cared for, occupied, and the rent paid. The center has also applied for a community development block grant through the city of Oaklawn, to help them to further their housing program. (Kansas Community Support Systems Grant 1980:14)

Hannah argued that Kansas needed “a major adjustment to the system” (Kansas Community Support Systems Grant 1980:16). He identiﬁed three obstacles to the establishment of CSS: (1) current funding practices do not support a “continuum of services,” (2) current third-party reimbursement favors inpatient care and discourages “less expensive alternatives,” and (3) lack of coordination among the public state hospitals, the public community mental health centers, and private hospitals creates aftercare problems. At both national (through NIMH) and state levels (through Commissioner Hannah’s ofﬁce), policymakers laid the groundwork for the Kansas CSS social ﬁeld. Formed out of reaction to the depopulation of state hospitals, ofﬁcials helped create an oppositional structure. At the practice level, however, this oppositional nature was disguised. Indeed, in Kansas, CSS left the hospital system intact. The hospital, whose lifeblood was the lifetime patient, was not able to compete with CSS for “long-term” clients. It was a matter of time. Seventeen years later (1997) the Topeka State Hospital closed. Throughout the 1980s former patients were relocated to the community and helping relations were reconﬁgured: “patients” became “clients” or “consumers” of community support services. By bringing the hospital under their continuum of care rubric, the CSS advocates redeﬁned it as a space for shortterm use and stabilization. It was in the catchment area that former patients could expect to ﬁnd long-term treatment. There, practitioners would learn to monitor clients’ progress or movement “toward higher levels of independent living.” Though these settings were only vaguely understood in 1980, I will

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show in subsequent chapters that it took the disciplinary knowledge of strengths case management and the situated practice of case managers to construct the details. But two important components were missing, components that were fully functional in 1997 when my study began. First, who were to be the primary practitioners? And what disciplinary knowledge would they embrace? Second, the speciﬁcs of High County’s CSS had yet to be constructed. I take up these issues in chapters 3 and 4. Each issue warrants separate treatment, and I turn ﬁrst to the incremental rise of the case manager.

C HAPTER 3

The Rise of the Case Manager

T

he National Institute of Mental Health, the Kansas Department of Mental Health, and the local mental health center used policy initiatives, administrative mandates, new funding sources, and everyday experience to construct a rudimentary community-based social ﬁeld, the new home for the former hospital “patient.” The CSS social ﬁeld had secured juridical claims to the deinstitutionalized population; thus, as speciﬁed by Andrew Abbott, the objective conditions for professional work were in place. In this chapter, I show how Abbott’s subjective conditions of work—diagnosis, assessment, and treatment activities—were not fully developed, however, suggesting that workers relied on raw experience that was relatively unmediated by disciplinary case management schemes. The ﬁrst CSS workers learned by doing. In this chapter, I analyze historical data to show how case managers were produced out of what Abbott would call the subjective conditions of work. The goal to keep individuals out of hospitals required that workers learn to monitor meds, money, and manners. Because the disciplinary knowledge of the clinic and hospital social worker were of little use to CSS, I examine how mobility and the constant movement of former hospital “patients” required a mobile case manager. I show how the CSS ﬁeld evolved and why it would later beneﬁt from the disciplinary knowledge of goal-oriented strengths management. And in naming the service recipient, I conclude with an argument about why the early social ﬁeld used the subject categories “client” and “consumer.”

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I recount this history using the voice of one social worker. Sarah Teasley, director of CSS during its formative years (1982–1989), relied on everyday experience and savvy administrative skills to create individual case management. She wrote dozens of quarterly reports describing CSS activities, progress, and early case management activities. I have used these data to show why the social ﬁeld required case managers. Although in the beginning there were no case managers, there was incipient case management.

LEARNING BY DOING: THE EARLY YEARS

In 1977 Sarah Teasley earned her master’s degree from the University of Kansas School of Social Welfare. At her ﬁrst mental health center job in Oklahoma she helped “patients” make the transition from a state mental hospital to life in urban and suburban communities. In the transition (1978) from student to employed practitioner, Sarah was unaware of useful model programs or case management paradigms. Moreover, graduate education had not prepared her for community support services. The social work curriculum in the 1970s had not yet incorporated a community or strengths perspective; like most graduate programs, hers had emphasized family and individual psychodynamic assessment and intervention. Sarah had enrolled in abnormal psychology or psychopathology courses to learn about schizophrenia and manicdepressive illnesses, but she found these traditional courses uninspiring and mostly irrelevant to community work. What actually worked proved more pragmatic than what was presented in traditional university instruction. Sarah assumed a role as coordinator of CSS at a time when High County received its ﬁrst community support program block grant. Although eager to try her ideas in an environment where resources were committed to discharged patients, she had more than just professional interests. Her brother had been diagnosed with schizophrenia, and after many hospitalizations she concluded that they had largely been ineffective. Sarah had strong feelings and personal dedication regarding the direction of mental health services. A 1982 grant report described the services she inherited from the previous coordinator: These included traditional [my emphasis] clinical services such as daily group therapy, case management, crisis intervention, individual therapy, early morning and evening weekly therapy group and medication group. . . . Non-tradi-

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tional [my emphasis] psycho-services consisted of pre-vocational assessment, recreation therapy, assistance in ﬁnding and maintaining independent living, contact with landlords and employers, money management and independent living skills development. (High County Mental Health Center 1982a)1

This contrast between “traditional” and “nontraditional” suggests where Sarah was to place the emphasis. In the realm of the nontraditional, and in contrast to psychodynamic perspectives, was the language of her situated knowledge: “assistance in ﬁnding and maintaining independent living, contact with landlords and employers, money management and independent living skills.” Former “patients” could live outside the hospitals as long as they had assistance in managing money, negotiating apartment leases, and buying groceries. Her early daily and community-based successes encouraged her to ﬁnd supportive funding mechanisms. Sarah turned to three funding sources to help build a ﬂedgling CSS: state grants, county taxes, and federal and state Medicaid. The earliest substantial federal and state gesture to community support services came in the form of partial hospital program (PHP) monies. What made a hospital program partial? Hospitals had been making adjustments for years, developing aftercare programs, residential programs, day programs, and then ﬁnally, partial hospital programs. Because recipients of PHP services did not live at the hospital, “partial” mostly signiﬁed a transitory status where individuals lived in the community at night but participated in day group activities at the hospital. The disciplinary knowledge organizing the PHP practitioner was medical, psychiatric, and rehabilitative. Group workers taught PHP recipients daily living skills. The NIMH turn to “community placement” encouraged hospitals to use Medicaid to fund PHP services: activity and recreational therapy, life skills training, and psychosocial services. Likewise, as long as they followed Medicaid guidelines, creative program directors like Sarah could establish PHPs independent of hospitals. In retrospect, even though one foot was in the hospital disciplinary knowledge and one foot in the emerging CSS social ﬁeld, PHP was a signiﬁcant instrument for system change because it provided forward-looking practitioners with a ﬁnancial mechanism to establish a foothold in the community. Of course, Medicaid guidelines do not spell this out. Practitioners used their situated knowledge to discover how old ways could be adapted to the future.

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Although High County arranged the elements of its early CSS social ﬁeld around PHP monies and services, PHPs remained a point of controversy among staunch advocates of community programs. Activity therapy, a fungible PHP activity, reminded many of macramé and pottery classes, and the latter were indelibly associated with hospitals and custodial care. Most important, case management was not a funded PHP service. Consequently, Sarah used her situated administrative knowledge to maneuver and manipulate PHP guidelines.

TRANSITION FROM GROUP TO INDIVIDUAL WORK

During a six-year period (1983–1989) CSS staff 2 spent 52,088 hours (table 3.2) organizing 192,504 hours of client activity. In table 3.1, I divided the number of client activity hours into each billable category. Clients spent 67 percent of their time in PHP group activities—21 percent in life skills training, 15 percent in activity therapy, 14 percent in daily group, 4 percent in group therapy, and 13 percent in recreation. From the clients’ perspective, this was not a program of individually tailored community-based treatment. Funding heavily favored institutional group work; Sarah wrote in the fall of 1982 that the North program will add activity therapy and recreational therapy to conform with the partial hospitalization guidelines and also plans an additional weekly group psychotherapy. (High County Mental Health Center 1982b)

And in early 1984, she noted that services were beginning to involve more staff in the daily group structure to offer clients a greater variety of group experiences. This is an attempt to accommodate the inﬂux rate into the program, to maintain a manageable group size, and to afford clients a greater choice of group activities. (High County Mental Health Center 1984a)

Because clients received mostly group-based services, one might expect that Sarah needed only group workers; however, an analysis of staff time (table 3.2) suggests otherwise. CSS workers spent the bulk of their work (63.4

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TABLE 3.1 CLIENT ACTIVITY, 1983–1989 CLI ENT ACTIVITY TYPE

TOTAL HOU RS

PROPORTION OF SI NGLE ACTIVITY TO TH E TOTAL

life skills training activity therapy daily group recreation/activity case management transportation medications group therapy vocational

39,882 29,626 26,830 25,894 16,663 14,485 9,421 7,131 7,466

21% 15% 14% 13% 8.5% 7.5% 5% 4% 4%

SU BTOTAL

177,398

92%

Other client activity listed below: here, combined ⇒ assessment community integration crises family therapy nursing prevocational individual therapy

15,106

8%

192,504

100%

TOTA L

percent) performing individual case management work—case management 31.7 percent, individual therapy 5.8 percent, medication 7.2 percent, transportation 7.0 percent, vocational 6.7 percent, and prevocational 5.0 percent. Why did clients get mostly group work while CSS workers conducted mostly individual work? Simple arithmetic3 shows, in general, that a single group worker spent one hour with four clients; it was surely efﬁcient, but more important, when one conducts and bills enough fungible group time, a portion of the staff time is freed for individual work that is not billable but perceived as necessary.

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TABLE 3.2 STAFF TIME, 1983–1989 STAFF ACTIVITY TYPE

TOTAL HOU RS

P E RC E NT O F TH E TOTAL TIME

case management life skills training medication transportation activity therapy vocational crisis individual therapy daily group prevocational recreation/activity group therapy nursing assessment community integration family therapy

16,527 3,745 3,745 3,688 3,248 3,469 3,283 3,010 2,867 2,620 1,709 1,629 924 806 620 198

31.7% 7.2% 7.2% 7.0% 6.2% 6.7% 6.3% 5.8% 5.5% 5.0% 3.2% 3.1% 1.7% 1.5% 1.2% 0.4%

TOTA L

52,088

100%

Because hospital-based services were seen as antithetical to the CSS project, Sarah was not a big fan of PHP group activities. She used PHP monies to help subsidize early experiments in underfunded, community-based case management services. In contrast to clinic-based group work, workers helped clients pay rent, drive to appointments, take medications, explain mental illness to employers, and negotiate roommate crises—all “in vivo” community activities. And even though the individual work reduced hospital admissions, a full-ﬂedged disciplinary paradigm for case management assessment and intervention was not yet practiced, nor was the role of the case manager clear. Sarah drew upon her situated knowledge of casework and took advantage of PHP guidelines. Her staff conducted individual work with consumers, not because the state had mandated and funded case management, but because they experienced ﬁrsthand that focused case management was more effective than group work at keeping consumers out of hospitals. Sarah, in the early

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years, discovered good case management: monitoring mobility. It would eventually become the core of CSS.

STRUCTU R I NG COMMU N ITY TIME

My analysis of the age distribution (see table 3.3) of the earliest communityplaced clients supports my thesis about the need for case managers; between 1983 and 1989, 70 percent of the CSS population was between nineteen and forty. The older patients (over 50) had not yet been discharged, nor had they simply been transferred to nursing homes and intermediate care facilities (ICF)—an effect of transinstitutionalization, not deinstitutionalization. And those below eighteen had been absorbed into the child welfare social ﬁeld.4 Thus, CSS captured a young adult and middle-aged constituency, and this group placed speciﬁc practical demands on staff time. Had mental illness not interrupted the lives of nineteen-, thirty-, and fortyyear-old individuals, they would have reported typical life achievements: high school and college graduation, employment, marriage, parenthood, and home ownership. That is, within these same cohort groups, the “non-mentally ill” structure their time by commitments to education, to career, to marriage and partners, and to children. However, when the normative and ordinary is taken from the mentally ill, ﬁlling the nine-to-ﬁve routine is strenuous and challenging. While hospitals structured time from sunrise to sunset, in community placement former patients were expected to ﬁll time with their own self-directed activities. NIMH had insisted that community workers integrate the discharged patients into mainstream life, but this was not so easily done when most do not or cannot ﬁnd work, and when many ﬁnd it hard to establish ongoing relationships. PHP mainstay services—life skills training, activity therapy, recreation therapy, and prevocational services—were brought into the CSS social ﬁeld, and they were used to structure clients’ time in the open system of the community. Surrogate life activities allowed the CSS social ﬁeld to realize the TABLE 3.3 CLIENT AGE DISTRIBUTION, 1983–1989 B ELOW 18

19 – 29

30 – 39

40 – 49

50+

2.6%

41.7%

28.5%

15.6%

11.5%

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principle of normalization. Case managers and CSS directors learned to organize suburban space and activities so as to imitate the cultural norms regarding work and leisure. Whereas in the clinic and hospital, PHP programs privileged group and site-speciﬁc surrogate activities, CSS uniquely and increasingly aimed its work at multiple community sites. The CSS social ﬁeld sought in vivo intervention because movement between various surrogate and real activities was not accomplished in a straightforward way. It follows that (see table 3.2) staff spent roughly as much time in providing transportation (7.0 percent) as they did in providing medication (7.2 percent), life skills training (7.2 percent), and vocational (6.7 percent) services. Under the rubric of continuum of service the CSS social ﬁeld organized and structured clients’ time in the community. Daily skill training and recreational activities ﬁlled clients’ time at CSS ofﬁces while case managers learned to monitor clients’ movement through various suburban spaces or “least restrictive environments.”

THE SUBJECTIVE CONDITION OF WORK: MANAGING MOVEMENT

The grant applications and quarterly summaries I studied acknowledged the direction of change. The effort to track clients’ movements was remarkable and evident in outcome measures. On a quarterly basis, Sarah queried staff about four client domains: medications, employment, social skills, and living situation. In table 3.4 I list the four domains and their respective inquiries into client behavior and status. These life domains highlight how monitoring movement became essential and problematic. I found two emerging management tasks. First, there was monitoring. How did staff know whether clients refused meds or took them regularly? They monitored clients’ behavior. The same was true for social skills. Because case managers had inspected clients’ dwellings often enough, they could draw the conclusion that clients cleaned their apartments “intermittently.” The second and related work task was the need to encourage transition, change, and movement. I draw this conclusion from the gradation of the domain inquiries. For example, a client moved from “refusing meds” to a state of medication “self-regulation.” Staff, in turn, learned that clients’ movement within a life domain was variable; in a three-month period, a single client resided in a hospital, lived with a family member, transferred to a halfway

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TABLE 3.4 FOUR CLIENT DOMAINS MEDICATION

EMPLOYMENT

S O C I A L S K I L LS

refuses meds

not pursuing training for employment

rarely

talks favorably about meds

intermittently

takes meds as prescribed with self-regulation

attending GED or job training/working as a volunteer completed GED or job training or interviewing for jobs or recently placed in a sheltered work setting working regularly parttime in a sheltered setting or regularly parttime in a competitive setting working full-time in a sheltered setting or regularly full-time in a competitive setting working regularly fulltime in a competitive setting

unknown

unknown

unknown

takes meds when administered orally

takes own meds irregularly

takes meds as prescribed with monitoring

1/4 the time

1/2 the time

LIVI NG SITUATION

lives in hospital or other institutional setting lives with relatives but essentially being taken care of lives in community transitional living settinghalfway or transitional semistructured housing

3/4 the time

monitored apartment living

regularly

independent living in an apartment, house, by self, with friend, with spouse unknown

house, or moved to a supervised apartment. The residential supervisor reported in 1986 that Clients have been referred to the apartments for a variety of reasons. Some were discharged from hospitals without adequate housing, a few had no place to live and were “drifting,” and others needed a place to stay due to conﬂicts with family members or roommates. Several clients have moved from the Res-

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idential Group Home into the apartments as a transition to independent living. Most of the clients were able to establish permanent, independent housing. (High County Mental Health Center 1986d)

Administrators and workers used metaphors of time and space to name program services. There were “temporary apartment living” programs and “transitional employment opportunities.” Housing in particular was cast in time dimensions.“Permanent” was opposed to “temporary” and “short-term” was opposed to “long-term” housing. Each client domain—medication, employment, social skills, and living situation—had measurable baseline behavior that emphasized a lack of selfmonitoring: client “refuses meds”; client “is not pursuing training for employment”; client “rarely” keeps house clean or pays bills; and client “lives in a hospital or institutional setting.” Clients became “graduates” of various programs. Staff, then, worked to move clients from an implied negative status, “refusing meds,” to a more positive one, “takes meds as prescribed.” The use of a graduation metaphor helped organize both the continuum of services and the workers’ activities. Sarah wrote that “CSS continues to offer a variety of vocational services. . . . Six ‘graduated’ after having completed six consecutive months of employment” (High County Mental Health Center 1987). And one year later she wrote, Six percent of the ICF-MH [Intermediate Care Facility-Mental Health] clients graduated to a less restrictive setting during the ﬁrst quarter of this grant period. The graduates have continued to function well in the community. After nearly three years of operation, only one graduate has been re-hospitalized. (High County Mental Health Center 1988)

Upon graduation, clients were expected to become self-monitoring, implying a natural progression toward an ideal behavior or state. The progression toward “self-regulation,” “regular employment,” and “independent living,” implies, of course, movement from a nonnormative to a normative state. In practice, however, case managers rarely experience clients in ﬁxed states. Fluctuation might better capture the movement along a single domain’s gradations. And it was exactly this ﬂux in time and space that workers learned to monitor. Customarily, the traditional mental health centers expected clients to appear at ofﬁces, but Sarah wanted workers to go to clients. Given the need

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to conduct community monitoring, she had no choice but to reject ofﬁcecentered practice. It was with the help of social work professors at the University of Kansas that Sarah gradually transformed situated case management into disciplinary knowledge. In 1984 she wrote, High County Mental Health Center contracted with the Kansas University School of Social Welfare to become a placement site for their case management training project. Four M.S.W. candidate students are providing case management services to clients while receiving on-going supervision from K.U. faculty. (High County Mental Health Center 1984c)

And later: In Oaklawn, the four M.S.W. students from the K.U. School of Social Welfare’s Case Management Project just completed their ﬁrst semester in the CSP. They worked intensively with a total of sixteen clients who were considered “high risk” for hospitalization. Only three of the sixteen clients were hospitalized, and one has returned to a supervised apartment. One client dropped out of treatment. The other clients participating in the project remain actively involved in our CSP. The students will return in mid-January to begin a second semester placement. (High County Mental Health Center 1984b)

The university research project brought the incipient structure of a disciplinary knowledge to CSS. Case management was, however, still so malleable that Sarah reworked the concept when ﬁnancial exigencies warranted: The second quarter of this grant period was a time of signiﬁcant change for the Community Support Services (C.S.S.). Some of the change was related to the move, while other changes were motivated by increasing ﬁnancial problems due to a reduction in Medicaid revenues. One case management position was cut, yet clients continued to enter the program on an average of 22 per month. Staff have begun experimenting with providing case management services in small groups. The groups consist of 3–5 members. The groups frequently meet in the clients’ homes and concentrate on peer support, while setting individual goals. They meet on a weekly basis. Staff hope that this will be a means of ensuring that clients get adequate time for individual concerns and

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goal setting. The numbers of active clients have increased, and case managers’ caseloads are close to 30. (High County Mental Health Center 1986b)

The CSS social division of labor became complex as the ﬁeld’s power relations expanded into housing, employment, medication, and daily life activities. Sarah relinquished control and hired (in spring 1986) supervisors—PHP, residential, and vocational—to coordinate three sectors of the ﬁeld. Together, supervisors and case managers monitored clients as they moved through the continuum of services. Partial hospital services, later renamed psychosocial services, were ofﬁce-based, so case managers transported clients to and from group activities. Vocational services bridged the center and the community. While vocational managers assisted the client at the work site, there were also signiﬁcant “prevocational” activities at the center. The center prepared and served a daily lunch so a client who volunteered with shopping and meal preparation was performing a “prevocational” activity. Other clients might help with clerical administration. Some were involved with an “exchange store” that was stocked with food and nonperishable items that could be purchased with fake money earned through volunteer work. Each sector (PHP, residential, and vocational) developed independent programs. The residential supervisor focused on housing: negotiating roommates, turning utilities on, and buying and storing furniture. Transitional and rehabilitative concepts and language were intrinsic to the residential program. The Intermediate Care Facility for Mental Health (ICF-MH), Residential House group home, and the temporary and supervised apartment program, each had established admission criteria. Clients entered the residential program at any site. Some moved from the hospital to the ICF-MH, to Residential House, to a temporary apartment, to a supervised apartment, and often to an independent apartment. Case managers assisted them at every point along the way. In fact they became adept at moving clients’ belongings, often renting vans and organizing staff /client teams. The CSS social ﬁeld demanded a practice language of movement. Few were discharged; they graduated. At CSS case managers followed clients from one suburban location to another. Sarah noted: Our residential services are well utilized. Residential House continues to be full with a waiting list. During the year, we have decreased the average length of stay from approximately eighteen months to one year. The program has

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become more goal-oriented and clients are moving into apartments more quickly. The ICF-MH continues to develop into a viable residential service for the long-term mentally ill. A couple of clients are currently preparing for graduation to Residential House. Although the anticipated length of stay is two years, some clients will progress more rapidly. (High County Mental Health Center 1985b)

Like graduating from high school and entering college, movement was seen as progress. For staff and clients graduation evoked a celebratory mood. In sum, the power relations within the social ﬁeld valorized change, transition, and graduation. Jerry Hannah’s continuum of care (chapter 2) was put into practice by monitoring change along various service sites: group homes, residential treatment centers, supervised apartments, welfare ofﬁces, work sites, CSS buildings, public parks, and many other community locations. The vocational and PHP sectors of CSS developed a similar language and practice. Although PHP gave less emphasis to graduation than to vocational and residential services, Sarah incorporated A full range of group therapies and activities. . . . Clients are encouraged to attend activity planning meetings and community meetings to contribute their ideas regarding programming. In addition to the required medical services offered by Partial Hospital programs, clients can participate in a number of work crews or projects. These include meal planning and preparation (for 40 members), newsletter group, sewing club, and gardening. In addition to these groups, clients can apply to participate in the following pre-vocational crews: Janitorial, Library, Retail Store, and Clerical. Clients who do well in these projects either ﬁnd jobs on their own or with the assistance of the Vocational Placement Specialist. Fifteen clients are currently employed who have been placed by C.S.S.’s Vocational Placement Specialist. Evening groups are offered at C.S.S. for clients who are working during the day. (High County Mental Health Center 1986b)

A continuum of service was built into every sector of the social ﬁeld. This of course meant that clients would be variously distributed along the points of service. Sarah reported that Three levels of services are currently available to members of C.S.S. The levels of service are consistent with the new medical guidelines established in March. The short-term program is available to clients who require intensive case man-

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agement services and who have unsettled issues in their lives (need housing, have no ﬁnancial resources, poor support network, etc.). The supportive program stresses peer networking and participation in the planning of partial hospital activities. Clients who are stable and require minimal supports receive medication services through the C.S.S. outpatient program. The Residential and Vocational services are available to all C.S.S. clients. (High County Mental Health Center 1986c)

Managing clients’ movements became the organizational logic of everyday work. With levels of service deﬁned, clients connected with those that matched their ability: (1) to self-regulate medication (meds); (2) to set up, organize, and maintain a household (money); and (3) to follow a routinized schedule of self-directed daily activities (manners). Movement schemes organized both clients’ and staff ’s time. When the task required moving clients from one apartment to another, the job could take three, eight, ten, or twelve hours, whereas laundry required only one hour. Likewise, clients’ grocery shopping might take thirty minutes. In this way staff and clients became dependent on their relative perceptions of the time necessary to complete tasks. Other than intuition, staff used no assessment instruments (later, strengths management would introduce one) to allocate clients among levels of service. Indeed, the idea that clients were not ﬁxed at one level of service5 and could move to higher ones meant that case managers needed criteria for graduation. Although they lacked disciplinary knowledge/power, they and clients constantly negotiated movement along the continuum. And by not strictly applying a scientiﬁc gatekeeping method (i.e., a disciplinary knowledge) to determine entry into a service level, both used the indeterminacy and used situated knowledge/power. In the early years (1983–1989), I think staff and clients transgressed the boundaries between levels and services with such varied styles, manners, and reﬂections that this produced the social ﬁeld’s practice energy. I recall the shared excitement and enthusiasm as well as the exhaustion and frustration that accompanied routinization. Sarah’s invitation to professors at the University of Kansas was the ﬁnal recognition that she needed to routinize case managers’ efforts. The organization grew, and administrators needed assurance that from one case manager to the next outcomes would be similar. There was also the practical issue of bringing new case managers into the project; a disciplinary knowledge would standardize training. And her continuum of service begged for a goal-oriented scheme to measure clients’ movements. In short, Professor Charlie Rapp

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would code the early situated practices of CSS, add his insights, test, and then produce the strengths case management model to be discussed in chapter 4.

NAMING THE SERVICE RECIPIENT

Sarah used “client” and “consumer” to describe and name the service recipient of the CSS social ﬁeld. She wrote, “activity is planned to encourage client involvement in consumer advocacy” (High County Mental Health Center 1984a). The use of these terms raises questions and requires further interpretation. Who are the clients and consumers? Do they refer to the same individuals? If so, why? In all quarterly and year-end reports, Sarah referred to recipients as “clients,” as “the long-term mentally ill,” and as “the chronically mentally ill”; however, she used “client” most of the time. One might assume that this was her professional policy language. Social work has used “client” for a very long time. What was different about the CSS usage of “client” was the inconsistency and slippage among several categories; in contrast, in the hospital social ﬁeld, practitioners uniformly applied the term “patient.” Adjectives such as “chronic” and “long-term” signiﬁed the need to have a continuum of service for an indeﬁnite duration. In contrast, “short-term mental illness” or “acute mental illness” suggests time limits. Another commonly used name, still in usage today, was “severe and persistent mental illness.” Each of these names signiﬁed that the CSS social ﬁeld had secured a long-term constituency. As a policy language this secured funding. In practice, case managers did not call service recipients long-term mentally ill. Practitioners used names for the recipients (client and consumer) that referred to responsibility, accountability, and choice. If “patient” identiﬁes a passive, sick, and dependent service recipient, then for most practitioners the term “client” names a self-directed communitydweller. Yet the use of the term “client” was not threatening to practitioners because it did not place the service recipient outside the boundaries of the CSS social ﬁeld. To say,“I am a client of CSS” meant that practitioners still had constituents. The historical formation of CSS allowed a relatively ﬂexible power relationship between practitioners and service recipients. The “patients” loosened tie to the closed system of hospital signiﬁers, I argue, was mostly responsible for the change to “client.” In the open system of the community CSS service recipients could be seen and could see themselves through nonmedical signiﬁers. It is not surprising that many practitioners and service recipients

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appropriated the term “consumer.” This is after all America, a society that valorizes and links every conceivable lifestyle to speciﬁc patterns of consumption (Fine and Leopold 1993). Service recipients were consumers of the CSS continuum of services. And, perhaps most important, the subject category consumer is most inclusive, quotidian, and normative. And because it is so inclusive, the category consumer challenges Foucault’s dividing practice; because we are all consumers, no professional language can easily distinguish the practitioner from the service recipient. It is doubtful that the use of the designations “client” and “consumer” actually signiﬁed a relationship of equality. Clearly, professionally driven programs and practices were in control of the social ﬁeld’s power relationships. For example, staff arranged for clients to take control by devising prevocational programs that placed staff and clients on equal footing in the kitchen, library, clerical area, and in daily group programs. While CSS staff occupied a superior power relationship in the social ﬁeld, on the other hand, in order to encourage “client involvement in consumer advocacy,” few had to worry about recipients’ rebellion. And one could argue that the CSS social ﬁeld is unique: severe mental illness can temporarily suspend parity in relationships. An afﬂiction that affects thoughts and emotions as severely as schizophrenia hardly makes one a candidate for leading strategic political battles against social workers and the social welfare state. Consumer advocacy was seen by Sarah as an important activity to achieve the overall goal of dismantling the hospital social ﬁeld. By encouraging activist (former) “patients” to think of themselves as consumers of CSS, the new case managers became invested in soliciting more state monies for the project. I conclude, in part, that her use of the term “consumer” was a political maneuver to secure continued support for CSS. But that was not all. Sarah also wanted clients to take charge and live normally without intrusive therapists, doctors, social workers, and helpers. She believed that creating programs and services that solicited client involvement was helpful, therapeutic, and important to the goal of normalization. Sarah’s use of the terms “client” and “consumer” shows how her daily practice was not yet fully formed (strengths management, for a period of time, would forcefully replace “client” with “consumer”). She pressed the CSS language and programs to incorporate more than one term. Perhaps she purposively leveraged the ambiguity. Or perhaps it was not at all conscious. I need not account here for Sarah’s motivations. I need only point out that the categories of client and consumer had early origins and continued to exist at CSS.

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And much of the tension between these terms can be captured in a program that was both outside and inside the purview of the CSS social ﬁeld: Outreach Place. This program is best described in the words of an advocate: Since the long-term mentally ill frequently depend on families as a major source of identity and social support, the ﬁrst goal of FFMH, Inc., [Families for Mental Health], High County, was to establish a drop-in center. The objective was to provide a comfortable social atmosphere to help members learn skills to get into the community and establish their own peer relationships and personal support system. On 6-19-82, a drop-in center, “Outreach Place,” was opened. It was located at the East Multi-Service Center. Because of limited space and funds, “Outreach Place” was open on Saturdays, 1–500 p.m., and was hosted by families. After receiving funds from a federal block grant in 1983, High County Mental Health Center, FFMH Inc., applied for $25,000 in grant funding in March of 1983 to expand. (High County Mental Health Center, The Outreach Place Handbook:2)

Filling CSS with programs only Monday through Friday (8 a.m. to 5 p.m.) limited recipients’ access. The Outreach Place opened on Saturday to meet an important need in the continuum of service. Drop-in advocates were not CSS employees, and they adopted the label of “consumer” to deemphasize the medical, clinical, professional, or disciplinary language. Examining how Sarah wrote about the Outreach Place shows that the only difference between that text and her policy language was in her use of the term “consumer.” The Outreach Place is a Psycho-Social Rehabilitative program serving the mentally ill of High County. The physical facility is located in North County although consumers throughout the Mental Health System are encouraged to attend The Outreach Place and its activities. This is being achieved through mutual efforts of the Mental Health Center in Oaklawn, and the staff of The Outreach Place. The primary goal of The Outreach Place remains that of a drop-in socialization center where consumers are encouraged to participate in both formal and informal gatherings that would enhance and develop skills in socialization, independent living, and peer relationship in a non-clinical setting. Opportunities are provided and voluntary participation is encouraged to develop these skills, accept responsibilities and experience leadership roles. October was the birth of a totally consumer-planned month of activities. At the monthly meeting in September, it was decided that the membership would co-ordinate program activities for that month. (High County Mental Health Center 1985b)

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Closely related to the term “consumer,” the above paragraphs convey the idea that service recipients were “members.” One gained membership into the Outreach Place, a unit ﬁscally responsible to CSS. Membership, of course, underscored one of the drop-in center’s goals: “voluntary participation.” The use of the term “client,” on the other hand, was not so readily associated with volunteerism. One does not “voluntarily” choose mental illness and then “voluntarily” choose to seek help at CSS. But one can choose to join a dropin center. Choice was an important concept to valorize. It signiﬁed that the recipients wanted help, and in the minds of most CSS advocates this was opposed to the “unwanted” help hospitals had provided. Most CSS professionals wanted to believe that clients desired services and programs. To want something meant it was self-directed. Thus the use of the designation “consumer” also created the sense that former “patients” chose CSS services. I think that “client,” “consumer,” and “member” were unique to the CSS social ﬁeld. In particular, these terms show how CSS was structured by an indeterminacy that was not easily foreclosed upon. Mental illness is not a voluntary condition. One does not choose to be so ill that thoughts and emotions result in a tangled web of fear, anger, sadness, and confusion. If the condition is not voluntary, then surely the system devised to help is no more so. But the policymakers and practitioners who built CSS needed to both gloss over the involuntary nature of mental illness and embrace it. Embracing it was evidenced by the use of the label “client.” Referring to service recipients as clients acknowledged that a welfare social ﬁeld had captured a constituency and signiﬁed thus a paternalistic relationship. Consumer and member, in contrast, pointed to how the staff believed that service recipients freely wanted help. The dualism communicated essentially that “yes, of course, you do not choose to be ill but now that you are, take control of how you get help.” The use of “consumer” conveyed the sense that recipients wanted and chose CSS. The next chapter will show that the architects of strengths management brought this usage of choice directly into their early model. The dualism also shows how the CSS social ﬁeld reorganized time, space, mobility, economics, and the disciplinary knowledge to rename or reclassify its service recipient. The difference between the hospital and the CSS social ﬁeld was that the latter, because it was in the open system of the community, developed broader power relationships than the medical model, thereby producing opportunity for a plurality of subject positions: client, consumer, and member. In sum, in the 1980s case managers were installed as the central ﬁgures in the social ﬁeld that replaced hospitals. They learned by doing; no speciﬁc disciplinary knowledge guided their practice. But by 1997 this was no longer true.

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After the passage of the 1990 Kansas Mental Health Act, a case management model called strengths management was institutionalized. By the start of my study, the new language, the new instruments, and the new system of classiﬁcation were already taken for granted. In the next chapter I will review the basic assumptions of strengths case management.

C HAPTER 4

Strengths Case Management

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eveloped at the University of Kansas School of Social Welfare (KU), strengths case management was commonly used at mental health centers in Kansas. At the time of my study, CSS program directors were obliged, in exchange for receiving state management monies, to send their case managers to strengths workshops. Sponsored by the School of Social Welfare, Ofﬁce of Mental Health Research and Training, which had a contract with the state of Kansas to provide technical assistance and training, two-day training workshops were offered to case managers. The ofﬁce also collaborated with the Kansas Division of Mental Health to monitor and evaluate statewide CSS outcomes. Several KU faculty were vital in the production of a rare instance of a statewide adoption of a single disciplinary knowledge. Indeed, for KU, strengths management became a cottage industry, practically and intellectually.1 Once the CSS social ﬁeld was created by national, state, and local efforts, ﬁlling the ﬁeld with workers, organizational structures, and helping paradigms varied according to the peculiarities of local and state mental health systems.2 State administrative mandates authorized the new power relations of CSS, not unlike the power handed to former hospital superintendents and legislators. At three mental health centers (1982–1984), social work professor Charles Rapp led a ﬁfteen-year effort to develop, test, implement, and evaluate strengths management. I asked a long-time director of the KU technical assistance and training program about the history of strengths management. She reported that

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The Strengths Model was developed in the early 1980s, it was known as the “Developmental-Acquisition Model of Case Management.” This model was initially outlined by Chamberlain, R. & Rapp, C. (1983), in “Training Manual for Case Managers in Community Mental Health,” published by the KU School of SW. The model was designed to address the social problems of persons with severe and persistent mental illness. This model makes use of “reidentifying a person’s strengths” and actively creates situations (environmental or personal) where success can be achieved and the level of personal strength enhanced. The second assumption is that human behavior is largely a function of the resources available to individuals and assumes that a pluralistic society values equal access to resources (Davidson and Rapp 1976; Rappaport 1977). The ﬁrst demonstration of case management mandated by the Kansas legislature was the Kansas Case Management Act of 1988. From that act case management was seen as an effective way of helping people with mental illness. With the passage of the Kansas Mental Health Reform Act (1990) and with the shift of funding to community-based services, case management ﬂourished. Mental Health & DD Services (state administrator of CSS programs) mandated that all case managers receive training. As part of the Kansas Case Management Act, legislation said that all case managers would receive training from an approved (by MH/DD) training program (KU). (Personal communication 1998)

High County, the site of my research, was one of Charlie Rapp’s ﬁrst testing locations, and it remained steeped in the discourse and politics surrounding the model. George Vega, special assistant to the commissioner of mental health, wrote to the executive director in 1986 to announce that Mental Health has contracted with the University of Kansas of Social Welfare to provide technical assistance in the development and evaluation of psychosocial programs. Dr. Charles Rapp will be consulting with community mental health centers regarding their respective needs for assistance. (High County Mental Health Center 1986a)

After Professor Rapp and his associates developed the idea of strengths management in the early 1980s, he received several NIMH grants to test the model. He then used this research to help shape the 1990 Kansas Mental Health Reform Act; ﬁnally, he introduced a means to evaluate strengths management

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(Rapp 1998:56–60). I argue that a major difference between situated and disciplinary knowledge is to be found in the scientiﬁc legitimization of the disciplinary. And KU was well suited for the task. Situated knowledge can and often does become incorporated into the disciplinary; Rapp had learned, for example, from Sarah Teasley’s experience at High County. But once he brought his pilot research data to the university and coded the variables, he attempted to transform the situated terms and practices into an operationalized disciplinary language. When researchers desire to prove a model’s effectiveness, they often take the abstract and make it concretely measurable. Second, in studying practice, researchers have identiﬁed the problem of ﬁdelity, that is, practitioners must faithfully follow the model because to do otherwise makes it difﬁcult to control for practitioners’ effects. Researchers need standardization and state mental health departments seek to homogenize social work practice. Therefore, the desire to standardize case management in Kansas coincided with researchers and state agents motivated to act. The result was an established and unique collaboration, one that many schools of social work and state systems envied. As High County’s early situated practice of case management passed through the scientiﬁc process at KU, a boundary between the disciplinary and situated knowledge/power of case managers was produced. In short, a speciﬁc biopower was produced for the practice of case management. It is not clear, however, that the theory and the scientiﬁc process left room for situated practices. Although in the early 1980s CSS programs had mandated no particular management disciplinary knowledge, by the 1990s practice interventions became institutionalized. Below, I use ethnographic data to examine strengths assumptions with an eye toward identifying the limits and potential of standardizing helping relationships through prescriptive models.

WHAT IS STRENGTHS CASE MANAGEMENT?

To describe strengths management I use my notes and transcriptions of recorded training sessions I attended together with thirty-ﬁve newly hired case managers from throughout Kansas in spring 1997 (Strengths Basic Workshop, March 19–18, 1997). The workshop leader, Betsy Taylor (licensed master’s social worker and adjunct professor), was the director of KU’s Technical Assistance and Strengths Model Training Program and taught a course on strengths case management. Prior to working full-time at KU, Betsy had

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helped homeless mentally ill men and women connect with community support programs. She had by this time been traveling throughout the United States and England conducting strengths management workshops. KU ﬁlled the Kansas CSS social ﬁeld with a model that became a dominant paradigm; it was not the only model, however. During my ethnography, I learned about others from case managers. But when asked to name the most important inﬂuences on their daily work, the case managers I studied identiﬁed KU’s strengths workshops. I have used the workshop to examine the normative and actual experience Rapp and his colleagues incorporated into the model. Although there are dozens of articles and several books that explore its basic tenets (Rapp 1998),3 I wanted to learn strengths management by getting out of the textbook and professional narrative and into the everyday oral narrative of a trainer; it was through the latter that I sought to understand what it meant to be taught strengths case management. Betsy, good at leading workshops, had learned to deﬁne strengths management by showing the listener what it was not. She said, “Okay, I’d like to go through history, real brieﬂy. There’s four case management models identiﬁed by the National Institute of Mental Health. So, if you’re here and you ask why do we use strengths, as opposed to another model, you’ll be able to know.” In her opening remarks she persuasively presented the model as nationally recognized, and NIMH approval was certainly noteworthy. Betsy then described the other management models one by one: Okay, the ﬁrst one is called the Psychiatric Rehabilitation Model. And, it basically comes out of Boston University, or BU. It is very heavy on skill building. That’s where the emphasis is. The helper records and scales a person’s functional levels, not what the person thinks about themselves, but what the professional sees as someone’s level of function. There is a twelve- to thirteen-page overview called, “A Functional Assessment.” The strengths model has a onepage front-and-back assessment, so that is quite a difference there.

Paperwork for strengths case management, she argued, was not overwhelming because it did not require lengthy assessments of social, psychological, and everyday functioning. Because writing and recording matters to busy case managers, Betsy’s emphasis on parsimony was generally appreciated. Moreover, as she pointed out next, The Psychiatric Rehabilitation Model assessment is very comprehensive. There are a lot of similarities between the strengths model and the BU model. But I

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think the main difference is probably in the name: Rehabilitation. When you see or think of the word “rehabilitation,” what comes to mind? What happens if you’re in rehab? Why would you go to rehab? Okay, if I’m in a car accident and I go to rehabilitation, I am focusing on something that needs ﬁxing, something is broken. So you’re starting from a deﬁcit point of view. In the BU model, the concept of recovery is similar [to strengths], that is we’re both working towards recovery. But the approach is different. In Psychiatric Rehabilitation, you’re starting on the problem, the deﬁcit, and the skill that needs to be added. Strengths isn’t about rehabilitation. Strengths is ﬁnding out who the person is and what they want. It’s not about their diagnosis, but again, their desires, their wants: what are their goals in life? And I think that’s really critical.

While the Boston psychiatric rehabilitation model is a deﬁcit model, strengths case management is not. Although brief in her description of the program for assertive case management, her comments bear presenting here in their entirety: Sometimes you also see it called the ACT model. PACT stands for Program for Assertive Community Treatment, and ACT is Assertive Community Treatment. The PACT model came from Madison, Wisconsin, and the PACT model was the early forerunner of a comprehensive program in the community. This is the ﬁrst model that really started looking at comprehensive case management. It kind of put case management on the map. There was a major study published in Hospital and Community Psychiatry, where they assigned people, who presented in crisis, either a case manager or not a case manager. And what they did is they compared the two groups. And, what they wanted to know is how people with case managers fared against people that did not have case managers. They found out that the people served by the PACT model did signiﬁcantly better at every outcome variable than those that did not have case management. The conclusion was that long-term hospitalization might be avoidable if comprehensive supports were available in the community. It was a very, very, powerful study. It really showed, for the ﬁrst time, that what all you guys are doing, case management, really does make a difference. The conclusion was that people with severe and persistent mental illness needed a different kind of helping approach than traditional outpatient therapy. And what it showed was that the PACT model replicated what was going on in the hospital, but it did it in the community. Let me give you an example. A lot of people in the hospital were involved in making ceramics, for example, you know, like a real popular thing! Well, the PACT model organized a

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ceramics class in the community. And, they would conduct cooking classes at the day program. People learned how to make spaghetti for twenty—you know, ever how many people were in the day program. Again, this is different from strengths. In the strengths model, if someone wants to learn how to make spaghetti, they learn how to make it for themselves or their family, not twenty or forty people. So there’s a real difference there. The other thing with PACT is it’s a multi-disciplinary approach, not a designated case management approach. Now the multi-disciplinary part is also a piece of the strengths model, where the multi-disciplinary team, the psychologist, the nurse, the psychiatrist, the social worker, the plumber—whoever is in that day—are all seen as resources. But, they are not the core team. In strengths, the core team is a case management team with a team leader.

In these comments Betsy pointed to strengths management’s departure from group-based social work; in short, this was work with individuals. The old partial hospital program disciplinary knowledge was inappropriate for real-life intervention. Who in the audience could disagree? Most nodded in recognition that cooking spaghetti for forty people is abnormal and institutional. The PACT model scientiﬁcally showed us that “outpatient therapy” was outmoded; one could sense that Betsy appreciated this contribution. And, third, we were told about the broker model: And sometimes you’ll also see this referred to as the generalist model. With the broker model, linkages are it. When you’re operating and doing case management under a broker model, what you basically do is link individuals to resources. For example, you have an individual that wants an apartment. If you’re doing a broker model, you might call the local housing authority. And, you know that Joanne works at the housing authority. You call up Joanne and say,“I’m working with an individual that’s really interested in the Section 8 program, and I’m going to give him your address.” You asked Joanne when she could meet with your client. So when you tell the consumer where the housing authority is, what day, and what time, your job is done. You’ve linked them to the housing authority. But you really haven’t gone with them or helped them. And that’s one of the big downfalls of the broker model. There’s been research study after research study showing that the broker model does not work. It does not work. And you’ll still hear, to this day, people using the broker model. I get the opportunity to go all over the country, and I’m still hearing it. People are using the broker model. It just kills me. You know, there’s research, research, and research that says it doesn’t work and people are using it.

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And there is another way to think about the Broker model to make it clearer. Has anyone ever gone on a vacation? Most of you guys. Okay. Did anyone call a travel agent? Okay. And when you called the travel agent, what happened? The case manager in the Broker Model is like a travel agent. The strengths model is more like a travel companion. When traveling, it is really neat to have someone along, a travel companion, to help sort out, for example, how, for the ﬁrst time, to ride a subway. And that’s kind of how the strengths model is different than the broker model.

The contrast among these models, according to Betsy, showed that CSS social ﬁelds were often anchored to various models of case management. The model used by any state or local organization depended on the historical development of the region’s CSS social ﬁeld. Although I did not experience Betsy’s comparisons as aimed at discrediting other models, she sought, nonetheless, to highlight strengths case management as a legitimate contender among alternative disciplinary schemes. In setting strengths against other models she convinced her audience that what they were about to learn was more than common sense; it had been scientiﬁcally researched, tested, and legitimated. Betsy’s was a subtle criticism, and her mode of presentation avoided pejorative judgments. She said, “research, research, and research” has shown that some models are better. Her introduction left little doubt that Kansas used science, not mere opinion, to adopt strengths case management. We now understood why we were at the workshop. There was no reason for lengthy comparisons. After all, Kansas had altered its Medicaid rules and administrative regulations to require strengths management. “Everyone in Kansas that’s a case manager in mental health,” Betsy reported, “is required to attend the two-day basic,” and “in Kansas the Personal Plan is the mandated treatment plan for case management.” In the same way that a client in Kansas cannot choose among two or three kinds of social ﬁelds, ironically, case managers were given no choice about case management models. Thus, policy practice in Kansas had ﬁlled the social ﬁeld with a single disciplinary knowledge. Disciplinary schemes in social ﬁelds like CSS are necessarily about behavior; social workers and case managers hope for behavioral change. For the purposes of practice, CSS took its lead from the policy process. Accordingly, the policy to depopulate state hospitals produced among released patients the need to think independently and adapt to prevailing norms. The self-conscious use of helping relationships to inﬂuence self-directed behavior should not come as a surprise, nor is it particularly novel to social work. The idea that

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one should use the effect of a relationship to produce independent behavior is as old as parenting. Indeed, all state or cultural projects, including those directed by social work, seek some kind of autonomous behavior. I preface my analysis of strengths with the above assumptions because I do not think one should see as extraordinary its mission to produce normal, self-directed behavior. There can be little debate. Strengths management techniques are intrusive, and case managers must encroach on the everyday lives of clients. Yet no one in his or her right mind would endorse an absolute form of nonintrusion: neglect, for example; even the most laissez-faire among us would not favor that. Thus, our choice not to abandon the mentally ill entails a second choice: to embrace some kind of disciplinary knowledge that produces self-directed behavior. My analysis of strengths management should not be mistaken for a study done merely to indict or demonstrate that social workers regulate and normalize the body; such an approach, very common today (especially among postmodern historians), would be an exegesis of the obvious. It is not my intention to ﬁnd fault with strengths management and pitch it on the evergrowing heap of misguided social projects or controlling discursive formations. I examine its assumptions to demonstrate why strengths management ﬁt so well with the social ﬁeld constructed by Kansas policymakers. I want the reader to understand strengths management so that my examination and contrast with case managers’ situated knowledge/power (chapters 6, 7, and 8) is revealing. Thus, I navigate among strengths management’s assumptions for methodological reasons; to see and discuss situated knowledge, one must ﬁrst know the kind of work strengths management is capable of. In identifying what strengths case management is not designed to perform, one can more clearly see the function of situated knowledge.

THE STUFF THEY DESIRE

Betsy told us next that the purpose of strengths management is “to assist people, who we call consumers, to identify, secure, and sustain the range of resources, both internal and external, needed to live in a normally interdependent way in the community.” But, she rhetorically asked, “what does this deﬁnition mean?” “The words,” she assured us, “were picked carefully.” She pushed on, “in case management we’re assisting people to get what they want. We are not treating. That’s very important. I want you to hear that. Case managers do not treat. They assist people to get the goals that they come up with, the stuff that they desire.”

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By resources “we mean community resources, and that is where your skill comes into play.” Betsy admonished us about not becoming case managers who think they are superman and make superpower claims, such as “I know where the resources are, I can help you secure them.” It was true that we were to help ﬁnd resources, but “the hard part, again, is sustaining, or keeping the consumer’s relationship with the resource ongoing.” We were further instructed to differentiate between internal and external resources. “External resources are all the things around us. This room is an external resource.” However, there are also “internal resources.” For example: “John’s sense of humor is an internal resource that he’ll always have, no matter what. And each one of us has unique internal resources that make us all different. One of the things that case management does is it helps people identify those internal and external resources. We do that through the strengths assessment.” Betsy did not elaborate upon how John may have acquired his humor; how or why, that is, do internal resources become attributed to individuals? How do internal and external resources produce or correspond to John’s sense of humor? And is it true that John “will always” have his sense of humor? Is humor a natural expression despite all socioenvironmental inﬂuences? Workshop participants did not ask such questions or seek clariﬁcation. Instead, Betsy pressed on with a discussion of the concept interdependent: We usually hear the term “independent.” For example, “helping someone to maintain independent living.” What is the difference between the two? One is relying on yourself, and the other one is not only relying on yourself, but others. We’re all interdependent. For me to be able to teach, I need students. When I think of the word independent, especially when you think about independent living, what I get in my mind’s eye is someone sitting in their apartment, twenty-four hours a day, by themselves, with maybe the radio on, never talking to their neighbors, never getting outside their apartment. Now, that is about as independent as you can get. But is that what we’re striving for? No. We’re striving for that interdependence that we all need each other.

Interdependency is a need, not a want. But if “wanting others” is not one of my desires, does this needs language resolve the thorny question of desire through making interdependency a basic need? What is the difference between a need and a want? The answer to this question came on the second day. First we had to deal with another key concept: normality. “What does normal mean?” she asked. It means, “socially acceptable and majority rule.” It is relative; “normal depends on the culture that you’re in, and what is happening within the culture’s rules.” For example, “if you’re

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doing case management with a young woman in the Netherlands and she needs money and she wants to go back to work as a prostitute, what would be your response?” A noticeable silence fell over the group; we had been handed a tough question. Betsy volunteered a response: “Do you want to live uptown or downtown?”“Do you want to work for a call-in-service, or do you want to have an apartment with a large window?” These questions followed from the focus on desire. Case managers do not treat; they assist. With this answer I could sense uneasiness among coparticipants, but Betsy handled this by applying the concept normal. “If, however, you are in Hutchinson, Kansas, what is your response?” “Is prostitution legal?” “No,” a woman from the back of the room cried out, “in our culture, that is not normative behavior.” “Yes,” Betsy replied, “normal is what is in your environment.” And “there are consequences for non-normative behavior.” Managers help clients balance the stuff of their desire with local cultural norms. I assumed this meant that I had a silent management partner; in short, culture produces, with assistance, normative behavior and appropriate manners. I was not alone; social norms would help keep the undesirable stuff in check. And, ﬁnally, we were instructed in how to name the service recipient.“Consumers,” she said hesitantly; “I really like the word people better.” There was, however, a reason for using consumer because “we’re really trying to convey the sense of consumerism.” What does that mean? “If you buy a refrigerator at Sears and you get it home and it leaks,” Betsy stated,“what do you do”? A quick response came from the back of the room: “You take it back, I had that happen to me.” Betsy rejoined, “that is the same concept when working with people.” The concept of consumerism is constantly “looking at” whether or not case management is “working.”Just “ask the people you’re working with if its working?” In other words, as case managers “are we doing the things that they want us to do?” I wondered how a consumer of mental health services would return the effects of case management. I don’t think the example of returning a refrigerator was to be taken literally. Rather, she wanted us to believe that consumers have a choice, and they can choose to work with us or not. In summary, Betsy alerted us to other names people have been called: “loonies, inmates, patients, clients, and now we’re using the word ‘consumer.’” For the ﬁrst time that morning, I detected in her instruction some ambivalence: The thing is, lots of people don’t like being called clients and don’t like being called consumers. Ask the people you work with how they would like to be addressed? The biggest response will probably be: “I’d like to be called “Mary,” or “Bill,” or “Joan,” you know, their name.

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Betsy summarized the workshop up to this point by reading a colleague’s poem: “A Person and a Patient.”“I feel that the poem really speaks to the concept of the language that we use, the words, and how the words really impart a speciﬁc meaning.” We use words in many ways to understand our being and we know our point of view affects what we are seeing. A diagnosis is a powerful word, it’s true for once a disorder is deﬁned, it’s the lens that we look through. A person gets excited—with a patient it’s manic A person has concerns—with a patient it’s panic A person is expressive—a patient’s histrionic A person can get better—while a patient’s often chronic A person may get angry—a patient becomes agitated A person is a creative thinker—a patient’s thoughts are not related A person may be sad—a patient is depressed A person may be childlike—a patient is regressed A person may be cautious—with a patient it’s guarded A person may change her mind—a patient must ﬁnish what they’ve started A person tries to inﬂuence—a patient manipulates A person gets a second opinion—a patient triangulates A person is an activist—a patient is antisocial A person is a visionary—a patient is delusional A person has a home—a patient lives in a facility A person has many strengths—a patient has a disability A reminder to us all that mental illness does not nullify personhood And each and every one we try to help may not behave the way we think they should Don’t let the illness shift our sights from the gift that people possess And we will see the wonder in each life and the joys in success.

An audience participant, a former social work student of Betsy’s, responded to the poem with the day’s ﬁrst challenging question. “What the poem sounds like it’s doing is saying that depression and sadness are really the same thing, but if you’re a patient, you get labeled. But I think they are different.” “Sadness,” he continued, “is a response to speciﬁc temporary circumstances and depression is organic.” The challenger was expressing doubts about the poet’s use of binaries to exemplify that strengths sees “personhood,” not illness, disease, pathology, or deﬁcits. Betsy agreed. Depression and sad-

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ness are different, but she added a caveat: “If we look at the diagnosis ﬁrst, that is what we are going to see.” She also agreed that a manic-depressive diagnosis is useful, but one needs to be careful, she argued, not to confuse normal, everyday excitement with mania. Betsy countered that “you need to look at the person as a whole, and depression may be a part of the person, but that is not the whole being.” Not persuaded, the participant reiterated that “it sounds like what you are saying is that depression and sadness are the same thing and that we [social workers] are bad people when we label someone as being depressed.” She refused to retreat from her position and closed the discussion with the following remarks: Well, I think we have done that. I think once you start labeling people—no matter if you’re labeling them as a cancer victim or as a diabetic—you start thinking these kinds of things. I think looking at the person as a person is really the point, and that if they do have a major depression, well, that is a part of who they are, but again, it’s not the whole thing.

The architects of strengths management were appropriately tuned to the 1960s critiques of labeling and the perils of DSM-IV diagnostic labels. In fact, because strengths case management’s language steers so far away from psychological categories, the language became remarkably commonplace. What in our language today is more common than, for example, the words “consumer” or “consumption?” I will return to a more detailed discussion of these issues in the chapter on money. It is no coincidence that service recipients are called consumers because it is very consistent with strengths management’s focus on wants, desires, and dreams. The valorization of wants and desires—as opposed to focusing on deﬁcits, diagnoses, needs, and problems—was not only a strategic move but it also entailed and required a corollary: the substitution of the consumer for the patient. Like a Sears clerk fulﬁlling a shopper’s desire for an exchange, the power relationships between the social worker and the service recipient were reversed with the idea that workers served the wants of consumers. Although one can disagree that simply renaming the recipient does not reverse power, the language of strengths management undermined the privileged and centered position of the doctor or social work clinician. I think the architects of strengths case management needed a common, ordinary language to establish equivalence between the service recipient and the helper. Strengths management’s argot—assisting, helping, linking, advocating, goal-setting, dreaming, brokering, sustaining, positive thinking, strengths, and success—is empirical

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and behavioral and therefore relatively transparent. Helpers do not need bachelor’s or master’s degrees—let alone a Ph.D. or medical degree—to access, use, and understand this quotidian language. Betsy was indirectly telling us to avoid language seeking a psychodynamic reality; thus, life is transparent, unexceptional, and commonplace. I was left with the notion that case management’s argot should not presume to know any realities below the surface. By suggesting the use of a practice language that decentered the helping power relationship, the workshop led us to understand that strengths case managers should perceive the consumers as (1) the drivers of their own uncomplicated desires and (2) the drivers of the helping relationship.

WRITING STRENGTHS CASE MANAGEMENT

What instruments does strengths management employ to do the work of writing practice? That is, what replaced problem assessments, diagnostic instruments, and clinical treatment plans? The instruments of psychiatric work that classify, name, label, and produce objects of practice have been the sources of much scholarly debate (Lunbeck 1994:130–133). Case records, for many critics, are among the most maligned psychiatric instruments. It is argued that recording takes the private and personal world of the client and transforms it into the impersonal, the general, and the public “case” (Tice 1998:17–46; Margolin 1997:151–164). To teach us how to write strengths cases, Betsy led us through three steps. First, she described the principles and seven primary functions. Second, she used an overhead projector to show us how to complete an assessment form; then in small breakout groups we used the instruments on ourselves. Third, Betsy described how the Personal Plan replaced the traditional treatment plan. On the ﬁrst day of the workshop we were told that six principles undergird good practice. These principles rationalize the seven functions of management. In effect, they provide a philosophical justiﬁcation for the use of speciﬁc instruments. The six principles focused attention on the consumers’ strengths (1) not on their weaknesses or problems. We were told that human beings have the capacity (2) to learn and change, and that the consumer is (3) the “director” of the case management process. An emphasis was placed on (4) the relationship becoming “one of collaboration, mutuality, and partnership.” Most important, case management should (5) occur “in the community” and not at the mental health center. And ﬁnally (6), “the entire community is viewed as an oasis of naturally occurring resources.”

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Consumer engagement, the ﬁrst of seven management functions, was efﬁciently accomplished by focusing on strengths. “The model,” Betsy explained, assumes that “people tend to spend time doing the things that they do well.” Identifying consumer strengths allows case managers to: (1) “maximize consumer interest and participation in the management relationship,” and (2) “maximize consumer action.” It was understood that people do not act quickly, nor as voluntarily, when they are made to think they have problems and no talents or strengths. “Strengths assessment,” added Betsy, is the key to ﬁnding out what motivates people. Everybody has motivation. Sometimes people have negative motivation. Someone may be living in a group home that is disruptive, and their entire day is spent arguing and ﬁghting with people. They are motivated to do those kinds of behaviors because something else is going on. Maybe they don’t like where they are living. Their disruptive behavior is a message: “I don’t like it here.” People do things for reasons, and it is our job to get underneath and ﬁnd out what that motivation is. When you are thinking about this, you really want to help people to dream.

We were told that “problem-solving therapies focus on fulﬁlling needs.” Betsy admonished the audience not to ask consumers “what do you need?” Case management is about “what do you want?” Thus, I understood this to mean that a needs- and problem-oriented language focused too much on deﬁcits. A language of “wants” was presented as more positive than one of “needs.” Indeed, desire underscored the idea of free will and abundance, while need tended toward drive determination and scarcity. Accordingly, a focus on strengths, especially when case managers framed its purpose as an exercise in dream fulﬁllment, encouraged clients’ participation. In short, “collaborative helping partnerships” were outcomes of pressing someone’s strengths so they could get what they wanted. The second function of case management, gathering information, is called Strengths Assessment. Consumer information is divided into six life domains: daily living, ﬁnancial, vocation/education, social supports, health, and leisure/recreation. Table 4.1 is a partial reproduction of the assessment tool. In ﬁlling the empty boxes with corresponding answers, Betsy showed us how the assessment occurs over time and in a variety of community settings, looking again for strengths. The strengths assessment should be detailed and speciﬁc. Instead of

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just writing “biking,” write “mountain bikes with son.” Again, get underneath and make it as detailed and speciﬁc as possible. It should be done in a conversational manner. Get to know the person. Disclose. Strengths assessment is based on what the consumer wants. And thinking about that, be clear on whose wants, aims, and goals are being talked about. Is it yours? Is it your agency? Is it your grant? Is it the consumers?

The six life domains were selected because they “appear to be directly related to successful community tenure.” The assessment form directs the manager not to ask the questions in terms of need but in terms of wants. “What kind of home do you want to live in?” “How much money do you want?” “Do you want to go back to college or ﬁnish your GED?” Case managers were told to link the consumer’s wishes to current conditions or statuses. For example, “You state that you want an apartment, but where have you been living?” “What kind of help or resources have you used in the past to get what you have wanted?” The inquiry and investigation into these life domains was designed, according to Betsy, to produce an action plan while helping to form and sustain an “ongoing” relationship. Strengths assessment was seemingly straightforward and complemented the six principles of good case management. What appeared not so clear, however, was the notion of “getting underneath.” Does such an idea suggest there were hidden truths? I was curious about Betsy’s repeated use of “getting underneath.” For example: Maybe we haven’t ﬁgured out and got underneath what Paul is motivated by. And it’s our job to get underneath there and ﬁnd out what that motivation is. What you’re doing right there, is really good, what we call, getting underneath. Okay. You could have just left it that she’s into health. But what does that mean? Walking a lot? Like how often do you walk? You know, do you walk with anyone else? Where do you walk? Those are the kinds of things you’re talking about, getting underneath, and really exploring it. Okay, that again is getting underneath, going from the generalized to the more speciﬁc. You may be working with a consumer who wants to be president. Are you going to write that down on their goal sheet? We’re making the assumption that they want to be the president of the United States, like on Pennsylvania Avenue, right? But they may want to be president of a consumer-run organization, and we’re making the leap to president of the United States. They may

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TABLE 4.1 CONSUMER STRENGTHS ASSESSMENT C U R R E NT STATU S :

WHAT ’S GOI NG ON TODAY?

I N DIVI DUAL DESI RES,

R E S O U RC E S, P E R S O N A L

ASPI R ATIONS:

SOCIAL:

WHAT DO I WA NT?

WHAT HAVE I USED

WHAT ’S AVAI L AB LE NOW?

I N TH E PAST?

Daily Living Situation Financial/Insurance Vocational/Educational Social Supports Health Leisure/Recreational Supports

want to be president of the United States, but talk with them and get underneath, get at what they’re talking about. What about being the president excites you? What would you like to do if you were the president? Ask those kinds of questions.

“Getting underneath” suggested that Betsy doubted a straightforward reading of consumers’ motivations and goals. “Getting underneath” could mean that personal motivation and desire required clariﬁcation, investigation, and deep inquiry of the apparent. I wondered what I was getting underneath? Did she mean there were layers to motivation and desire? What constituted these various layers? How many layers might desire have? And ﬁnally, as a professional, how did I see underneath, that is, what set of concepts allowed me to see below the empirical surface? Although no workshop participant queried Betsy about the meaning of “getting underneath,” strengths management’s philosophy in general does not lead me to conclude that its architects aimed to uncover subterranean motivations. Participants heard that “each of us have differences in our talents which are not deeply hidden. And one of the best ways to ﬁnd what those talents are is by use of a strengths assessment.” Thus, “getting underneath”4 was not about hidden motives. Rather, it was an assessment and intervention concept to produce goal-oriented action by (1) specifying in detail the myriad individual motives of human action and wants, and (2) translating the motives and wants into individualized action steps that produce consumer

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accomplishment. To get underneath meant going from less practical (“generalized”) goals to more realizable (“speciﬁc”) ones. It was impractical, for example, for a consumer to become in stepwise fashion president of the United States; yet, becoming president of a social club was realistic and, most important, achievable. In sum, “getting underneath” was about operationalizing desire and writing it down in measurable goals. Participants were strongly encouraged to use the assessment tool in the community. Whereas traditional diagnosis took place in clinicians’ ofﬁces, Betsy encouraged managers to act “in vivo.” To be “in vitro” is literally to be observable, as in a test tube. Betsy portrayed the hospital and associated clinician’s ofﬁce as a closed and controlled laboratory that could not reﬂect a realistic picture of consumers’ life. In vivo, on the other hand, meant acting in or upon a living organism in its natural environment. Her insistence upon in vivo reminded me of anthropological deﬁnitions of ethnography. I thought she was saying that case managers should be community ethnographers. In fact, we were instructed to be in the consumers’ environment and to carefully study and read their “living situation”: If you’re in someone’s home, you’re going to see photographs around. Photographs give you clues. Oh, is this your family? Who are these pictures of ? Or you know they’ll have a lot of plants in their apartment. Do you enjoy gardening? Do you like houseplants? It really looks like you’ve got a green thumb. If you’re in an apartment that has pictures of Michael Jordan on the wall, oh, are you into basketball? Do you like the Bulls? So it starts with a conversation, and you’re learning about someone at the same time that you’re conversing with him or her in their living situation. A home gives you a lot of clues.

“Clues to what,” someone asked? “Clues to their strengths,” Betsy answered. The strengths assessment form was a record of the consumer’s desires and strengths across the life domains. Betsy emphasized the importance of writing; indeed, she was adamant. She told us to see every consumer activity as meaningful, and everybody’s going to ﬁnd a different deﬁnition of meaningful. Ask about helping in the community. That’s a great question. How have you been helped in the community? What do you do during the day? How do you spend your time? You’re going to get a lot of clues from that. You know, maybe they’ve mowed the neighbor’s yard and in exchange, the neighbor gives them rides to the mall. That needs to be noted. That’s a meaningful activity. Or maybe they live in an apartment complex and when the neighbor across the

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hall wants to go grocery shopping, they watch their kids. That kind of information needs to be written down, too. Also, think about unique talents they possess—maybe doodling, crafts, or arts. Again, write that down.

The form itself was to be used as a means of intervention. Consumers were encouraged to participate by writing down information in their own words. Another technique that I used when I was doing case management is I had a clipboard, and I put the strengths assessment on the clipboard. As I was driving, I would hand the clipboard to the consumer and say, jot in it. I’ve got to keep both hands on the wheel or look out the window, so would you mind taking the strengths assessment and putting some information on it as we talk? And that way, it empowers the consumer to know more about what the strengths assessment process is. It also helps them to start writing their own, and seeing what strengths and abilities they have. It’s a great technique. Clipboards work great.

Recording the information and conducting a strengths assessment was portrayed as necessary but not sufﬁcient; it should be conducted in a helping and friendly way, as “a natural conversation.” Betsy admonished: “Don’t shove paper in front of them and ask questions in a mechanical fashion.” Paper is real scary stuff. Because maybe the last time that they saw a piece of paper—and especially if they signed it—the next thing they knew, they were at the state hospital. Involuntary commitment! They may wonder what this paper is all about, and why is it you want me to sign it? Again, when you’re explaining the purpose of case management and what you do, one of the things that also helps is to really bring people back to the idea that this is a helping relationship. Again, it’s friendly, but it’s helping. This is one of the tools that I use. If Jerry and I were working together and Jerry didn’t want to see the paper, you know, maybe a month down the line, I say, “Look Jerry, look at all the things I’ve been recording. Does this look right to you?” And, even if Jerry responds, “I don’t want to see that paper. Just get it out of my face.” Fine! Get it out of his face. But always bring it back up. Because again, the strengths assessment is a tool, it is just like a saw and hammer to a carpenter.

Assessment was considered ongoing and never completed; therefore “there is always going to be new stuff that you are ﬁnding out about the consumer.” Participants were instructed to record data “every time you meet with some-

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one.” These axioms of strengths management underscored one of its seven functions: “collective and continuous collaboration.” Betsy believed continuous collaboration was “typically thought of ” as monitoring. This concept addresses the multidimensional nature of ongoing modiﬁcation and adaptation that takes place during the helping process; that is, determining the extent to which consumers are able to engage in activities noted on the personal plan. The underlying helping goal in this function is empowerment. Helping consumers, in effect, monitor themselves, or to learn to use others in their social network for desired feedback.

The goal of strengths management was to produce the effect of self-monitoring. Strengths assessment forms recorded goals and the Personal Plan charted the course toward attainment. Personal Plans recorded progress, failure, and achievement. These instruments were related and managers were taught to use them concurrently. The Personal Plan was a road map delineating the terrain of the consumer’s and the case manager’s goals. It assigned accountability.“Who will do what by when? That is the Personal Plan right there.” The Personal Plan recorded consumers’ motivation and desires as measurable goals. To illustrate a key element in successful goal planning, Betsy engaged the participants in an exercise. She distributed paper and instructed us to fold it in half. “How many steps did it take to fold that paper?” Participants responded with estimates of one, two, and ﬁve steps. Betsy elaborated: There was a study done by researchers who looked at how many steps it took to fold a piece of paper. They were working with people that had developmental disabilities. What they did is break down each individual step. And what the researchers found was it took twenty-four steps. Twenty-four steps! Now think about that! What seems very easy for us is very complex for other people. The point is that goal attainment is complex.

Moving back and forth from the strengths assessment form to the Personal Plan, Betsy instructed us to think about positive goals “stated in terms of what the consumer is going to do, in contrast to what the person is going to stop doing.” “This,” she remarked, is “the power of the positive.” By isolating consumer motivations, we would “discover unique talents and desires.” A related step was to explore the many avenues through which desire could be met; in this way, it helped “them to see that there is choice out there.”

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Goals should be measurable and observable. They “should have a visible and explicit outcome.” Goal achievement should also be rewarded and celebrated: “Celebrate and celebrate the little steps. Goals should not be too high or they should not be too low, they should be just right.” A goal was “just right” when it was broken down into steps; small steps helped consumers experience daily success. Consumer goals—a stable living arrangement and a balanced budget—were not achieved in a day or a week. Goal attainment was a long, complex, and tiresome process; strengths management assumed that human beings needed positive encouragement to get things done. Goals should also be “written in consumer language.” To do so assured that the consumer’s aspirations drove the Personal Plan. And it was here that Betsy went to great lengths to differentiate needs from wants. She took a discrediting look at Abraham Maslow’s hierarchical model of human motivation. Betsy showed us a logical problem in Maslow’s disciplinary knowledge: how to reconcile desire with need? First, she described Maslow’s primary tenet: “self-actualization, the highest need, can only be reached if the lower needs are met.” “Needs are important too, but let us look at the basic needs: food, water, shelter, and safety.” Moreover, suppose you’re a case worker and you met with your supervisor in the morning, and your supervisor said we’ve got a new person for you and his name is Dick Gregory. Dick Gregory, for those who may not know, is an AfricanAmerican social activist and he does a lot of advocacy. He is a well-known comedian. And one of the things he does to really promote the cause of hunger is that he fasts and he brings attention to himself. You’re a New York City case manager and you come up to Dick Gregory and say, “Dick, we’ve got some reports that you’re not eating? We’re really worried about your basic needs. We have this group back at the center. We make spaghetti every Thursday, and on Friday the menu is chili and crackers. Would you come back to our center? You could eat and it wouldn’t cost you anything. We are really worried about you. It looks like you weigh just 100 pounds?” But Dick says,“You don’t understand, I don’t need to eat. What I want to do is make a point, and when I fast people listen to me.” Is Dick concerned about his basic needs? No! What is his want? He wants to advocate.

Betsy added two more illustrations. Another case manager encountered Evel Knievel. Knievel did not need to feel safe, rather he desired to experience an “adrenaline pump” by putting himself in dangerous situations. Next, we

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learned that Henry David Thoreau was not “worried about a need to belong.” He, instead, wanted to be alone: The point is that we are talking about wants and Maslow says we have to go from one need to another to another, and then we reach the highest: self-actualization. But I think with the strengths perspective that we start looking at wants versus the needs.

I did not think Betsy intended to use these illustrations to argue that consumers live entirely motivated by desire. As a case manager for the homeless mentally ill, she disclosed that she often helped people acquire shelter. A personal need to eat could become sublimated by a stronger desire to advocate for hunger. A homeless person could feel unsafe in a shelter. Thus, in her work experience, “we would start by being a part of their culture, instead of going in and saying to someone we will get you an apartment.” Different environments produced different relationships between needs and wants. Consumers’ wants were not always consistent with the desires case managers hoped they would have. Although Betsy never said so, I think she hoped that future case managers would resolve the needs and wants problematic by “starting with wants.” As a rule, she argued, “start with what they want because it is the sure way to keep them engaged in the relationship”; it also seemed egalitarian. In short, coding a consumer’s needs as wants created consistency between the Strengths Assessment and Personal Plan instruments. Put differently, the rule of starting with wants suppressed our intellectual uncertainty over the complex and often upside-down hierarchical relationship between needs and wants, that is, it foreclosed on a more subtle and complex theory of needs, wants, and desires. How did Dick Gregory produce the effect of sublimation? Did severe and persistent mental illness modify the ability to take a natural expression of an instinctual impulse (e.g., eating) and substitute in its place a socially acceptable one like hunger advocacy? If so, why? If not, why not? No workshop participant asked these questions, and Betsy did not provide answers. The Personal Plan wrote desires by recoding needs and wants as measurable goals. “Who will do what by when.” Strengths management reduces the complexity of human motivation, desires, and biological needs to goal achievement. Strengths management was uniquely designed to perform goaloriented work. The philosophy of the strengths model, its instruments for writing “cases,” and its overall aim was focused on one endpoint: “increasing

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community tenure.” The everyday language of strengths case management subverted other professional vocabularies. It was a language rich in potential but also burdened with limitations. However, neither the limitations nor the potential were readily apparent from analyzing the oral narratives of workshop training. We must see case managers in action to make further assessments. The landscape case management is produced in, for example, uniquely shapes how practice is conducted. In the next chapter, I turn to a description and analysis of that landscape.

C HAPTER 5

Landscape for a Case Manager: The Carless Mentally Ill

T

he arrival of the semimonthly mileage check routinely generated excitement among case managers. Some would plan a celebratory lunch. Others wanted to pay an onerous phone bill or satisfy their desire for an exotic vacation. “Unlike some around here, my mileage check is banked, and then I use it to replace my car every three or four years. I don’t like the wear and tear on my car; it is the one thing about this job that I get tired of.” The amount of the check had two meanings. One was the simple gratiﬁcation of having more “money in my pocket.” But because the check’s amount was dependent on the number of miles driven, a large check valorized the worker’s in vivo productivity; it marked the good case manager. For the case manager, being in the CSS community meant being in the car. A single case manager’s odometer recorded 12,000 miles each year, averaging ﬁfty miles every workday. It is in the nature of statistics that extreme values remain in the shadow of the average, which always hides the actual data points, and this is true of the average miles driven. The actual data was more dramatic and the driving was brutal. “It depends,” was the response to my query about driving,“how many appointments, where, who, what the need is, and how often in the same day I have to come back to the main ofﬁce.” Another respondent remarked, “one consumer may have three trips to make. When I visit ﬁve consumers in one day, on my worst day, counting each little leg of a trip, well, I could give trafﬁc reports to the local radio station.” Examination of monthly mileage sheets showed that case managers drove as much as 250 miles in a single workday. And given the realities of team meetings,

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ofﬁce phone calls, and business, the driving remarkably occurred in a four-tosix-hour time span—between 10 a.m. and 4 p.m. The hospital bound practitioners to the clinic. CSS workers are tied to automobiles; it was common for managers to use “car time” for planning consumers’ goals. Even the workshop leader had already encouraged the new case managers “to use a clipboard and ask your client to write, while you drive.” I experienced how and why this advice produced successful suburban case management. CSS and the corresponding strengths case management were circumscribed by social, political, and economic realities that composed a landscape, just as the mental hospital and medical model were associated with pastoral landscapes or large and fortresslike urban enclaves (Grob 1991). Association with country landscapes was thought to have a therapeutic beneﬁt—separation from the chaotic, urban, and industrializing landscapes was certain to produce salubrious effects (Morrissey, Goldman, and Klerman 1980). Moreover, these landscapes were meant to produce isolation from the community; indeed, the community was a potentially disruptive force and an impediment to successful treatment. In the CSS social ﬁeld, however, the community produced the opposite effect; that is, the new consumer of mental health services, in negotiating the urban, exurban, or rural landscapes, was not only liberated from the panopticon but also experienced an effect not unlike that purportedly produced by the hospital: well-being. Advocates of deinstitutionalization believed that inserting former patients into “real” landscapes was both democratic and progressive; in effect, this was the pivotal assumption driving the policy. The result was the creation of a pervasive discourse opposing the community to the hospital, one obviously right and normal, the other backward and wrong. Moreover, strengths case management was wholly committed to the community as the situs for work, while hospitals and mental health centers, even CSS group homes, contained a potential threat, segregation, what was called in the discourse a “segregated resource.” Consumers must live and receive services in real communities. For a case manager, the county catchment area constituted a physical landscape or social space that conditioned the work of case management.

WHY CALL IT A LANDSCAPE?

Although as a metaphor the term “landscape” has advantages over the term policy environment, my decision to think about High County as a landscape was also theoretical. A policy environment refers to the national, state, and

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local political ideas and practices that comprise essential ingredients for designing social projects. Case managers, however, work in real physical spaces—landscapes—that are embodied policy environments and therefore not reducible to administrative and bureaucratic systems.A practice landscape is a picture, fragment, or scene that is more than a representation or cutout from the policy environment. A landscape is part of a whole, but it also represents a single, bounded, and uniﬁed piece—High County, Kansas. The landscape, unlike the policy environment, reminds us of how important physicality and space is to social work projects, especially to deinstitutionalization. Theoretically, the notion of landscape helps explain how CSS is constrained and empowered by geopolitical space (i.e., the catchment area) and how practice space necessarily enables and limits the relationships between case managers and consumers. Social space is not just a mere reﬂection of our ideas, it helps (re)produce them (Soja 1996). Edward Soja, in Thirdspace, writes, The message is clear . . . that all social relations become real and concrete, a part of our lived social existence, only when they are spatially “inscribed”—that is, concretely represented—in the social production of social space. Social reality is not just coincidentally spatial, existing “in” space, it is presuppositionally and ontologically spatial. There is no unspatialized social reality [his emphasis]. There are no aspatial social processes. Even in the realm of pure abstraction, ideology, and representation, there is a pervasive and pertinent, if often hidden, spatial dimension. (Soja 1996:46)

Social work practice requires the (re)production of social space. The historic almshouse, poor farm, orphanage, and home for unwed mothers, and the contemporary residential group home, the domestic violence shelter, and the congregate-care home, were neither conceivable nor practical unless connected to speciﬁc constructed spaces. And this is no mere abstraction; for example, domestic violence shelters are predicated on a veil of secrecy about location. Secrecy is, of course, about safety, but it also ﬁts in with the shelter’s disciplinary knowledge encouraging independence. Spatial utilization deﬁnes and limits the work of social projects. Once the hospital carved out of the rough countryside the pastoral grounds and ward hallways, social space reproduced a segregated and aggregated disciplinary practice. In fact, by calling something a segregated resource, the architects of strengths case management unwittingly pointed to spatial signiﬁcance. I use my study of a speciﬁc

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CSS landscape to show that disciplinary knowledge and CSS projects must construct practice spaces that correspond to the ﬁeld’s abstract and concrete helping values, ideas, and assumptions. Landscape, then, is meant to conjure up images that are useful for understanding the work of the case manager. An analogy between a map (policy environment) and its territory (landscape) is instructive. While driving a car, we are looking at, acting upon, or driving within a speciﬁc scene, location, or physical space. The same is true for case managers; they work within and upon a physical landscape, not an abstract map of deinstitutionalization, but the real physicality of practice space. Case managers, like their new service recipients, the consumers of mental health services, circulate in the open community. First, I take up the idea of perspective or point of view. The High County case managers I studied began their daily activities in team meetings located at CSS. The landscape for a case manager must ﬁrst be seen from a point of view inside the ofﬁce looking out. Second, it must be seen from the outside—apartment, grocery store, bank, or highway—looking back in. Although CSS is central to the landscape, depending upon a case manager’s particular task, the ofﬁce may be background or foreground. And it is from both vantage points that case managers view the consumer’s relationship to the ofﬁce and surroundings—apartments, grocery stores, banks, pharmacies, social services ofﬁces, department, discount, and convenience stores. Third, landscapes produce real and symbolic effects. In the hospital, staff assured patients’ acquisition of “segregated resources” (e.g., medications, counseling, medical care, food, and shelter) by constant movement along a building-centered axis of symbolic and real power relationships: hallways, waiting rooms, wards, commons, nurse’s stations, cafeterias, locked doors and windows, ofﬁces, and patient rooms. The panopticon, after all, needed a certain kind of spatial arrangement in order for the medical model to work (Foucault 1979). These spaces, moreover, were forcefully marked with the symbols of the medical and nursing professions. To understand the real and symbolic effects of a suburban CSS, it is important to map the case manager’s landscape.

INSIDE LOOKING OUT

In general, I speculate that social work projects reach signiﬁcant historical milestones at junctures where advocates harness enough power to spatially

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enclose the social relationships of helping. Our latest ideas and practices often have invisible but certain ties to the old; most aftercare, outpatient treatment,1 and Partial Hospital Programs, for example, began inside the mental hospital. When community support services claimed its own spatially organized workspace, it moved from a trial-and-error project to a full-ﬂedged disciplinary project. Today, CSS advocates conﬁdently exercise policy and practice power in ways that parallel those used in the hospital at its zenith. CSS of High County, Kansas, has had three locations. The ﬁrst site was inside the traditional outpatient facility. The earliest (1974–1980) CSS ofﬁce and spatial arrangement, heavily dependent upon Partial Hospital Program (PHP) monies and knowledge/power, required just a handful of staff ofﬁces and, most important, large group rooms to conduct client training and skillsbuilding exercises. This use of space was borrowed from aftercare and outpatient programs, which had long helped ﬁfteen or twenty patients at a time in group workspaces. In the early years, work outside the center was negligible; therefore, the community landscape was signiﬁcant only to the clients. The forerunners of the modern case managers conducted most of their business inside and without automobiles. In 1980 High County Mental Health Center had one large room dedicated to PHP recipients; indeed, staff had not yet congregated in areas identiﬁed as CSS. Except for daily group rooms, clients were not given access to clinic space. The disciplinary knowledge of Partial Hospital Programs restricted early CSS to ofﬁce-centered practice and the power relationships embedded in the discourse left clients only two options: either to come to the center or to not receive service. In chapter 3 I showed how Sarah Teasley redesigned her workspace to encourage case managers to leave ofﬁces and go to clients. Making the case manager a public practitioner was an outcome of reorganized practice space. In 1984 Sarah carved out of the Oaklawn ofﬁce the ﬁrst segregated CSS area. It did not require a struggle. Traditional outpatient therapists were not keen on CSS clients hanging out in lobbies, mixing with the so-called worried well. As much as deinstitutionalization sought to desegregate, the power relations of actual work sites forced Sarah into a area cordoned off in the basement of the outpatient facility. Oaklawn was the perfect experimental location; it was home to a large portion of the county’s affordable housing, and when staff ventured out, trafﬁc was easy to negotiate. In 1980 Oaklawn was still a small town, a “developing margin of exurbia,” waiting to be engulfed by an everexpanding interstate highway and its associated population growth. Although the population of High County grew by 48 percent between 1980 and 1990 (from 180,694 to 260,862), the city of Oaklawn expanded signiﬁcantly faster,

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namely, by 70 percent (from 37,258 to 63,352).2 The turn to community placement coincided with the development of the exurban landscape, rapidly ﬁlling in with middle-class homes, schools, industrial parks, corporate headquarters, and shopping centers, all of little use to low-income CSS consumers. CSS moved to its ﬁrst independent location in August 1985. The ofﬁce moved from Oaklawn, which was fast becoming the center of economic growth, to the municipality of Andover, which is in the northern part of High County and away from encroaching exurbia. Andover, together with twelve other northern municipalities, experienced a depressing 1.5 percent population loss during the period in which Oaklawn had its 70 percent gain. I was not surprised to learn that the CSS population moved with the ofﬁce; indeed, consumers may have unwittingly prompted the move. Increasingly, former hospital patients found more affordable housing in older and decaying neighborhoods in Andover. Although the county experienced a remarkable 88 percent (from 13,938 to 26, 001) increase in multifamily units—buildings with ﬁve or more units—this increase was conﬁned to exurbia. Andover, a post–World War II inner suburban ring, located in an older area of High County, like other early suburbs in the United States, had experienced a steady decline. While the newer 12,000 multifamily units commanded high rents, older apartments in Andover competed in the low-income market. Indeed, some landlords recruited CSS clients, and by the late 1980s many enthusiastically accepted federally subsidized (Section 8) vouchers. I cannot ﬁrmly establish whether consumers pulled or administrative staff pushed the ﬁrst CSS ofﬁce to Andover, but it is clear that more and more consumers established residence near the new facility. One indicator of the population movement can be found in two prominent van routes. Between 1985 and 1990, regular van service for clients was provided to Oaklawn and several parts of older Andover and adjoining Eastview. In Oaklawn, of the 9,391 new residential permits issued in the 1980s, 70 percent were for single-family, detached units. Thus, as upwardly mobile Andover residents rushed to their new Oaklawn homes, the expanding CSS population moved into the abandoned areas. And even after the CSS ofﬁce moved out of Oaklawn in 1985— and even as late as 1997—workers maintained a van route so clients could take advantage of the cheaper rents in old downtown Oaklawn. Andover CSS ofﬁces consisted of four adjacent buildings, cheaply constructed, that could easily be mistaken for two-story, single-family tract homes. In fact, the buildings melded inconspicuously into the suburban landscape. Gradually, to accommodate staff growth, CSS leased all four buildings. The buildings were divided according to function. One was home to staff

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ofﬁces and group rooms, and the second housed a lunch program, an exchange store, a few vocational program ofﬁces, and the consumer lounge— a rectangular room with a ﬁsh bowl at one end and chairs and couches scattered indiscriminately around the perimeter. The Andover ofﬁce was the testing ground for learning how to use a centralized ofﬁce and from there deploy case managers into the community. The NIMH and the Kansas Department of Mental Health offered no standards for the spatial organization of CSS. The situated knowledge of case managers determined how space was used. One arrangement was institutionalized and repeated in subsequent moves and architectural designs: shared ofﬁce space. After all, case management was not to be conducted in the privacy of an ofﬁce. Privacy, ironically, would be sought in public spaces: cars, parks, or restaurants. CSS and case management unfolded in these suburban and exurban spaces, limiting and enabling the case manager. In general, the body was disciplined by the spaces of work, popular culture, school, and home, each of which required continual movement. For those mentally ill unable to sustain employment or altogether barred from work on a regular basis, living in the community meant isolation, often being alone or with several roommates, who lived together out of necessity, not by choice. In suburbia, created and deﬁned by the automobile and highway, with minimal or no access to mass transit, the CSS consumers had limited access to the public sphere, to shopping, entertainment, school, and work. With little income, they were even less likely to gain access to the commodities that gave meaning to life in suburbia. Case managers drove consumers continually through these organized suburban spaces helping them search for marginal places where their bodies, like ours, could be routinized. Advocates for strengths case management did not generally approve of large lunch programs, exchange stores, and consumer lounges; these were reminiscent of hospitals and tagged “segregated resources.” Because of the realities of suburban landscapes, I found the prescriptive ideals of strengths case management lacking practical sensitivity. Case managers purposefully used manufactured work and living spaces where the commodity-ﬁlled High County landscape—which strengths case management identiﬁed as the location of naturally occurring resources— presented formidable economic barriers. At CSS the lounge and multipurpose areas provided needed alternatives. They were de facto daily living spaces for socializing, working, and shopping. The lunch program, for example, functioned to provide inexpensive food and social activity. At the exchange store, clients performed ofﬁce work and

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swapped labor (they could accumulate value in what were called exchange reps) for commodities—especially dry goods—that could not be purchased with food stamps. Case managers encouraged consumers to use these programs, even though in many ways they were reminiscent of the spaces and activities typical of the total institution. These spaces and their associated activities gradually became essential to the project; in 1997 they were still actively reproduced inside the CSS building. In 1996 CSS made yet another move. This time, however, it joined its ﬁfteen-year experience with an architectural dream, form with function. Three million dollars later CSS had achieved its goal: to suppress institutional architecture and blend into the suburban environs. Today CSS can be found at 5000 Avenue Road, Harrisville, Kansas, just a mile from its former home in Andover, in the western part of the county. Although not a central location, the building site belonged to the county and land prices were lower there than in the expanding south. And although Oaklawn at the center of the county would have been a logical choice, most of the consumers were not equally distributed throughout the county; they clustered in Andover, Harrisville, older parts of Eastview, and Oaklawn. With its easy access to major interstate highways, Harrisville was an ideal location for consumers and case managers. The new stucco-and-brick structure has wide overhangs, low windows, and its prairie-style architecture is reminiscent of Frank Lloyd Wright. The building can be approached by car from north or south on Avenue Road; both approaches produce the same view: a serpentine one-story structure with no discernible central entrance. The parking lot deﬁned the landscape. CSS space, however, unlike that of state hospitals, lacked the tree-lined lane leading directly to “Inpatient Admissions.” When I ﬁrst visited the site, I drove around the parking lot looking for some clue to give me a sense of orientation. State hospitals, by contrast, required detailed maps outlining the intricate streets connecting wards, administration buildings, occupational therapy sites, cafeterias, recreational halls, and so on. I observed that most visitors to CSS experienced a similar disorientation in their search for the main entrance. They simply picked a door. But there was one entrance on the east side, especially during the spring, summer, and fall, that oriented the careful observer. This part of the building juts outward like the bow of a ship. Around the bow were outdoor chairs and tables where it was not uncommon to ﬁnd consumers milling about, sitting, standing, talking, relaxing, and smoking. Inside, smoking was not allowed. I soon learned that this area, called a “consumer drop-in center,” was not subject to an ongoing disciplinary gaze. What happened in this space, indoors

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and out, was an ad hoc surveillance. Case managers could certainly see consumers there, but they did not make purposeful trips through the drop-in center. It was subject, rather, to a monitoring of consumers by consumers—a liminal space, betwixt and between professional and self-monitoring. The drop-in center was purposefully designed to need minimal staff interference. It was a place where consumers take time out from watchful case managers. In the entire time of my ethnography, I did not follow one case manager through the drop-in center. We always entered and left CSS through other doorways. The resource development team supervised the site by encouraging consumers to structure the space. Staff had minimal expectations; consumers could sit, relax, talk, and smoke. A case manager explained to me that “John hangs out there because it’s kind of like a second home to him. He doesn’t get out into the community much, so he comes to the drop-in center two and three times a week and just hangs out. I think it is good for him.” In the strengths management’s lexicon, however, a CSS drop-in center was not a naturally occurring resource; depending on the use of such a space was to be discouraged. Case managers’ situated knowledge /power suggested otherwise. “A lot of my consumers don’t work, so they enjoy meeting up with other consumers at center programs.” Case managers created CSS simulated living space when consumers, for whatever reason, did not integrate into mainstream daily activities like work. Public space in suburbs was limited. There are doughnut shops, which were popular places for meeting with clients. There were indoor shopping malls, strip shopping malls, and restaurants, which were also popular destinations. Some consumers found meaningful work driving other consumers to appointments, grocery stores, and apartments. In a landscape empty of suitable employment opportunities, which is the primary gatekeeper to socially produced commodities, practice brought the case manager face to face with the necessity of creating alternate CSS-based socializing and simulated workspaces. To the observant rush-hour traveler on Avenue Road the drop-in entrance with its usual inhabitants would be the only indication that the road sign Community Support Services of High County Mental Health Center identiﬁed segregated services. I can imagine a local resident routinely driving by Avenue Road and 100th street and never connecting the use of this space with the severely mentally ill. I asked several business owners and shoppers if they knew what the building across the street was used for. “I guess it is a county building,” remarked a frequent shopper at the Osco drug store. “But I don’t know what they do there,” she added. Not surprisingly, however, the owner of a pizza delivery and the Osco pharmacist knew that the “mentally ill” got help

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there. I was told the architects had been instructed to blend the building into the suburban environment so that the “stigma” could be minimized. They succeeded. The building looked like any other one-story suburban ofﬁce complex. To the north of CSS was a high wooden fence that separated the center from a middle-class apartment complex, where few consumers could afford to rent. Across the street, along Avenue Road, facing east, were a bridal store, a dance studio, a video lab, and a pizza carryout. Only the pizza delivery had any special signiﬁcance for consumers. However, looking south across 100th street was a convenient Osco drugstore, and consumers were often seen crossing this dangerous intersection in a beeline for medications, cigarettes, and other amenities. South and west of CSS was another apartment complex, also beyond the ﬁnancial reach of most clients. Directly west was a wide open space where one can see nearly a quarter of a mile to a large suburban supermarket and car dealership. This empty space and tall grass reminded me of both the prairie and yet also the suburban location of CSS. Entering CSS from the east one ﬁrst walked into a small foyer. To the left was a hallway stretching some thirty yards into the distance and to the right was a shorter hallway approximately ﬁfty feet long. At every CSS entry point, unlike at the state hospital, there was a conspicuous omission: there were no directories, no signs, no arrows, no color-coded lines on the ﬂoor, and no maps. At the east entrance, for example, where one expected to ﬁnd some sign pointing toward the location of the center director, the waiting room, and admissions ofﬁce, there hung a pencil drawing of a large camera. The drawings, other attractive paintings, the corridor architecture, and absence of a directory didn’t mark this as a social service ofﬁce. Although each ofﬁce door had a number, suggestive of a hotel, dormitory, or hospital, the open doors and desks ﬁnally oriented the visitor to the building’s real occupants: case managers. An Edward Hopper reproduction hung near the intersection of the two major hallways, and though I’m sure it was picked by an interior designer to match the wallpaper, one could not help but notice the irony. Hopper, known for the way he brought urban private space into public view, now seemed to provide a useful comment on the project of deinstitutionalization: bringing patients out of the privacy of hospitals and into the public domain, subjecting them to a radically different kind of gaze. In transforming patients into consumers had deinstitutionalization not transformed the private into the public? There was an irony in the new organization of space. The open ofﬁce doors meant that deinstitutionalization also brought the primary clinicians,

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the case managers, into full view. They, too, could not be concealed behind ward doors and pastoral grounds. They could be seen and heard, just as they could see and listen, just as their charges had once been subject to the gaze, they themselves were now in that gaze. Indeed, the main occupants of these dormitorylike rooms were not patients. However, unlike the hospital, CSS was run like a business—the building’s doors opened at 8 a.m. and closed at 5 p.m. These rooms emptied out at night, and the building was locked to keep those on the outside from getting in, not those inside from getting out. At closing, the occupants of these sixty ofﬁces, a dozen conference rooms, a clerical area, a medication room, a medical chart room, a nurse’s station, and several activity rooms, retraced the streets that brought them to work each morning. The work of the hospital, in contrast, never ceased; it was 365 days a year, dawn to dusk. Finally, Topeka State Hospital shut down, but only after nearly 40,000 days and nights of continuous operation. It was, after all, the work of around-the-clock supervision that deinstitutionalization sought to end. The CSS project was well adapted not only to its physical environs. It was also perfectly suited to the temporal work expectations of suburban workers. Most managers did not desire to work after 5 p.m., on weekends, or on holidays. Consumers were left to self-monitor when the case managers’ eyes turned elsewhere. The spatial allocation at CSS was closely correlated to its social division of labor: case management, crisis case management, vocation /education, transitional employment, resource development, psychosocial rehabilitation, and medical services. The large activity rooms and adjacent ofﬁces were reserved for the resource development team and psychosocial rehabilitation services. The northwest corner of the building housed the vocational services while medical and clerical services shared a large space in the southeast corner—it was divided into cubicles, exam rooms, a medication room, and a medical chart room. The main lobby, the front desk, and the only waiting room were next to the medical chart room. Compared to the other spaces, the main lobby was small; the architects sought to erase any association with the hospital or physician’s waiting room. Thus, the physical layout prevented consumers from gathering in large groups. Case managers were assigned to teams sharing adjacent ofﬁces. While the team leader and the team’s assigned qualiﬁed mental health professional occupied private ofﬁces, two and sometimes three case managers squeezed into a single room. There were ﬁve teams charged with the primary responsibility of individual case management. These teams, their leaders, and half a dozen supervisors ﬁlled in the spaces not taken by conference rooms.

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Although three desks easily cramped a case manager’s ofﬁce, two desks, two ﬁling cabinets, and several chairs per ofﬁce left ample room. In understanding the case managers’ use of ofﬁce space, it was important to recognize its very public nature. Even with ofﬁce doors shut, I often saw consumers entering without knocking. “We want consumers to feel that this is their building,” a team leader remarked. Doors were rarely closed. An open door sent two messages about work: the case manager was either out in the community or in and available. I often found several case managers and consumers in an ofﬁce at the same time. The phones rang constantly and hallway conversation and trafﬁc was especially heavy before noon, causing some employees to pull the door shut. At any moment—and this occurred often while I was there— a consumer crisis could erupt in the hallway. Staff may or may not intervene. In one incident, shrill crying and moaning interrupted ofﬁce talk. Case managers looked up and listened carefully, then one said, “that sounds like Bob.” Nobody moved; a consumer from another team was responsible for the public outburst. I experienced crisis events where team boundaries did not matter, and intervention was left to the nearest case manager, but in this hallway crisis, no one from my team responded. Case management resumed. At 9:55 a.m. on one typical day the ofﬁce door was closed, and two managers were busy planning the day’s activities. Maria was on the phone arranging a consumer’s Prolixin (i.e., an antipsychotic drug) shot. Across the room, Betty was scheduling a pick-up time for a consumer’s grocery shopping. Without knocking (at 10 a.m.), a client opened the door and brusquely reported that “my car still doesn’t work and I need food.” Having just hung up the phone, Betty suggested that he “stay focused on one issue at a time.” “When was the last time we went shopping?” Betty patiently asked. Then, almost as if she had been in the room, a third ofﬁce mate walked in and answered the question: “We will go on Thursday. Anything else?” For a short while, the consumer talked about his car not starting: “I can’t get anyone to ﬁx it.” A case manager from across the hallway stepped in (10:10 a.m.) to discuss another brewing crisis; he also offered input regarding the disabled car. Simultaneously, still another consumer, with his body wrapped around the door frame and partially hidden so only his head can be seen through the door, asked a case manager: “When do you see me next?” Maria checked her schedule to ﬁnd the answer, but in the meantime her phone rang, and it was a consumer wanting information about affordable apartments. With the phone in one hand, Maria with her free hand scribbled the day and time of the appointment on a piece of paper. She handed it to the consumer, who had pulled himself from behind the door frame and was standing in the entrance;

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he left as quickly as he had appeared, assured that grocery shopping was scheduled. Maria’s phone conversation continued with a discussion about affordable apartments. In just twenty minutes, four case managers and two clients were physically in the room, three other consumers had phone conversations with case managers, and at 10:15 a.m., another consumer walked in. Asking for her cigarettes, she was making one of several unscheduled weekly visits. Why? If not closely monitored, “she chain-smokes and runs out of money and cigarettes before the ﬁrst of the month.” The team devised a plan and the consumer agreed to store the cigarettes in the ofﬁce; case managers rationed and monitored her usage (I checked the case records and indeed this was a consumer goal). The kind of management activity reported in this snapshot epitomizes the melding of public and private space. Consumers’ needs and desires, like cigarette rationing, were varied and constant; thus, deinstitutionalization had insinuated case managers into the private lives of consumers. The spatial arrangement of the CSS building placed case managers’ ofﬁces side by side along two intersecting hallways extending about 100 feet in both directions. Add to this picture the kind of transactions described above and this space reproduced for me the image of a farmer’s market. The fact that neither money nor goods (usually) changed hands made the CSS ofﬁce only like a marketplace, not a real one. Needs, desires, goals, and action plans were the stuff negotiated, bartered, and exchanged in these management stalls. And just as the exchange of money was essential for the rise of commerce, so perpetual negotiations between case managers and consumers were essential to the project of deinstitutionalization. Consequently, the spatial arrangement of this kind of strengths case management deﬁned the helping relationship, reproduced the project of CSS, and made strengths management’s abstracting of wants a concrete practice reality. For an idea like case management to be practiced it must actually occupy social space—e.g., community and CSS—presenting the strengths case manager with formidable scheduling and negotiating challenges. By 10 a.m. case managers were usually ﬁnished with team meetings, had conﬁrmed their appointments, discussed unusual problems, and organized the day. Between 10 a.m. and 2 p.m., I generally found case managers gone. Later in the day, they returned to wrap up business, attend late afternoon meetings, and plan for the next day. Thus, nine hours a day, several hundred bodies—staff and consumers—moved through the serpentine halls, ofﬁces, and activity areas, sometimes swiftly, doing the work of community support services.

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No entrance or door was locked until after 5 p.m. Consumers’ mobility and freedom—they were denied access only to the medical chart and medication room—was symbolically rich and physically palpable. Even a visitor with experience in mental health might have had difﬁculty distinguishing staff from consumers. The goal of CSS was to create equivalence between the helper and the service recipient. The building’s design and layout as well as its allocation and use of space reﬂected a democratic sensibility. The price for this openness was, however, privacy. Although occasional conﬂict erupted, consumers and practitioners shared the ofﬁce space created by the social ﬁeld. Keeping consumers out of hospitals and living “independently” required regular intrusions of case managers into consumers’ homes. For some observers, the case manager’s movement in and out of apartments would have been unequivocal evidence of a kind of intrusive monitoring (Margolin 1997:117–134). I am not going to argue otherwise, except to point out that no double standard existed. Since consumers had considerable freedom to negotiate the space at CSS, the underlying though subtle message was that case managers should have equal access to the private apartments of those they serve. I rarely saw consumers refuse apartment visits. Consumers intruded into the workspace of the case manager to press their demands, and case managers found privacy in consumers’ apartments while also monitoring daily living skills. A ﬂuid boundary between workers’ and recipients’ space prevented case managers from using the building as a coercive “spatial” power. This purposive blending of private and public space was consistent with the logic of the CSS social ﬁeld. Moreover, I am making no claim that contestation did not occur. Case managers often complained about the lack of private space, and like schoolteachers they frequently took paperwork home or to a restaurant. Case managers organized a meeting with the director of CSS to voice these concerns and often complained to me about consumers who do not knock before entering. They found loud intercom announcements bothersome and boisterous hallway conversation particularly annoying. One case manager described her frustration to me: I can’t do it here. There’s always someone coming in. I can’t do paperwork in this place. It’s hard to get it done. I’d rather talk than do paperwork. I need a place to get paperwork done. I do what one of my colleagues does, I have a booth at Perkins restaurant.

The CSS case managers were surrounded by a parking lot that was a constant reminder of the practical demands of the landscape. The inside was

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public. And paradoxically they went outside to ﬁnd privacy. Case managers used ofﬁces to plan trips, discuss challenges, ﬁnd support from fellow managers, and hold meetings. At times I sensed a genuine ambivalence about ofﬁce work; it was associated with a tension between paperwork and a lack of privacy, between “doing for” and “doing with” consumers. One manager expressed a radical view: “Give me a laptop and a cell phone and I wouldn’t need my ofﬁce.” He went along with the view that managers rely too much on fabricated and building-centered activity spaces. His was an imagined landscape without any practice center where he could move through the streets and suburbs, realizing what I call idealized in vivo management. Not surprisingly, this techno-manager did not fret about driving and formed a real identiﬁcation with his car. Other case managers were not anxious about consumers fulﬁlling important needs and desires by occupying CSS space. No case manager, however, commented upon the myriad ways that suburbia constrained strengths case management. There was an eerie silence about the consequences of a landscape that produces a fragmented sense of place by monstrous interstates dividing municipalities into mere shopping districts. Cars moved consumers from one goal to the next, satisfying wants and desires. Who among consumers and case managers wanted cars? Wanted or not, the suburban landscape imposes the car on the case manager and consumer.

THE VIEW FROM OUTSIDE LOOKING BACK IN

In the CSS social ﬁeld case managers and consumers tediously crossed the busy intersection at Avenue Road and Suburban Parkway many times a day, fulﬁlling their in vivo obligations. One image that produces a recognizable case management landscape is, then, that of High County’s 475 square miles, interlaced with 2,698 miles of roads, streets, and highways. The Kansas State Department of Transportation reported that vehicles travel each day an astonishing 9,907,000 miles over these 2,698 miles of road. Using mileage records, I have calculated that CSS workers drove each year a total of nearly 750,000 miles or 2,000 every day. “John barely ﬁts in my car,” said one case manager. “When I shift gears, my hand would rub his thigh and it always makes me feel a little uncomfortable.” Accidentally rubbing a patient’s thigh was an unlikely occurrence when disciplinary schemes placed the practitioner behind the couch or desk. John weighed nearly 250 pounds, so size mattered to the case manager with a small, fuel-efﬁcient car. “The springs in the seat are going to go, I know they are; it

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has happened before.” She worried about safety, the longevity of her car, and the meanings attached to uncomfortable, car-speciﬁc interactions. Case managers fretted over the aftereffects of consumers’ poor hygiene or coffee stains. “After Bill rides with me, I have to air out my car.” And it was true; I rode with Bill and his case manager. Bill did not easily connect his body odor to the ways people responded to him. Was it an intentional decision, an unconscious wish, or was it an inability to test reality that produced the body odor effect? The case manager did not wonder about Bill’s hidden motivations. If it was Bill’s wish to wear dirty clothing and not bathe regularly, then in principle such wishes had to be honored by strengths management. For body odor to be improved, Bill had to ﬁrst identify it as a want, then inscribe it into his Personal Plan. In the meantime, the case manager said nothing to him about her unpleasant car experience, but I often overheard her complaining to other managers: “I can’t go near his apartment, it is so foul smelling.” In this particular instance, moreover, the body odor complaint was not registered in Bill’s case record; I assume it was perceived to be a deﬁcit, or it was never counted among his personal goals. Just as suburban borders deﬁne resource availability, the car trapped and intensiﬁed the effects of Bill’s body odor and the regularity of his manager’s complaint. The landscape set the conditions for this work effect, not the strengths disciplinary knowledge. Strengths management is silent on such issues; it purports universal application, as if landscapes did not matter. Only situated practice resolved Bill’s effect on the manager; she learned, adapted, and scheduled car trips on sunny days when her window could be open. This did not mean that Bill could not some day work on his body odor. He might develop awareness. But it could take time, and the manager felt that “Bill has a lot of needs right now and he is very low functioning. It takes a lot of time just to take care of his basics.” Driving linked a naturally occurring suburban resource to consumers’ wants, a huge and seemingly endless job that required a great deal of patience. The landscape for the case manager is one dominated by the automobile, the highway, the trafﬁc jam, and delays. It means reconciling driving time with management time. Loosened from the “total institution,” which provided basic necessities on-site, former patients need suburban case managers to drive them to and from the ofﬁce, the apartment, or the grocery store. Case managers typically used their personal cars, but they often encouraged consumers to access transportation services—the CSS van service, suburban taxis, or High County transit. Consumers who regularly used CSS-based services and who lived along a van route could make requests for van rides. Few used High County transit; it was not convenient. Spaces, sites, and services ﬁgure

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prominently in the strengths model: they were what consumers accessed as “naturally occurring resources.” The bus was an example of a naturally occurring resource and the case manager’s car was an example of a “segregated resource.” When the resource was produced by CSS, it was not natural. As the workshop leader had pointed out, “the community is a reservoir of untapped potential resources.” Just as the painter ﬁlls in a mountain landscape with pine trees, streams, and valleys, the case manager must constantly have in her imagination the High County roads leading to “naturally occurring resources.” But what resources are to be found in High County? Does this landscape have geopolitical borders? For case managers, High County political lines determined both resource availability and accessibility. Chief among the peculiarities of High County was the absence of cheap, single-room occupancy hotels, boarding homes, and large congregate-care facilities. Suburbia is deﬁned by the single-family home, which is neither useful nor affordable for most CSS clients. The processes of urban, rural, and suburban political formation create different landscapes for case managers. There was no recognizable population of homeless mentally ill in High County. This, however, is not true in most urban environments. Suburban public space, where it exists, is not amenable to the peripatetic; one needs car transportation in order to lounge in High County public parks. In urban environments, the homeless walk from the bridge underpass where they sleep to the downtown park or commercial district where they live by day. In suburban landscapes, there are few homeless but many carless mentally ill. Medication and money are life domains that require driving to pharmacies and banks. To be a good case manager in suburbia is to demonstrate the ability to concatenate errands close to each other and to speedily accomplish each one, while maintaining the “ontime” manners and composure of an airline boarding crew. The CSS social ﬁeld bound case managers and consumers to driving from one naturally occurring resource to another, complete with all of its road rage frustrations. As mentioned above, the strengths model considers the whole of County a pool of “untapped potential resources.” Skills training could take place at home or at the bank. This means that case managers, if necessary, would assist clients with shopping, banking, laundry, health care, that is, with anything that was part of their everyday life. Although strengths management calls banks and food pantries naturally occurring, to me a “natural” resource means the absence of human and social input. It should be obvious that community-based commodities originate with human and social effort. Perhaps the architects of strengths management coded commodities, friendship, and family-based help as “natural” simply to make residential, building-speciﬁc, and government-sponsored services

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“unnatural.” For one thing, this plays on our epoch’s sensibility that natural things are better. CSS-based programs, the “segregated resources,” are inferior to the volunteer services of civil society. Second, ours is a capitalist, commodity-driven economy that provides goods and services to anyone with purchasing power; therefore, it is natural to be seen purchasing commodities. This is especially true in a landscape where leisure activities are often realized in shopping malls. A fabricated space like the CSS exchange store was too socialistic and institutional. Coding socially determined things as natural served to remind case managers that their mission was to decrease the consumers’ dependence on the “totalizing”effects of “institutions.”Case managers learned to be wary of the dole’s unintended side effects. The idea that there were “naturally occurring” social resources was congruous with strengths management’s philosophy and, in general, supportive of the policy of deinstitutionalization while also providing the case manager with a suburban orientation for “driving while linking.” The High County landscape was a unique geopolitical cauldron of sites and services. Above all, it was the monitoring and linking function of case management that made the movement between these many sites necessary and suburban deinstitutionalization possible. And it was this movement that energized the activities of the case managers and deﬁned their point of view outside CSS. Naturally occurring resources may be found anywhere in the 475-squaremile grid representing the twenty-one adjoining municipalities uniﬁed under the political rubric of High County. Social class and race politics heavily conditioned the borders trapping resources and thereby deﬁning case managers’ acquisition of or linking to resources. Geopolitical realities produced the conditions for the kind of segregated resources CSS reproduced, for example, the need to budget considerable monies for transportation. In short, urban environments produce the homeless, and the suburbs produce the carless. The political economy of suburban growth favors car case management. High County’s population was 95 percent white; its population was significantly boosted by white urban and rural migration from contiguous cities and counties. In 1990 High County contained 22.7 percent of the metropolitan area’s 1,566,280 residents. However, between 1980 and 1990 it accounted for 63.8 percent of the area’s net 132,882 growth in population. And 65 percent of that growth was due to net migration (the number moving in minus the number moving out). In the same period, two adjacent urban cities contributed only 3 percent to the population growth in the entire metropolitan area.

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In table 5.1, I compare the median household income of High County with that of two adjacent counties. High County’s lowest income residents, in Riverside, had a median income ($30,132) nearly $7,000 higher than the median income of the adjacent county ($23,780), a region characterized by poor, urban, and African-American residents. And High County’s wealthiest residents boasted incomes ﬁve times the median incomes of the two adjacent counties. Moreover, the 1990 poverty rate in High County was 3.6 percent, signiﬁcantly lower than the Kansas rate of 11.5 percent. Thus, political and eco-

TABLE 5.1 HIGH COUNTY, KANSAS: MEDIAN HOUSEHOLD INCOME (1989) H I G H COU NT Y C ITI E S

Highland Lake City East Hills Southpark Forest Hills South Village Knoxville Eastview North Village Hillside Northpark Oaklawn Harrisville Centerville Andover Millertown Centre Overlook Middletown Riverside COU NTY

MEDIAN I NCOME

$122,821 $83,733 $78,859 $74,980 $59,512 $46,935 $46,481 $44,246 $43,750 $40,179 $39,776 $39,742 $39,206 $34,675 $34,013 $33,702 $32,898 $31,355 $31,117 $30,132 $42,741

EAST COU NTY

$27,853

NORTH COU NTY

$23,780

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nomic forces produced the effect of a homogeneous landscape: white and middle-class. The conditions producing homogeneity were not particularly good for case management. A median income of $42,731 meant that the markets in groceries, dry goods, pharmaceuticals, psychiatric services, and especially housing, were aimed at households with incomes that far exceed those of the average CSS consumer ($6,000). The borders that created landscapes rich in commodities, discount stores, highways, schools, homes, and a growing tax base, also made things difﬁcult for case management. The median price for a home in 1990 was $91,500, and the median monthly gross rent was $515. Not attracted to low-income markets, housing developers contributed to a severe crisis in affordable housing. Less expensive housing could have been found across the border in adjacent counties. Here’s the rub though: case managers could not provide services outside the catchment area. For consumers wanting to live alone in High County, a federally subsidized Section 8 voucher was a necessity. They could not, for example, live in a run-down and cheap studio apartment or hotel room because the suburban landscape economically and politically restricted slum housing. The case manager’s view outside the CSS ofﬁce was shaped by the constraints of helping consumers live in High County. In the community consumers did not have equal access to public space as they did inside CSS. Money and the ability to purchase commodities shaped the view from outside. And among commodities housing was the most troublesome. Rents consumed most of the monthly check. Case managers must help consumers budget and monitor spending; money needs to go a long way. They must ﬁnd the cheap deals. In short, case managers found ways to adapt low incomes to high-income landscapes. A case study of one typical case management day illustrates the relationship between linking, monitoring, and driving. This day was typical of most I experienced, except that money issues (e.g., bills, bank deposits, and spending money) were intensiﬁed at the ﬁrst of every month. It’s easy to “rack up the miles” at the beginning of every month. At the CSS ofﬁce, the case manager’s ﬁrst task (8:30 a.m.) involved medication monitoring: “Joe, I got your morning meds.” The consumer’s response was habitual; he took the meds, small talk ensued and then a second monitoring question: “Joe, how did you sleep last night?” “Better, I didn’t wake up early,” he cheerfully replied and then quickly left. Joe and the case manager would have this routine interaction whenever both converged at the ofﬁce around 8:15 a.m. Had the case manager been somewhere else, Joe would have

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looked for a nurse to hand him the meds. It did not seem to matter. The case manager explained to me that Joe must have his medication monitored “until he shows he can do it.” Following the adjournment of the daily team meeting (9:15 a.m.), we looked for a consumer who was expected to be milling about the building. We found him in the drop-in center smoking. “Meet us at my car and we’ll go to the bank and get that money you want.” Together we made our way to the bank for $30 cash: the consumer needed some spending money. “It was good that we stopped at the bank, Karl, your social security check has not been automatically deposited yet.” Next stop: a discount store where Karl bought a carton of cigarettes. By gently prompting Karl about the amount, the signature line, and date, while driving away from the cigarette outlet, the case manager monitored Karl’s writing a $56 utility check. We arrived at the consumer’s apartment, and we had not been inside long when the manager noticed that the television was missing. “I loaned it to a friend.” A skeptical case manager responded, “I see.” Later, as we were driving to the next appointment, I asked why the missing television concerned him. “He likes marijuana but lacks money to buy it and this has happened before,” he responded, sounding a bit frustrated. “He will sell things that we have worked hard to get and use the money to get marijuana.” If Karl had enough money to buy marijuana and keep his television, this type of monitoring might have been averted; it was only the television’s absence that signaled to the case manager that something might be amiss in Karl’s manners. Case managers looked for evidence; they looked inside apartments and read their content and context. Monitoring was made up of these bits of everyday life; it was as the workshop leader said,“look for clues in the apartment.” The clues that most case managers looked for were those that help evaluate the degree to which the consumer had selfdirected manners, especially regarding meds and money. At 10:30 a.m. we drove to the next scheduled appointment to help a consumer ﬁll out a referral application to the CSS vocational rehabilitation program. It was hard to determine if the consumer’s interest in working was selfdirected or due to the case manager’s prompting. The manager did a lot of prompting and motivating: “Would you feel better if you worked?” The answer was one I heard often: “I could sure use the money.” Before we left, the consumer made sure there was enough time to drive to Quik Trip and “pick up some cigarettes and soda pop.” We obliged, returned him to his apartment, and drove away. I learned we were thirty minutes behind schedule, but our delay did not cause the next consumer to cancel (11:40 a.m.). This stop was routine moni-

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toring. “I want to make a quick hello and see how he is doing.” The case manager recognized a purse and speculated: “Is your girlfriend back?” The consumer was not particularly disturbed by the query; instead, his response was unguarded (I later learned that his girlfriend regularly ﬂoats in and out but never stays longer than three days). “I need to know who is staying in the apartment because his lease and Section 8 voucher restricts who can live at this residence,” the case manager replied to my question about why the girlfriend’s presence mattered. In addition, “were he to get kicked out, it would be a ﬁnancial disaster. His portion of the rent is $89 and the feds [i.e., federal government] pay the market balance to the landlord.” Our last task was to drive the consumer to yet another convenience store to buy cigarettes and soda pop. It was, after all, the ﬁrst of the month. Breaking our morning tempo, we experienced our ﬁrst “no show” at 12:15 p.m..; after a short lunch break, we drove back to the consumer’s apartment and found him home (12:50 p.m.). Here, our monitoring attention was focused upon monthly utility bills. Last month “you neglected to pay your bills, so it’s double now: $104 electricity and $89 for natural gas.” Today’s money monitoring required: (1) overseeing the check writing, (2) a trip to the bank for a little spending money ($10), and (3) to the post ofﬁce to mail the utility payments. In addition, we drove to the welfare ofﬁce and ﬁlled out an application to determine the consumer’s eligibility for a government-supported utility subsidy. Although on this day I saw no evidence of drinking (and later the manager agreed), while driving back to the apartment, the manager quizzed the consumer about drinking and attendance at Alcoholics Anonymous (AA) meetings. “He can get into a lot of trouble when he drinks, so I support his going to AA,” the case manager later revealed. At 3:15 p.m. we were making our ﬁfth “home visit” (that’s how the case manager coded the visit in his daily reminder calendar).A consumer goal was being followed up: “Did you take the vocational interest exam at the local junior college.” He had, but the question triggered a thought that was more pressing: “I lost my apartment keys and haven’t locked my apartment for several days.”The vocational follow-up would have to wait for another day. The keys did not turn up in our search, so an unexpected trip was added to the day’s task list. We ﬁrst drove to the bank to get cash. Next, we drove to the apartment manager’s ofﬁce to deliver the rent check and ask for a key. We doubled back to a hardware store to make new keys; during the trip to return the master key, we made three separate stops to get cigarettes (cigarette discount store), a hamburger (McDonald’s), and milk (Quik Trip). Back at the apartment, the manager used the consumer’s telephone to call our next appointment.

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Around 5:40 p.m., at a roadside park, the manager took a break before his last two appointments. We engaged in some routine car chat: “I like this job because I can sort of work when I want to. I am not tied to an ofﬁce. I plan my day around what needs to be done, and it’s better than being cooped up behind a desk all day.” At 6:15 p.m. we picked up another consumer and went to Radio Shack to purchase a radio. There was little prompting with this consumer; he knew when, where, and what kind of radio he wanted. In the car, as they discussed their excitement over a recent college basketball game, the case manager and the consumer seemed like two friends hanging out for a short while. Moreover, the manager’s observation of the consumer’s recent haircut and beard trimming was conveyed in a style more typical among friends than what one would expect from a watchful case manager commenting on the consumer’s hygiene. At the last and eighth home visit of the day, we dropped off evening medications. It was a very short visit, but not so short that the manager did not fail to notice a sack of clothes and wonder, “Who’s staying with you?” Before we could leave, we were asked for a ride to a drop-in center. Except for writing case records, billing, and related paperwork, which were not completed until two days later, case management on this day ﬁnished with our driving the consumer to his destination. I examined this manager’s daily calendar and counted 1,182 home visits in one year, or nearly 5 every workday. Today’s eight home visits meant we had an above-average workday. The view from outside was structured by the daily work of enabling those with limited incomes to live in a landscape of the wealthy. And it was with this task that the case manager often faced the most arduous and daunting work: driving back and forth between apartments, CSS, grocery stores, doctor’s ofﬁces, and banks. And at the end of the day, the work often left the case managers exhausted. They returned to CSS to seek the inside perspective on the outside landscape and to get recharged for the next round of work. While the case managers were in the community, they felt good about helping consumers get what they want—against the odds. This produced a sense of case management competence. Was the kind of daily monitoring I experienced intrusive? Yes, I believe it was, but could it be otherwise? In or out of the hospital, many individuals with severe mental illness require assistance with self-monitoring. When does monitoring become intrusive? Case managers provided only a situated response to this question: “too much doing for them.” For strengths management, monitoring problems or deﬁcits was inappropriate. When case man-

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agers did not facilitate progression toward an adequate level of self-monitoring, when their work did not produce self-directed activity, then, according to the case managers’ situated knowledge, monitoring was controlling and dominating. Each consumer and his or her particulars was simultaneously weighed against the manager’s style of monitoring meds, money, and manners and against the demands of suburban landscapes. I did not ﬁnd the watchful eyes of case managers as disturbing as the constraints of the landscape. Driving sapped important time and energy from a case manager’s day, signiﬁcantly affecting his or her ability to do more than goal management. Case managers constantly had to assess the time it takes to conduct car, home, and ofﬁce monitoring and linking. The strengths model provided little guidance for confronting the challenges of a suburban landscape. Well, sometimes it is a matter of convenience. I have a consumer that would prefer to go to the bank with me, withdraw the money, and then go to the grocery store. She is very suspicious of how her money is handled, but she doesn’t really want to get involved in the actual transaction. So sometimes, instead of having to go all the way to the bank and then go all the way back to where the grocery store is, I will go to the bank and just hand her the money and say, “here is your grocery money.” Because sometimes when I do try to save myself steps, it is for me, like it doesn’t matter if I do it for them. She could do it with me, but I could use that time in a more constructive way, rather than just being their errand runner, or whatever.

The case managers’ emotions and sense of well-being were in a constant tension with the outside and inside, where tasks are often unﬁnished and where there was an interminable sense that something else remained to be done. The hospital used the wall, the locked ward, the countryside, and the key to isolate and protect; the resulting boundaries produced the freestanding and autonomous total institution. The demands of everyday life could not penetrate the surrounding pastoral ﬁelds, which resulted in a unique kind of hospital monitoring. Although deinstitutionalization dissolved the hospital walls, it did not eliminate boundaries. Landscapes, as argued by John Brinckerhoff Jackson, have boundaries that stabilize social relationships. They make residents out of the homeless, neighbors out of strangers, strangers out of enemies. They give a permanent human quality to what would otherwise be an amorphous stretch of land. Those

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roughly geometrical enclosed spaces are a way of rebuking the disorder and shapelessness of the natural environment; seeing them from the outside, the alien wanderer wishes he too belonged. It is when we ﬁnd ourselves in a landscape of well-built, well-maintained fences and hedges and walls, whether in New England or Europe or Mexico, that we realize we are in a landscape where political identity is a matter of importance, a landscape where lawyers make a good living and everyone knows how much land he owns. (Jackson 1984:15)

Inside the CSS social ﬁeld, the hospital, the medical model, and the “patient” were no longer distinguishable. Hospital boundaries were destroyed, but new geopolitical catchment areas reinvented borders. A new helping landscape was redrawn for the purpose of stabilizing relationships between the consumer and the case manager. Case managers and consumers experienced suburbia as a fragmented social service landscape. Case management for the carless was a necessary condition for restabilizing a relationship between helper and service recipient in a landscape ﬁlled with desirable commodities.

C HAPTER 6

Oral and Written Narratives of Case Managers

H

istorians and sociologists have recently discovered social work case records and are using them to write the history and sociology of social work practice (Kunzel 1993; Gordon 1994; Odem 1995; Margolin 1997; Tice 1998). These works generally disregard the limits of textual analysis, especially when they rely entirely on the case record. And for many, the written texts produced by social workers represent the totality of practice, policy, organization, and theory. Many lead us to believe that the written text is a facsimile of actual practice, as they debate the problematic nature of objectifying clients through the writing of “cases” (Epstein 1995; Townsend 1998; Chambon et al. 1999). In their provocative collection, The Natural History of Discourse, Silverstein and Urban (1996) have assembled essays examining the problem of reducing culture and everyday life to textuality. They write that to equate culture with its resultant texts is to miss the fact that texts (as we see them, the precipitates of continuous cultural processes) represent one . . . phase in a broader conceptualization of cultural processes. Moreover, to turn something into a text is to seem to give it a decontextualized structure and meaning, that is, a form and meaning that are imaginable apart from the spatiotemporal and other frames in which they can be said to occur. (Silverstein and Urban 1996:1)

Thus, for those who study social work and social workers, using the text alone presents similar dilemmas, that is, confusing the map with the territory, the text with the practice and the practitioner.

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In this chapter, I analyze case managers by combining their written and spoken narratives to show how the written is a partial representation of case management. I juxtapose the written and oral narratives of case managers to demonstrate how written text silences meaningful and powerful aspects of practice that can be studied only by analyzing oral narratives. My research challenges those who critically interrogate social work practice solely on the basis of the written texts. These analyses often reduce social work to its social control function, where social workers are dominated by particular and hegemonic knowledge/power schemes and biopower and thus regulate and routinize the behavior of their clients: unwed and welfare mothers, adolescent girls, and hospital patients. To uncover whether social workers are dominated by or are independent of knowledge /power schemes, I argue that the situated (the everyday, strategic, and contextual) and disciplinary (textbook knowledge or theory) must be studied in action. Thus, I shall avoid the tendency to argue “that human subjectivity itself is a side-effect of textuality [and] that texts create worlds rather than refer to them” (Jackson 1991:15). I shall show, instead, that, although disciplinary knowledge is often inscribed in texts, the oral narrative captures the situated knowledge of case managers. For social work, my argument will provide a balance to the critiques of sociologists and historians of practice; regarding the latter, I challenge current methodological and theoretical approaches to the study of practice. I use two data sources—written texts and oral narratives of the same case management event. Using case managers’ progress notes, monthly goals, and treatment plans, I show how the act of recording creates a disciplinary narrative about the self-directed consumer. I use the oral narratives of case managers to demonstrate that their situated knowledge performs unique work; it recovers illness, dependency, and chronicity. And ﬁnally, by comparing the two narratives, I establish that in some instances the written and spoken do similar work, and in other instances the spoken performs work that the written cannot begin to do. I collected the data by utilizing ethnographic methods, which allowed me to collate the oral and written narratives about the same event. Ethnography permits the retrieval of the oral narrative, and it recovers the silence of situated knowledge by placing the written and spoken narratives in context (Silverstein and Urban 1996). Methodologically, my examination of disciplinary knowledge was simpliﬁed by the strict application of a single case management model—the strengths perspective. State funds were speciﬁcally allocated to mental health centers that utilized the strengths model. At my research site, this administrative mandate meant that practitioners were required to use a single model; thus, case managers were carefully instructed

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and supervised to think and write according to strengths management’s philosophy. As part of the ethnography, I attended a statewide strengths management workshop, reported in chapter 4. I completed the training in order to immerse myself in the language, and all of the case managers I studied had attended a similar workshop. Familiarity with the strengths management lexicon was an important ﬁrst step in identifying the work of disciplinary knowledge. I found that the disciplinary practice of strengths case management and case managers’ situated practice performed different work with unique languages. For example, strengths management deliberately suppressed the biomedical language of needs, deﬁcits, pathologies, illnesses, and weaknesses. Case managers were trained to use assessment and goal plans to ask the client “What do you want?”“What have you tried in the past?” and “How can we get there from here?” By including a method that captured the oral narratives of case managers, I discovered their situated knowledge/power, a language that referred to need, dependency, and illness. For example, case managers used the term “gets it” to indicate a client’s ability to understand goals, steps, and actions. No matter how much planning occurred, when the client failed to take the right steps to meet goals, “natural consequences” were invoked. The expressions “low and high functioning” and “low and high need” were situated diagnostic terms used by case managers for categorizing consumers along a continuum of needs. The expression “doing for” meant that a consumer’s illness required direct assistance while the corollary term “doing with” suggested that a consumer was capable of self-sufﬁciency, but the case manager was needed “to walk alongside.” ROB ERT: A CASE STU DY

I began following Robert closely in February 1997. By age thirty-seven he had been a client for nearly ten years; his diagnosis was schizo-affective disorder with a secondary substance abuse problem. Below, I introduce him through my account of a home visit I made with his case manager. I then return to Robert’s February Monthly Goal Plan to give a chronological account from the written and oral narrative of case management.1 A HOME VISIT: FEB RUARY 24, 1997

In March 1996 Robert established residence in a one-bedroom apartment. The landlord required his parents to cosign, something they were not happy about,

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but they felt it had to be done. There was little room in Robert’s ﬁnances for mismanagement. His rent was $410 a month. His social security disability (SSI) was $456. He received $65 in food stamps. And Medicaid paid for most of the medication. Indeed, he lived alone only because the team used ﬂexible funds to subsidize his rent—$200 monthly. Money for fast food occasionally came from his parents. It was a ten-minute drive from the ofﬁce to his apartment, a typical suburban complex that catered to a secondary rental market. He was scheduled to clean every other Tuesday with the help of a case manager and housecleaning crew. Robert, I was told, “becomes quite nervous about cleaning,” so the team decided to reduce his anxiety by routinely helping the crew. Robert answered the door after one knock. I scanned the apartment as the case manager and Robert engaged in small talk. A year ago, I learned later, the walls had been newly painted and the ﬂoors carpeted; now they were dirty, some had grafﬁti, and the carpet was hopelessly stained. I followed the case manager as she assessed the day’s cleaning task. In the bathroom I noticed holes in the ceiling. I later learned that Robert had punched these. In the living room I sidestepped piles of papers. A closer examination revealed that these were pages torn from magazines, many with highly suggestive sexual content. They were scattered on the ﬂoor, chairs, couch, and coffee table; indeed, there was no place to sit. Robert, burrowed between the piles on the couch, sat smoking, his ashtray overﬂowing with cigarette butts. One was still burning. The smells from dried pop on the kitchen ﬂoor and a moldy frying pan permeated the place. Empty coke bottles, a Burger King sack, and a cereal box sat on the kitchen table. On squares and rectangular pieces of torn scrap paper Robert had been drawing multicolored designs. After some minutes of frantically rearranging these on the ﬂoor in front of us, he asked,“What do you think?” The case manager thought “they were interesting.” Robert’s attention quickly shifted, however. He seemed compelled to show me an autographed baseball and proudly read the names. Impatient, the case manager called to ﬁnd out why the housecleaning team had not yet arrived. Then she asked Robert if he would “like some help in preparation for the cleaning crew.” Robert answered, it seemed, by ignoring the question. He was reminded that everything left on the ﬂoor might be discarded. The case manager suggested that “we could help you pick these things up, so they won’t be thrown out.” To which Robert wittily replied, “You mean, I have to clean up before the maid arrives, that is so upper class.” Abruptly, Robert changed the subject: “can I get $100 of spending money at the ﬁrst of each month?” His money management agreement provided only $25 each

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week. The team believed that allocating $100 in four parts prevented him from “spending it all at once, sometimes on [illegal] drugs.” “We discussed the issue,” the case manager responded,“and agreed not to give you $100.” Robert ﬁrst questioned the mechanics of the change, understanding this allocation as a mere procedural problem. When the case manager explained that “it was not a matter of how, it was a matter of if,” Robert became irritated and exclaimed: “Time is money. It’s proﬁt. If you give me my money, I can reinvest it and get the things I need. Time is money.” As the palaver continued, Robert became more and more disturbed. He seemed unable or unwilling to see the team’s perspective: “a fourpart installment is necessary because of your bare-bones budget.” Robert kept repeating, “if I had all my money at the beginning of the month, I could invest it and make more money.” Finally, the cleaning crew arrived. There were no compromises. The case manager offered: “How about $50 every two weeks.” Robert refused. He insisted on $100 at the ﬁrst of the month. Before the crew had started to clean, he asked that we leave. Neither the case manager nor the crew tried to dissuade him. We left. During the twenty-minute drive back to the ofﬁce I learned that Robert’s parents thought he should not live alone; they believed he was more organized in the hospital or in structured residential programs. Although Robert had shared many apartments, he somehow always faced a housing crisis. And according to the case manager, he had a history of abusing illegal drugs and diet pills. Occasionally, “by pressing an artery on his neck, he likes to experience unconsciousness by blocking the ﬂow of blood to his brain.” I asked the case manager if his illness prevented him from understanding money and cleaning, or if he was just being uncooperative? She replied: “I think he just wants his way, and when he does not get it, he gets angry.”

In table 6.1 I have reproduced Robert’s February Monthly Goal Plan. I found no situated language in consumer goal plans. Robert’s plan was typical because all case managers were required to write notes according to the mandates of the strengths model. All the case managers had been trained in completing monthly goal plans. I found no situated language in Robert’s written case notes; instead, the notes were concise, repetitive, and largely reported on activities the case manager and consumer had completed. To contrast the disciplinary and situated languages of case managers, I ﬁrst analyze the written narrative. What have the texts produced? The written records of case managers produce a “textual,” self-directed person. And in

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TABLE 6.1 FEBRUARY MONTHLY GOAL PLAN GOAL(S)

1. “I want to handle my money.” 2. “I want to feel better emotionally.” 3. “keep my apartment clean.” STEPS TOWARD GOALS

1. Robert will meet with case manager for monthly money mgt. session by 2-2897. Not accomplished 2-28. 2. 2-3-97 Our case management team will provide daily med drops by 2-28-97. Accomplished 2-28. 3. 2-3-97 Robert will take meds as prescribed by CSS psychiatrist by 2-28-97. Not accomplished 2-28. 4. 2-3-97 Robert will come into the center every Monday to have blood drawn for Clozaril level by 2-28-97. Not accomplished 2-28. 5. 2-3-97 The cleaning crew will clean Robert’s apartment weekly (Tues.) and the team will assist in the clean up by 2-28-97. Not accomplished 2-28. P RO G R E S S TOWAR D G OA LS

February 5, 1997 TCM 060 1400 I met with Robert today at his apartment to bring him his medicationhe [this typographical error is left to show it was copied from one month to the next] took it without any problems and was somewhat upset about his ﬁnancial situation. Apartment very unhealthy, refusing to let cleaning crew assist him. [case manager signature and credential]

doing so, the text reproduces strengths management’s disciplinary knowledge/power, CSS, and the policy of deinstitutionalization.

THE WRITTEN NARRATIVE

Case managers speciﬁed goals and goal-achievement (see table 6.1) in written documents where, according to strengths management, Robert’s goals were listed in his words (the quotations that enclose his monthly goals signify that

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these were in fact Robert’s words). Then case managers dutifully speciﬁed the “steps toward goals,” or in strengths management’s lexicon,“who will do what when?” A rational, linear being was constructed—from goal to assigning responsibility to action—by the structure of Robert’s monthly goal plan: goals, steps, and progress. When case managers wrote their thoughts in strengths language, in effect, they produced a textual, self-directed consumer.2 Yet, is Robert’s textual production a copy of actual case management? Similarly, can this particular culture be simply read as text? According to Silverstein and Urban, the process of “entextualization” creates “durable” and shared cultural images, which should not be reduced to the “co(n)text” of lived experience or practice (Silverstein and Urban 1996:1–17). Thus, although case managers’ written narratives produced textual subjects, these should not be confused with the processes and narratives that co(n)textually occur. Practitioners helped Robert identify his monthly goals or wants: “I want to handle my money,” “I want to feel better emotionally,” “keep my apartment clean,” “I need more money,” “I want to stay out of the hospital,” and “I need to let the cleaning crew in my apartment.” I discovered, in examining the July monthly goals of consumers, that Robert’s goals were typical—especially his goal “to stay out of the hospital.”3 Robert’s textual self was an independent apartment-dweller in the community. Thus, a case manager’s written texts instantiated the theoretical principle of normalization and the policy of deinstitutionalization: the return of “patients” to the “normal” community. The February progress notes were written to afﬁrm or negate the case manager’s and the consumer’s accomplishments: WR ITTEN PROGR ESS NOTE: FEB RUARY 5TH

After calling Robert numerous times, I went by his apartment for a med [medication] drop. Got no answer at the apartment. Left note on his door that his medication would be at the ofﬁce and it’s his responsibility to take his medications as prescribed. WR ITTEN PROGR ESS NOTE: FEB RUARY 10TH

Provided Robert with daily med drop, watching him take. Discussed his attempt to take the van yesterday for lab [laboratory] work and the option of getting it done by Thursday.

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WR ITTEN PROGR ESS NOTE: FEB RUARY 14TH

Case manager watched Robert take medication for the day. He reports that his sister took him to get lab work today. Apartment covered with magazine pictures. Robert was wearing an eye mask when he opened the door. Discussed ongoing struggle with obtaining weekly lab work—explored possibility of medication change; however, Robert states he is not interested at this time. WR ITTEN PROGR ESS NOTE (EVENT 1): FEB RUARY 24TH

Provided Robert with daily med drop watching him take. He started off in pleasant mood, showing art work. When conversation switched to his budget and apartment condition, his attitude changed. He became argumentative and loud, seeming not to believe what I was saying. By the time the cleaning crew arrived, he’d had his ﬁll of Jerry [this was the home visit I reported earlier] and myself, so he asked us to leave. WR ITTEN PROGR ESS NOTE (EVENT 2): FEB RUARY 24TH

Assisted Robert in getting to the ofﬁce for lab work. Spent time discussing his past involvement with a church. Resource Development staff offered support if Robert chooses to explore going back to work in the future. WR ITTEN PROGR ESS NOTE: FEB RUARY 26TH

I met Robert at his apartment. He took medications without any problems. We ran to the pharmacy to pick up his medication. I dropped him back by his apartment. I encouraged Robert to clean his apartment. He stated that the apartment didn’t need cleaning.

Similarly, other records reported where management activity occurred: “Robert and I went to the grocery store for a pack of smokes”;“Apartment very unhealthy, refusing to have cleaning crew assist him”; and “I met with Robert today at his apartment. We talked about some vocational options.” Not only does this last note address Robert’s desire to earn money, the case manager also wants the reader to know that the conversation and activity took place “at his

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apartment.” Why? Medicaid speciﬁcally reimburses home visits. And, of course, strengths management emphasized in vivo intervention. It seems no coincidence that case managers’ textual narratives purposively placed their work in apartments, grocery stores, and discount cigarette stores. In effect, case managers produced, in Robert’s case record, a “textual” community dweller. By placing written and oral narratives side by side, I found that the case record contained: (1) only a fragment of the total management action, and (2) a representation of strengths management’s knowledge/power scheme. The written narrative did not and cannot mirror actual unfolding events. Because strengths disciplinary knowledge was primarily concerned with goal achievement, case managers dutifully inscribed only goal-attainment activities and actions into the case record. The written texts, repetitive and banal, read: “Provided Robert with daily med drop.” In fact, a subsequent note and the February 5 progress note were exactly identical—even the typographical errors remained unchanged. These notes, unlike most I examined, were entered using a computer; thus, the February note was copied and pasted to a later one. Furthermore, there was similarity in the choice of verbs, adjectives, and style of writing. For example, “provided daily med drop,” is short, to the point, and provides no additional information. But more important, the repetition in the text demonstrates that CSS were accomplishing the task of providing medication drops. Although the reader learns that case managers delivered daily medications, the narrative does not comment on why nor provide an explanation. Why, for example, is Robert not self-monitoring? Or why give him medication? For some sufferers of mental illness, the change from month to month is often minuscule. Chronicity, after all, signiﬁes indeterminacy. Case managers acknowledged this by writing goals as “baby steps.” The message was: “change is slow, so go slow.” Numbed by the monotony of rewriting the same goals, case managers recopied narratives, creating a simulacrum. Moreover, because the written texts lack spontaneity, they tend to repeat the disciplinary knowledge of CSS and strengths management; in this way the texts represent a synchronic picture of what the policy of deinstitutionalization and the CSS program expects. The written texts of case managers, I argue, become a normative project; they lack difference, contrast, and ambiguity. Thus, the notes of case managers were textual attempts to represent (or copy) strengths management and CSS. Perhaps most important, the written narrative assumed, without question, that Robert was a rational subject thinking in a linear fashion. Texts thus produced Robert as a subject who thought in terms of cause and effect, in three simple steps: (1) goals and timetables were set, (2) task responsibility was

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allocated to Robert and the team, and (3) progress was measured, resulting in observations such as: “Keep the apartment clean,” which means that workers made observations on Robert’s goal to clean his apartment. Their written narratives were observations about whether he was successful or unsuccessful in achieving goals. Producing a goal-oriented subject in the case record was expected, given the strengths model. The written narrative reproduced for administrators, policymakers, and advocates of deinstitutionalization empirical evidence of the efﬁcacy of disciplinary power; in effect, it reinforced the idea that longterm, residential facilities were unnecessary and produced dependency. I think that Robert’s textualized subjective wants (“I want to stay out of the hospital”) instantiated the project of CSS and strengths case management. In short, whose goal was it to stay out of the hospital? According to strengths management, it was Robert’s goal. Although the narrative functioned to produce self-directed consumers, paradoxically, it also produced an omission: the possibility that illness prevented goal-oriented thinking and action. When goals were not achieved, how did the narrative explain Robert’s failure? How was responsibility for the failure distributed? The written narrative assigned responsibility to Robert’s lack of ability. For example, in a revocation letter to the court, the case manager and psychiatrist wrote: “Robert lacked initiative for being responsible for his treatment and resists case management support.” In a failed medication drop, the case manager recorded: “Left note on his door that his medication would be at the ofﬁce and it’s his responsibility to take his meds as prescribed.” And last, there was frustration with the consumer’s inability to achieve a goal: “When conversation switched to his budget and apartment condition, his attitude changed. He became argumentative and loud, seeming not to believe what I was saying.” Textual entries like these can easily be interpreted as “blaming the victim.” Without comment, the written narrative constructed lived experience as an assignment of daily tasks and their accomplishment. When Robert failed at keeping the apartment clean, the written narrative offered no explanation. The progress notes did not provide depth. Did Robert fail? Or did CSS fail? By writing a consumer’s subjectivity as wants, goals, steps, and progress, the strengths language ironically had nowhere to go; case managers working in this model had to see “nonaccomplishment” as “lack of initiative.” Was this a misapplication of strengths management, an example, perhaps, of untrained case managers who thought in terms of deﬁcits? I do no think so. In the strengths training workshop I attended, the leader instructed her neophyte case managers on the transparent nature of reality. She said, “each of us have

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differences in our talents which are not deeply hidden.” Because strengths management necessarily suppressed a language of illness—chronicity, cognitive psychology, and other disciplinary (clinical) knowledge/power schemes —the narrative could go nowhere else. In not accomplishing a goal, strengths management led case managers to Robert’s lack of initiative. To question initiative follows directly from goal planning: [case manager] “What do you want?” [Robert] “I want to stay out of the hospital.” [case manager] “How?” [Robert] “I need to let the cleaning crew in my apartment.” When the cleaning crew could not do its job, there was no acceptable strengths language to explain why. Strengths case management lacks a language to explain Robert’s refusal to allow the cleaning crew into his apartment. Without an alternative explanation, the strengths-based text became repetitive, merely rewriting goals into next month’s textual subject.

THE ORAL NARRATIVE

From their situated knowledge/power, however, case managers accessed another language to explain Robert. I contrasted the written and oral narratives to understand how the oral ﬁgured into the production of case management. My analysis revealed a situated knowledge expressed in oral accounts, which also produced effects. The situated knowledge was expressed in a language and practice found not only among the team of case managers I intensively studied, but also among others I have observed and queried. In talking about Robert, case managers repeatedly used several terms: “doing for,” “doing with,” “gets it,” “low functioning,” “do him,” and “natural consequences.” However, these situated expressions did not appear in the written texts. Furthermore, they are not part of the lexicon of strengths management. Finally, by juxtaposing the unwritten narrative and the written text, one can see how the situated language was excluded from the case record. I recorded the oral narratives in team meetings and routine ofﬁce discussions. These narratives are about the same events the written texts (see above) refer to. ORAL NAR RATIVE: FEB RUARY 5TH, TEAM MEETI NG

I saw Robert yesterday. He was in a good mood, maybe because the cleaning crew did not show. His apartment is a mess. Plates with food on it. I said to him, “You know, the cleaning crew is coming tomorrow. You better get the papers off the ﬂoor or tomorrow it goes into the trash.” He replied that this was his stuff and he

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wanted to help clean. I think we should be there for him when the cleaning crew comes over. He seems to be less anxious when we’re there with the cleaning crew. ORAL NAR RATIVE: FEB RUARY 10TH, TEAM MEETI NG cm1 4 :

Did the cleaning crew get over there? cm2 : No. cm1 : They’re supposed to go today. cm3 : Who has got his daily med drop? cm4 : I do him today at 1 p.m. cm3 : Okay, he’s covered. cm1 : What are we going to do about the damage to the bathroom ceiling? cm2 : He’s pretty good at repair work. Get him to do the research about the cost of the repairs. cm1 : What happens if he doesn’t do it? cm2 : We can do it. cm1 : No, we shouldn’t. cm1 : What about using the apartment maintenance workers? cm2 : What if tomorrow I do a goal plan and ﬁx the holes with him? I don’t mind helping him. I like the idea that he would ﬁx it himself. If he knows he has to pay for it, then maybe he will do it. ORAL NAR RATIVE: FEB RUARY 14TH, OFFIC E TALK

He amazes me how he doesn’t catch that apartment on ﬁre. I would like to see the cleaning crew go through it. I think we should give him the natural consequences about that because we co-subsidize the apartment. ORAL NAR RATIVE (EVENT 1): FEB RUARY 24TH, TEAM MEETI NG cm1 :

Who can do Robert Monday and Tuesday? I can do him. cm3 : Are we still picking up medications on Friday? Did he have labs done last week? cm2 : I’m not sure. I doubt it. I’ll call him today and see if he had labs. cm2 :

ORAL NAR RATIVE (EVENT 2): FEB RUARY 24TH, OFFIC E TALK

I’m ﬁnishing graduate school, but I’ve never had a class in house cleaning. Sometimes you get things done now, but later you ﬁnd out it wasn’t helpful. Sometimes

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if you do it for them now, it saves them later. But there isn’t any way of knowing how the client will respond. For example, take Robert, we don’t know if he really can “get it.” But we must decide what we are doing. ORAL NAR RATIVE: FEB RUARY 26TH, TEAM MEETI NG

[Here, in a team meeting, the case manager is describing the same home visit that is recorded in my ethnographic account above, “February 24th, Home Visit.” The February 24th (event 1) progress note was her written account of the home visit; below is her oral narrative.] cm1 :

Well, it started out okay. He talked about his art. But his cleaning crew arrived late. It didn’t go well then. The cleaning crew student reported that Robert accused her of saying things. I think housecleaning will drop him. I think the need is there, but I think housekeeping wants to close him. He gets more worked up with the cleaning crew, then he reaches a point and he won’t listen. We may have to—I hate to say this—but we may have to let the natural consequences step in. cm2 : I think it is okay for us to acknowledge that we have limitations. He has medication through today. If he misses lab again, he will not have enough medication. If we look at his outpatient treatment order, he is missing medication. cm3 : At what point do we make it a clinical issue? cm1 : I think we should pull more of our strings and tell Robert we are pulling out. His mother is giving him the message that we have said not to rescue him. We are going to subsidize only $100 instead of $200. cm2 : Should we get this in writing that we will pull our subsidy if he doesn’t keep his apartment clean? cm1 : We can offer to help him, but he must show us that he is willing to do it. He really struggles with our standard of cleanliness. cm3 : Yes, but with his piles of paper, it is a ﬁre hazard. cm4 : Well, yes, my standards go down every time I go near the place. I think we should get the landlord to do an inspection. Maybe we don’t have to set him up. Maybe we could go with him to the landlord’s ofﬁce. ORAL NAR RATIVE: MARC H 25TH, 1997, TEAM MEETI NG cm1:

Robert’s rent is going up to $435 a month. If we don’t let it go to a month-tomonth lease, it stays at $410. I think we should reevaluate his housing. How do we present this to Robert and give him choices?

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cm2 :

We gave him a shot at an independent apartment. Now I think we should go to structured housing. Until this guy can get his emotions and substance abuse together, he can’t live alone. I bailed him out several times that I never reported. cm3 : We have the wrap-around services to keep him in his apartment. cm2 : Well, I’ll play the devil’s advocate. I don’t think he can make it. At times, he is too low functioning. cm3 : Robert prefers and wants to live in his own apartment. On Friday, he was willing to cooperate. I agreed to give him another try, but this time we can’t let it go for so long. I think it should be structured every day. He needs to get the clear message that if we are going to subsidize his apartment, then we should have some input. And, we must help control his diet, all he buys and eats is sugar. cm2 : Yes, okay. But we need this plan laid out. And we are looking at some kind of behavior-mod plan. We can tell him that this is our treatment plan, so if he wants to work with us, then I think we should put these things into the Outpatient Treatment Order. cm3 : This is a toughie. [Meeting ends without clear resolution]

In the written progress notes, practitioners chronicled Robert’s daily med drops. The oral discussions, however, expressed the tediousness of the deliveries. The concrete expression “I can do him” referenced the mundane in constantly “doing for” Robert, statements commonly used to describe those receiving routine daily and weekly services. Here the situated language and action it referenced (distributing medications to community sites) complemented the medical model. “I can do him,” moreover, expressed something the disciplinary did not: the maintenance of chronicity. Robert needed medications every day and indeﬁnitely. Was that a want or need? In Robert’s February Monthly Goal Plan, medication was not among the listed goals or wants. It appeared, interestingly, in the “steps toward goals”; the management team would “provide daily meds” and Robert would “take meds as prescribed by community support service.” Taking medication, apparently, was not among Robert’s wants. The situated expression “I can do him” was about illness and the need to provide medication; that is, Robert must have meds, but meds must be done “for him.” “I can do him” referenced the routine relationship that bound consumers to case managers. Case managers hoped that by their “doing for” Robert now, he would eventually learn self-directed behavior. The latter, however, did not occur. Situated case management recovered a language of needs. Strengths management did not make sense when individuals did not want medications or

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when they failed to produce the desired effects. From a case manager’s standpoint, a consumer may not want medication, but his or her illness means that the consumer needs it. I think this was why Robert and his case managers did not list medications among wants. It was a need. And why did he need it? Strengths management cannot say, because needs are suppressed by its language of wants. The situated language of “doing for” and “doing with” functioned to guide case managers’ actions.“Doing for” justiﬁed daily med drops.“Doing for” was getting the job done, that is, “I can do him.” In an oral narrative (March 13, Breakfast Team Meeting), Robert’s case manager reported that “sometimes I think Robert is like a small child and pushes us until we will make decisions for him.” Situated comments like these did not appear in the case record. Indeed, they contrasted sharply with the court revocation letter that clearly identiﬁed the culprit as “lack of initiative.” In this situated expression we learned that Robert was not a rational adult. Sometimes he was “like a small child.” In other instances—but only in the oral narrative—the case managers wondered if Robert “gets it.” “Gets it” and “doing for” were situated terms that recognized illness and acknowledged that, given our current knowledge of medication, individuals like Robert were incapable of self-monitoring. “Doing for” expressed the case managers’ willingness to help regardless of the presence or absence of initiative. In sum, situated knowledge privileged illness over Robert’s rational action, that is, his willpower and goal-oriented action. In the textual narrative, the disciplinary knowledge of CSS and strengths management did not acknowledge the possibility of the irrational subject; instead, consumers like Robert were produced as rational, linear-thinking subjects by goal-achievement treatment plans and notes. For disciplinary knowledge there were no illnesses; there were only individuals who lacked goals or could not achieve them. Robert did not follow medication instructions and did not keep his apartment clean. These practical realities befuddled everyone and created the conditions for situated understandings—“he doesn’t get it.” Strengths management’s language, in contrast, lacked the concepts necessary to think about these irrational thoughts or actions. After repeated attempts at “doing for” and “doing with,” it seemed that Robert would never “get it.” In tracing the unfolding drama in the written and oral narratives, one could see how the situated expression, “he doesn’t get it,” correlates with another common expression, “natural consequences.” Case

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managers did not use the term “natural consequences” in written narratives. It was instead part of the oral narrative’s production of Robert: “We may have to—I hate to say this—but we may have to let the natural consequences step in.” The condition of the apartment led case managers to conclude that he “doesn’t get it” and that natural consequences would be the next step. Regardless of his desire to live in the apartment, the team considered pulling the monthly subsidy, because “he is living in the community and he has to live by the rules.” When Robert did not follow up on the desire to live alone with appropriate manners, the power of strengths management was neutralized. Invoking “natural consequences” permitted the case managers to think in ways contrary to those speciﬁed by the disciplinary, namely, goal setting and achievement. Natural consequences signiﬁed a failed outcome. Consequences followed, naturally, when no plan or action seemed to make a difference. Case managers could not translate failed goals into strengths management language because improperly set or irrational goals would have been emphasized and problem-saturated language was frowned upon. Thus, situated practice emerged when the disciplinary was muted. Situated knowledge was rooted in but not reducible to its companion, the disciplinary. In one sense, situated knowledge was complementary to the disciplinary. Had Robert been evicted for failing to pay rent, he would have experienced natural consequences. By feeling the effect of not paying, they hoped, Robert would learn that failure to take action had consequences. Even more, learning that B followed from A might have produced a rational subject. Thus, the situated use of “natural consequence” had a complementary relation to the disciplinary. Yet in another sense, natural consequences were ambiguous and distasteful. Proposing eviction was taboo: “I hate to say this.” Allowing the eviction might result in a regrettable, long-term hospital stay, homelessness, or dependence on family, and these options were proscribed by the policy of deinstitutionalization, CSS, and strengths management. After all, hospital beds had been replaced by CSS. Case managers, therefore, could not allow Robert to fall through their safety net. They did not. On April 15 Robert received an eviction notice from the landlord. Staff encouraged him to move into a supervised group home, Residential House. After several weeks of hesitation, Robert agreed. The group home was a temporary program where it was hoped that residents would learn skills and organize the appropriate social supports to return to independent apartment living. Although case

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managers could have intervened and convinced the landlord not to evict Robert, they allowed the eviction to occur and believed natural consequences had been invoked. Situated practice that supported market forces—in this case eviction through the landlord—could have been contrary to strengths philosophy and deinstitutionalization had it led to long-term, supervised housing alternatives. Case managers never used natural consequences to promote permanent, twenty-four-hour residential care, nor did case managers use arguments and resources for permanent supervised living. In Robert’s case, upon eviction, a transitional group home resolved the tension between the textually produced independent apartment-dweller and the situated understanding that Robert “can’t get it.” Tenant law and enforcement produced a housing crisis. CSS, however, absorbed and resolved the tension by creating therapeutic spaces like Residential House, a group home designed to rehabilitate consumers like Robert. Although Robert moved into the home and hospitalization was averted, case management continued with med drops and money management. At Residential House, residents never become full-time occupants; in this space, it was hoped that Robert would ﬁnally “get it.” Under supervision, he might learn skills needed for apartment living. Thus, by using a transitional space to reinvigorate the conditions for strengths management to once again become operative, the limits of this model were hidden. Yet, no oral or written narrative commented on Robert’s apparent “need” for permanent congregate care. Instead, his “want” to live alone was honored. The situated and the disciplinary, together, had reproduced CSS. In this case study, I have shown that workers’ situated practice complemented the disciplinary, but it was not a necessary condition. Situated practice performed its own work. The disciplinary and situated produced the same effect, but they correlated with different powers that operate upon unique objects of practice. In Robert’s life, both knowledge/power schemes kept him (and others like him) moving through the network of related sites and services. At some future date, Robert will be discharged from Residential House. He will likely reemerge in an apartment, and as one case manager noted, “the cycle will begin again.”

C HAPTER 7

Money

I

t can be said that money is the measure of successful deinstitutionalization. Nineteenth- and twentieth-century social welfare projects moved adults and children out of “totalizing” institutional spaces—the workhouse, the almshouse, the orphanage, the nursing home, the mental hospital—with income maintenance schemes (Lerman 1985, 1982). Policy debates about outdoor and indoor relief were fundamentally about reducing poverty by distributing money directly to the poor (Patterson 1986). The almshouse and poor farm provided food and shelter on-site and their demise was predicated on cash transfer programs assisting the poor in private homes. Aid to Dependent Children (ADC), for example, established standards in the 1930s to provide mothers and children a source of income so institutional or indoor relief would be precluded (Gordon 1994). Early welfare caseworkers monitored clients’ spending hence [the] preference for what came to be called the “budget” approach in ADC. Rather than ﬂat grants, it preferred that caseworkers negotiate individualized family budgets because the process could then be integrated into holistic counseling about personal, moral, and social as well as economic matters. (Gordon 1994:103)

In three recent books on case management there is general agreement that the practice originates in helping deinstitutionalized clients access fragmented services (Frankel and Gelman 1998:4–5; Moxley 1997; Vourlekis and Greene 1992:11–23). Case management functions to link clients to beneﬁts

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they are eligible for, money being the highest priority. Yet my research shows that case management goes far beyond linking consumers to ﬁnancial resources; case managers and consumers negotiate budgets, rationalize decisions, and make moral judgments. Commodities are exchanged with money; therefore, money can determine well-being and it can symbolically determine identity. And it always has attached to it certain moral problems and questions. For the anthropologists Parry and Bloch the meanings with which money are invested are quite as much a product of the cultural matrix into which it is incorporated as the economic functions it performs as a means of exchange, unit of account, store of value and so on. It is therefore impossible to predict its symbolic meanings from these functions alone. (Parry and Bloch 1989:21)

At the same time, it is often assumed that buyers make rational decisions even though prevailing economic theories are often unable to “account for exceptional behaviour since both rational (economic) and ‘irrational’ (social) elements will often inﬂuence particular purchase decisions, the rational element must be considered dominant” (Fine and Leopold 1993:57). Others have observed that a shopper’s decision is “more often than not a matter of ‘habit, imitation and suggestion—not reﬂective choice,’ and bears the imprint of traditional, irrational economy” (Godelier 1972:40–41). For the mentally ill and their caregivers, managing money and consumption share with neuroleptic chemicals a kind of ontological signiﬁcance; in short, they deﬁne the limits and potential of everyday life. However, unlike chemicals, the need for money forces the mentally ill out into the world of consumption, where they join others in the quest for work and commodities to fulﬁll both needs and wants (Fine and Leopold 1993). And in the world of money, the mentally ill confront, together with their case managers, the following spheres of management and consumption: housing, transportation, food, clothing, and entertainment. The hospital was a socialized economy where governments paid for administrative costs and patient life unfolded without much concern for everyday commodities (Lerman 1982). Hospitals placed money and commodity exchange in therapeutic suspension so that these stressful events were isolated from patient life; thus, it was hoped that the clinic’s gaze could focus exclusively upon illness, symptom management, institutional practice, and treat-

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ment (Doerner 1981; Foucault 1965:159–199; 241–278). CSS advocates unwittingly correlated the status of dependent “patient” to the prevailing logic of communistic or institutional provision. Thus, de facto the success of deinstitutionalization is measured by the ability of former patients to appropriately budget and spend their money. The state-run and controlled economy of the hospital was replaced by radical individualism, even libertarianism (Szasz 1961; Scheff 1966), where the central project was the production of personal autonomy, unproblematically rooted in the pecuniary logic of economic individualism. Once “in the community,” former patients needed money; although they could sometimes rely on their family and the market, the state and CSS have been there as both safety net and incentive. And although policymakers and practitioners did not articulate or even acknowledge the transition from “patient” to “consumer”—in the change from the state-controlled hospital economy to free-market mental health—deinstitutionalization cannot work without this new economic ideology and its associated practices: dollars must be put in the pockets of former patients and concomitantly, a consumer identity (rational economizer) must replace the socialistic-produced “patient” who was not part of the commodity market. Much of case managers’ situated knowledge/power is about producing bona ﬁde consumers. Former patients must become responsible for their ﬁscal affairs and a new language must be used to produce these realities. Substituting consumer for patient is a remarkable illustration of Michel Foucault’s idea about pervasive power as opposed to power-over (Hoy 1986:123–147). At stake here is not a simple top-down and heavy-handed move by the state or case managers. Indeed, many former patients prefer the status of consumer to that of patient. Service recipients of CSS want (or need?) to learn how to purchase commodities efﬁciently. Thus, strengths management’s delineation of consumers’ money goals is not reducible to “power-over” (Lukes 1974). It requires the active participation of those at whom strengths management is aimed. And the need to incorporate patients into the money economy and its consumer ideology points to the historical and cultural underpinnings of social work projects. Social work did not create the economic social ﬁeld called capitalism, but it necessarily works within the power relationships established by the social relations between capital and wage earners. To the architects of strengths management, money is coded as a want; in actual money management issues, money is simply the medium for the realization of consumers’ desires. Spending, for strengths management, is about the functional meanings of money (Parry and Bloch 1989:21). However, is

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budgetary spending a need or a want? Case managers must see it as a need; that is, efﬁcient and smart shoppers avoid ﬁnancial crises that cause apartment eviction and threaten community tenure. Clients may not want the disciplinary gaze of money management, but a market economy and low monthly incomes make vigilant budgetary monitoring a need. Strengths management’s silence about the symbolic meanings of money is more an indication of the commodity economy that is taken for granted than an omission. In the life domain of money, strengths management’s contribution to case managers’ work is the idea and practice of goal-oriented budgeting: set monthly budget goals, take steps to meet those goals, and measure progress in balancing checkbooks. In short, the most important work, the moral management of money, is left to situated knowledge/power.

THE MORAL ECONOMY OF CASE MANAGEMENT

The case managers I studied were constantly reacting to the inﬂuence of money on their work, and their own experience with money was refracted or read into moral dilemmas. “I’ll tell you a secret about mental illness,” commented one case manager and added, they [the mentally ill] often think they have more money than they have. I have one who always thinks that her mother takes money out, and the reality is, her mother is the one who puts money into her account. Sometimes I just tell them no [in response to a request for money] and at other times, after paying the bills, I check to see if any is left.

In a chat with her ofﬁce mate, this manager was worried about her own uncertain ﬁnancial condition. She didn’t know “if she had enough money for her car payment,” and she hoped her mileage check was coming soon. Her desire for small-time gambling at a new showboat had resulted in recent losses. “You never know how much to put in and you never know how much you’ll win. It’s a gamble, but its fun.” In charge of balancing consumer checking accounts, a CSS accountant overheard a manager telling me: “I hate balancing checkbooks. Gag me with a spoon.” The accountant quipped,“Yea, and I bet you don’t balance your own checkbook at home.” The manager countered: “No, I prefer to spend as little money as possible, then I don’t worry about my balance.” For anyone living on a ﬁxed income, balancing a checkbook is a necessity. The accountant continued,

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on average I record about nine transactions per consumer per month. I can tell you what six of those are without looking: rent, electricity, gas, phone, groceries, and cigarettes. The little money left after those checks clear is so insigniﬁcant it seems silly to struggle over it.

However, relationships between case managers and consumers were conditioned by money, and managers conﬁded in me that they abhorred this dimension of work. High County CSS uses three interrelated mechanisms for managing consumers’ money: (1) representative payee, (2) personal money management, and (3) ﬂexible account monies. Each mechanism presented moral issues regarding the spending of money, and each produced a struggle over privileging functional needs (i.e., rent, utilities, cigarettes, etc.) over symbolic wants (i.e., spending money).

CASE MANAGER AS R EPR ESENTATIVE PAYEE

At the time of my study, social security had designated CSS the representative payee for sixty consumers—about one in every seven. Monthly disability checks not automatically deposited into consumers’ private bank accounts were mailed to CSS where authorized staff—usually the case managers— deposited checks into consumers’ bank accounts. There are CSS systems that choose not to designate managers as payees, but High County assumed legal authority over money as workers discovered that former patients found it very difﬁcult to budget and spend money. Before a major shake-up in 1995 and the implementation of policy number 4.1.6 (Money Management Services), bookkeeping had been governed by case managers’ idiosyncrasies; they stuffed receipts in innumerable places, and checkbooks were often lost or found on desktops. Although case managers understood the necessity of accurate record keeping—after paying rent, utilities, and purchasing a few personal items—money left for consumers to squander or for case managers to pilfer seemed inconsequential. While a 1995 audit found no malfeasance, the recommendations were unequivocal: the old system had to go, and a new ﬁscal order was established. The manager was to keep books balanced, current, and in one location. The accounting change placed new spatial demands on case managers; all consumer checkbooks, receipts, and related materials were ﬁled in a cabinet next to and in view of an ofﬁcial accountant. On any given day, I observed case managers making numerous trips from their ofﬁce to the money ﬁle cabinet. I sat near the ﬁle drawer and logged case managers’ tasks; this revealed a great

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deal about daily money management. During one three-hour period (10 a.m. to 1 p.m.), seventeen (out of thirty-ﬁve) case managers visited the ﬁle drawer. I asked them why they were there, and the responses were as follows: 1. I am checking on a balance because my consumer believes he has more money than I think is there. 2. I need money for my consumer’s groceries. She thinks I stole a million dollars and I won’t give it back; [laughing, the manager continued,] do you think I would be here if I had? 3. I may have inadvertently mixed my own $25 with my consumer’s money. 4. My client needs cigarette money. 5. I am writing a check for monthly laundry expenses. 6. I need a deposit slip to make a school refund deposit, and then I need to write a check for medication. 7. I hope I misplaced my driver’s license with the consumer’s checkbook. 8. After balancing it, I am returning the checkbook. 9. I am getting my client’s spending money for the week. 10. I need a checkbook to get money for medication. 11. I am writing a check for $8.50 for laundry, but the client only needs $6.00 for laundry. The balance he uses to buy a hot dog at the Laundromat. He is so delusional about money. He has cash on his window seal, but when I suggest that he use that money, he says, “I have to be frugal with my money.” So I learned that if I write a check for more than the cost of the item, he will use the change to buy things he wants. For some reason he likes his money to come indirectly, he doesn’t think it’s his money that way, I guess. 12. I am putting a receipt in the folder. It is probably not necessary, but if I didn’t, then we would need it. 13. My client asked that I check on his balance. 14. I need a checkbook to buy medication. 15. I am picking up a check for grocery shopping, and ﬁling dental, grocery, and laundry receipts from last week. 16. I am reconciling a discrepancy between the checkbook balance and the bank statement; the latter listed a deposit that was not in the checkbook. [The manager was confused about how much money was actually there. She decided to go to the bank to resolve the discrepancy.] 17. The accountant called and reminded me that the bank automatically pays utility bills for my consumer and that I was not subtracting the

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amount from the consumer’s personal checkbook. I am worried about an overdraft. In a single three-hour block of time, there were seventeen money transactions! Case managers were overseeing 540 transactions per month for sixty consumers, and I estimated that twenty-seven transactions had to occur daily (540 divided by twenty workdays per month). It was not, however, the number of debit and credit transactions that made this work tedious; it was not the headaches connected with keeping the receipts and properly ﬁling them, and it was not the act of balancing checkbooks. It was in the endless requests for money and the moral monitoring of spending that case managers experienced drudgery, discomfort, and disillusionment. On average, one case manager was the payee for three consumers. Of a case manager’s remaining caseload, twelve required various money management activities. Spending habits are never alike so the permutations are immense, and the combinations make money matters unpredictable. It was my experience that case managers had at least one money crisis every day. Because most payees had less than $20 at the close of each month, case managers felt pressured to vigilantly monitor expenditures; a simple request for a pack of cigarettes could sink a positive balance. Before giving in to consumer requests, case managers often examined actual checkbook balances, or they relied on their memory, which saved precious management time. More important than tedious and precise bookkeeping was the burden—often seen in the emotional strain on case managers’ faces—of continuous money requests: I have a consumer that has been in this ofﬁce eight times today; one person has been in here eight times repeating the stuff they want: a coke, a hamburger, or something. Just basic stuff! I can tell you what day, Monday through Friday, who I am going to see and when I am going to see them. I can ﬁx my schedule on their money needs.

Managers felt tied to consumers’ money, and they had to assert management power on every occasion when consumers needed or wanted money; denying and granting a request both required the exercise of power and both regulated the case manager’s time. Denying a consumer’s money request means, “I am setting boundaries”; it says,“I can not always do for you, you must learn to manage your own money.” The decision to assume the responsibility of payee was often based upon case managers’situated assessment of consumers’self-directed abilities:“I spoke on

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the phone with her yesterday. She wanted to know why we wouldn’t be her payee. I told her we weren’t ﬁnancial advisors. There are other options before she goes the route of payee.” In this case, the consumer’s request was deemed unnecessary, and the team believed she was capable of budgeting. The manager’s statement, “we weren’t ﬁnancial advisors,” was not a lie (of course, they were money advisors) but a denial, a way to defend against “doing for” the consumer. By narrowing their scope of inﬂuence over daily money management, case managers hoped that this consumer would learn how “to manage money without our help.” The message was consistent with a basic tenet of the CSS social ﬁeld: a capable and self-directed person does not ask others to do what he or she can do for himself or herself. Staff also encouraged consumers to seek outside payees because this displaced the struggle over money, a struggle that often “blows the relationship with the consumer.” The management relationship was blown, according to case managers, when money dominated every interaction. “Once they [consumers] see us as full-time money managers, a wall goes up and nothing else can happen.” Strengths management did not instruct case managers about the myriad motivations behind consumers’ desires; that is, how money, as a mechanism to realize wants, is psychodynamically, symbolically, and practically constituted. Strengths management naively directs case managers to help consumers readjust or renegotiate spending to neatly ﬁt a wants accounting. “If the goal is too high, set it lower,” the workshop leader had said. But no disciplinary tools were available to help the case manager working out of strengths management dig beneath functional consumer goals to discover other goals or symbolic wishes. Had money management been limited to blowing relationships, case managers might have refused to exercise its power. But it was also true that case managers believed that money builds and sustains relations.“I would just love it if they [the family] would let us control Mark’s money, then we could teach him how to budget.” Here, staff thought a parent and sibling had failed to encourage self-sufﬁciency; instead, some families perceived consumers’ “illness and inability to keep track of money.” In this use and understanding of money case managers found two meanings: money management teaches life skills while it also establishes a helping alliance or bond. The manager continued, I did his goal plan yesterday but I don’t feel like he is bonding with us. I can’t seem to get through and past the money. I think it would change if we were the payee instead of the family. He calls his brother when he needs money. He remains ambivalent about changing payee.

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Consumers’ dependence on case managers was perceived as important to establishing a “working” relationship; yet case managers hoped to use money dependency as a lever to teach good spending habits or self-directed money manners. As payees, case managers said they were “doing for” consumers who do not understand money: “she gets so angry when you talk about money. I don’t know if she just doesn’t get it, or if she is just stubborn.” In response another case manager said,“I think she doesn’t get it, can’t understand it, then gets angry and frustrated.” To not “get” money meant to spend money impulsively. To “get” money meant spending it according to a rational cost-beneﬁt analysis. I saw many cases where consumer’s did “get it,” and many when they did not. Strengths management practitioners ﬁrst suppressed the questions about why consumers may not “get” something, and second, they broke down money goals and desires into budgetary items. Thus, a practice void was produced and then ﬁlled in by managers’ situated expression: “doesn’t get it.” Moreover, strengths management’s emphasis on budgetary goals unwittingly gave managers line-item veto power. There were numerous examples of money deals turned sour. I studied money crises to learn how case managers became involved in money management and how they thought about money. At Kmart, a consumer with insufﬁcient funds bought his girlfriend (also a consumer) an engagement ring by writing a check for $360. “He should know better,” said his case manager. He continued: We have been over and over the problem of check writing. The last bad check was just taken care of. I don’t think he would have done it, but she pressured him into it. She made a big deal at Kmart by crying and making him feel bad that he wouldn’t buy her the ring. He would not have done it, if it had not been for her [the other consumer].

The incident widened in scope because it involved two case managers and two consumers from different teams. Stories like this circulated. This example demonstrates why it was necessary to act as a representative payee: the consumers lacked pecuniary judgment. What was the case managers’ response? Here is how the story was recounted in one team meeting: cm1 :

He told me he wrote eight bad checks over the weekend. One was for $360 for a diamond ring. And guess who? Nancy. It goes on and on and on. Through all of this, and Nancy does not have a payee. Mom said she would rather pay off her bad checks rather than become her payee. I am real stuck. We can’t continue to do for this client and keep him out of trouble.

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cm2 :

Can we talk with them about taking the ring back? He has written overdrafts before. I agree, we can’t ﬁnancially rescue him. cm3 : When is this going to stop? I see this as a drug problem. He has done this before. Remember how he got addicted to chocolate milk? Now he is addicted to this relationship with Nancy. And like all addictions he gets something out of it. cm1 : Well, what do we do? cm3 : Like drug addictions, let him experience the natural consequences. cm2 : Do you think there will be criminal charges? cm1 : Yes. He wrote the checks on a closed account. And he knew it was a closed account. cm3 : I think if he doesn’t take the ring back, then let him sink. cm1 : But he doesn’t have the ring. She kept it. cm2 : If we could just pull off getting the ring back. When do we step in as an advocate for him and confront Nancy? cm4 : This is tricky. There’s a ﬁne line between being an advocate and harassment. They both think the center is against their getting together. At what point do we ask him if he thinks this is an abusive relationship?

The meeting ended on this note: “Yeah, I know, but remember, we are still talking about someone [the male consumer] whose thinking is impaired.” And as usual, in cases where moral issues overlapped, a single team discussion did not lead to a resolution. This money episode ended when the ring was returned to Kmart. No criminal charges were ﬁled. The ring affair highlights key features of the moral economy of case management. First, purchasing commodities by writing a bad check is illegal, and criminal charges should be a natural consequence. Case managers believed they should not protect consumers from the law nor should they “rescue” someone from impulsive acts. The team’s dialogue illustrates a typical tension between letting the consumer “hit bottom” (natural consequence) and the purpose of CSS as safety net. It also typiﬁes how the situated expressions “doing for” and “doing with” were put to work. Managers did not act to cover the bad check because that is “doing for.” Instead, by convincing the parties to return the ring to Kmart, they succeeded in having charges dropped. In situated terms, “we stood alongside [doing with] and helped return the ring.” I checked the case record to ﬁnd that returning the ring had not become a written goal; instead, it was left to the work of the oral narrative. Second, the statement “it goes on and on” acknowledges that goals about money are endless and that consumers’ recorded wishes (e.g., “keep a balanced budget”) are often parallel to or superseded by other desires that are not so readily apparent. For example, whose desire was it to buy and return

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the ring? Is this a functional need or a symbolic want? Strengths management cannot say and neither could the case managers’ situated language of natural consequences. Of course, managers experienced a practical need to balance budgets, but they also desired it because consistent and accurate accounting marks case managers’ competence. From the client’s standpoint, one can’t eat diamond rings, but gifts fulﬁll symbolic needs and desires. The situated language of “doing for” and “doing with” did not, in this instance, work toward understandings in opposition to strengths management; it was instead concerned with using the ring as an indicator for evaluating self-directed behavior. Returning the ring was situated knowledge/power enforcing appropriate consumer manners. Third, there was a message that writing bad checks and spending money is not wrong, rather “Nancy” is the problem. Consorting with Nancy was believed to be a “drug addiction.” Was this a strengths manager thinking in terms of deﬁcits? It is possible, although it was not discussed in either oral or written narratives, that the ring was purchased to please Nancy. Is purchasing a commodity for one’s girlfriend a desire that can be written as a spending goal? Case manager’s disciplinary and situated language did not ponder this question, and why not? To ask the question opens the possibility that money goals are stratiﬁed both practically and theoretically. Money management reduced the ring to a surface spending goal, rather than a goal about conﬂicted desires. A case manager might have written a strengths management progress note as “the goal is to understand the conﬂicted goal of buying an engagement ring.” But case managers didn’t do this, I think, because to do so is dangerously close to examining hidden psychological motivations, and the latter are off-limits to a strengths case manager. Strengths management condenses everyday money issues to surface manifestations, to the functional and practical problems of spending. Unlike strengths management, however, case managers’ situated understanding (i.e., is this like a drug addiction) tried coming to a deeper understanding of the consumer’s motivation, but in this case situated work did not resuscitate such a deeper or stratiﬁed understanding of consumer desires. Fourth, had he purchased a portable electric heater, would the discussion have taken a different turn? It was February; it was cold, and a heater would have been practical. Would such an episode therefore have been forgivable? Meeting practical needs by writing bad checks is morally more understandable. Heat is a naturally occurring resource that is harnessed by good case management to satisfy basic needs. Engagement rings, on the other hand, signify desires of a symbolic nature. Fifth, impulsive buying is culturally reinforced. Money management was

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about containing a consumer’s impulses to buy: returning a ring one cannot afford. Yet without a means to understand impulse and desire, case managers’ disciplinary and situated knowledge substituted moral and practical decision making—returning the ring to Kmart. Case managers have seen it all. One consumer emptied his savings account to purchase a used car for $2,500. He drove the car to his apartment, parked it, turned the motor off, and when he came back one hour later, the car did not start. Two blocks from CSS, a used-car salesman had snookered him on a weekend when the case managers’ watchful eyes were turned inward.“We told him to wait and we would go with him and buy a car from someone that is trustworthy.” Upon hearing about the car on the following Monday, the case manager attempted an intervention. We walked to the dealership and confronted the owner. The sales receipt permitted no returns: caveat emptor! We learned that the consumer had not taken the car for a test run; rather he had merely looked and bought. In the case record (in the lexicon of strengths management), the goal was reported as “I want a car.” The step toward reaching that goal, “shopping for a good deal and buying from a reputable dealer,” was foiled. Strengths management is powerless when impulse overwhelms “rationality.” After all, the want is often stronger than the need. Moreover, who is to sit in judgment? Who has not been warned: “let the buyer beware?” Acting as a representative payee, that is “doing for,” was often justiﬁed in order to protect consumers from unscrupulous deals. The hope was that consumers would learn to sit in judgment over their own spending. Another consumer went on a one-day buying spree, spending $3,000. He wrote the checks on a closed account. This was not the ﬁrst time he had written bad checks. A hardware store employee, tipped off by the consumer’s authorization card at the bank, called for assistance in retrieving the commodities. “No charges will be ﬁled if all the items are returned.” We packed up and drove to the consumer’s apartment. The consumer casually led us to his bedroom closet, which we found stuffed with camping gear, a computer, compact discs, ﬂashlights, electric tools, and automobile supplies, and wrenches (and he did not own a car).While we visited, a security ofﬁcer and an employee from a local hardware store arrived with a clipboard and sales receipts. It was time to take an inventory. Unaffected by their queries, the consumer respectfully answered and handed over a socket set, an electric screw gun, and various assorted wrenches. Some wrenches were missing, however, and we later learned that he had given them away. The computer and compact discs he had purchased at a Best Buy discount store. Together we loaded the goods and returned them to the store. During our long drive to CSS, I was puzzled by the

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consumer’s composure. There seemed to be no remorse for writing the checks and no resistance when asked to return everything. With frustration and resignation, the case manager said, “no, he doesn’t get it.” She continued, “he will have to ﬁnd the missing wrenches, pay for them, or if not, face criminal charges.” The manager on this day was inclined toward the courtroom solution, hoping the consumer would learn about “the consequences.” When the case manager is the consumer’s representative payee, manager and consumer are entangled in a web of moral judgments. Strengths practice focuses the manager on the functional meanings of money: spending goals. Situated work and oral narratives ventured into the symbolic, but as the ring affair exempliﬁed, case managers used strengths and situated knowledge/ power to convince the consumer to return the ring.

MON EY MANAGEMENT

To overcome the boredom and distribute the workload associated with weekly money management tasks, one team inscribed on 3 x 5 cards daily and weekly consumer money tasks. Early each Monday, the cards were read aloud and managers volunteered: “I can do it,”“I can do him,” or “I can do her.” This shorthand, “do him,” acknowledged the need to produce a management effect, and it answered the strengths question: “who will do what when?” It meant getting something done efﬁciently and routinely. The strategy was designed to prevent burnout resulting from meeting repetitive, daily needs. Of the approximately twenty-three cards read every Monday, typically nine referred to budgeting and spending money. On a typical day, the cards read as follows: case 1 :

Cigarettes every Monday. If weather is good, he can get a check and walk to the Cigarette Outlet. case 2 : Monday and Friday monies for groceries and cigarettes. case 3 : Med (medication) drops1 Monday through Friday afternoon. While there encourage laundry. Help him plan grocery and cigarette purchases. case 4 : Groceries, bank, cigarettes every Monday AM. case 5 : Wednesday grocery shopping. Pharmacy on Friday. case 6 : Grocery shopping every Thursday. case 7 : Tuesday groceries. case 8 : Cut weekly check for $30.00. case 9 : Monday morning go to the bank, get $40.00 in spending money.

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Managing money required more than a monthly budget. As a ﬁrst step, many consumers needed help with retrieving money from bank accounts. Then they needed help spending it at grocery stores and pharmacies. Moreover, these tasks required constant negotiation as consumers confronted endless commodities. Though a single debit to a consumer account was simple, it was the last in a long train of actions preceding the ﬁnal accounting. To illustrate this I will describe one shopping event. Two blocks from CSS, the case manager remembered that she had forgotten the checkbook. We backtracked to CSS and arrived at Ted’s apartment behind schedule. He was eagerly waiting at the door. In the car they talked money. Ted asked, “How much is in there?” And he quickly followed with “Will I have some spending money this week? The manager did not offer a deﬁnite answer; the question was met with another: “Have you done a monthly budget for it [spending money]? Hesitating, Ted answered “No.” We arrived at the discount cigarette outlet, and the conversation was interrupted. Ted needed cigarettes. The manager watched and approved Ted’s check writing (considered “doing with”), but Ted hurried into the store alone. In the meantime, the manager told me that we used to give him more control over checks. He has a forgery charge against him now. That scares him and keeps him from tearing checks out and writing them without our signature, which he must have in order for the check to be legal. He was using the money for drugs.

Ted returned, and our journey through suburbia and the moral economy of money continued. We headed to Kmart to purchase household supplies. “What do you need?” Ted replied, “ I need quite a few things.” The manager prompted, “Well, you have $15 to spend, so if you are careful, you should be able to get what you want.” Inside Kmart, she patiently coached and advised Ted on bargains. A $15 mop, for example, one that Ted picked out, was put back by the case manager who spotted one “on sale for $4.99.” After the thirty-minute shopping trip, we piled into the car for our trip to the apartment. The work continued in the car. The case manager asked, “When is your rent due?” Ted responded, “Today!” “How much is it?” she asked rhetorically. Incredulously, Ted said: “$87.00.”2 I interpreted the client’s disbelief as a comment on the case manager’s motives, as though he was saying: “How could she not know that my rent is $87.00 when she knows everything else about my budget!” (Indeed, I learned later that the case manager did know the rent amount. Her rhetorical questioning was meant to help Ted track his expenses.) The manager rationalized:

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We can pay the rent now. That is nonnegotiable. This doesn’t require waiting until we do a monthly goal plan and budget. But the spending money you asked for will have to wait until we have a new monthly goal plan.

Although disappointed, Ted reluctantly agreed to the management scheme; that is, rent, a need, was “nonnegotiable” and spending money, a want, was deferred. At his apartment, we unloaded his purchases. After returning to CSS, the case manager entered the checks, balanced the checkbook, and returned it to the ﬁle drawer. Money management meant being resourceful: “I used his Vision Card [Kansas food stamps] last week, so you will have to take him to a food pantry.” It meant budgeting money one day or week at a time: “He gets $35 every Friday for groceries.” Among staff, money requires constant double checking: cm1 :

What about Sonya’s needs on Tuesday. Does she get cigarettes, groceries, or just meds? cm2 : Well, she doesn’t need cigarettes because I did that yesterday.

Handling money requires rendering moral judgments on what constitutes a luxury item: “I don’t feel comfortable subsidizing cigarettes, they are a luxury not a necessity.” Or for one manager, “spending $60 on U-2 concert tickets or paying for a professional dog grooming service or buying a $100.00 coffee pot is extravagant, things I don’t even have or do myself.” One consumer reported that he spent $160 on an escort service. In the team meeting the case managers did not think his “blow job” was unacceptable; rather, “he could have gotten that a lot cheaper.” Sex and money were also at issue with consumers’ use of (1-900) telephone sex services: “He just spent $100 on a 1-900 number and then he comes in here asking us to pay for his utilities.” Weighing the morality of desire against the banality of need is the essence of money management. Because strengths management focuses on the surface goals (i.e., spending goals) of desire (ask them, “what do they want, not what they need”), situated practice faced actual needs in a suburban landscape as well as another component of desire: the symbolic. The result is a moral economy of case management. Money managers must be resourceful in other ways. The case managers I studied rewrote goals to make the case record look as though new ones were constantly being achieved. In fact, they were often the same functional goals. For example, one manager told me that ongoing case management can be difﬁcult to justify if you do not have different goals. But how many different ways can you write a spending goal. Teresa

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needs money management. Today, she wants to buy a watch. She could do it herself, but I do it with her. Teresa cannot keep track of money. She doesn’t seem to know what to pay for things. She might pay $50 for something that she could buy for $5.00. So I make “getting a watch” one of her monthly goals.

By recording in the chart “getting a watch,” the manager inscribed the consumer’s desire as bargain shopping. The case manager monitored shopping and did not undermine the desire to have a watch. Bargain shopping, moreover, required skillful price (cognitive) comparison; because ten dollars could represent half of a consumer’s monthly discretionary spending, discussions over small amounts seemed tedious, if not petty, but they were practically necessary. Still, the amount of spending money is not a measure of how much meaning is attached to purchases. When consumers wanted a pack of cigarettes ($2.50) or an escort service ($160), managers had no instrument to weigh meaningful desire against rational budgeting. In one instance team members assumed that a consumer had sold his household objects for drug money, objects they had helped acquire. In order to demonstrate natural consequences, they refused to give him his weekly $15 disbursement. Yet they remained unconvinced that this punitive use of money made a difference: “He will get money for drugs regardless of our giving him his weekly spending money or not. After all, it is only $15. What can he buy for $15?” Practitioners strove to make management a “doing with” learning activity. By breaking down the budget and purchasing process into “baby steps,” what the strengths workshop leader called “getting underneath,” managers hoped that consumers would learn how to self-monitor their spending. Some steps were as simple as dating, signing, and recording the purchase, and case managers could patiently wait months for consumers to take initiative and learn the basics. Although progress was often slow, breakthroughs did occur and did not go unnoticed. Grocery shopping was particularly onerous and important to get right. We drove miles to the store, Teresa grabbed her cart, took off, and had no shopping list to refer to. The case manager, doubtful that she could stay within her $21 limit, said,“Teresa does not like it when I follow her, she doesn’t like for me to say she is spending too much.” On this day the case manager’s fears were unwarranted. I watched as Teresa carefully weighed wants against price. She purchased a case of cola, two pounds of hamburger, a ﬁve-pound bag of sugar, and three pounds of coffee for the total amount of $20.57. Success! The manager explained that,“ before money management, Teresa bought

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whatever she wanted. On one grocery trip, she wrote a $230 check, which bounced due to insufﬁcient funds.” Budgeting was not easy for Teresa. She liked to eat, and she often gave in to her desires. I saw her pick up a package of cookies that she later left in the produce isle. “Why did you leave the cookies,” I asked. “I wanted them, but I couldn’t afford it,” she replied. “I can’t wait to report Teresa’s success in our team meeting,” the manager declared. I asked what would have happened had she overspent her budget and needed more groceries later in the month. I would take her to a food pantry, but I would not take her to the same food pantry more than once a month, that would be taking advantage of the food pantry. When we show Teresa that we are not eager to use food pantries, she learns from the natural consequences.

In less then thirty minutes, case managers often helped consumers list their income and expenses. To the consumer, money management was about discretionary spending. For the manager, the bottom line was a positive balance. Again, it was not bookkeeping that was particularly difﬁcult or time consuming; rather, it was the ongoing monitoring of purchases and the associated moral judgments that became burdensome.

TEAM DISC R ETIONARY MO N EY: TH E FLEXI B LE FU N D

In a seven-month period, ﬁfty-six consumers experienced a short-term ﬁnancial emergency, a cash shortfall that might threaten community tenure. Managers and administrators gradually learned that team discretionary spending could address ongoing money crises. The establishment of the ﬂexible fund was a situated, not a state or federal policy innovation. It provided an organizational mechanism to deal with functional money problems, but perhaps more signiﬁcant, the fund produced sticky moral dilemmas. CSS administrators allocated $56,000 to ﬂexible funds in 1997. Five teams received equal shares of $32,730 or $6,546 each; other CSS programs received the balance. Had the money been equally distributed, every CSS consumer would have received a $140 subsidy; of course, distribution was based on needs, so not every consumer beneﬁted equally. The teams’ use of money (see table 7.1) illustrates the functional effects of the ﬂexible fund. Suburban rent was the single largest expense and together with utilities (73 percent) these data suggest that housing costs were the most common trigger of ﬁnancial

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TABLE 7.1 TEAM FLEXIBLE FUND EXPENDITURES EXPENSE

TEA M A

TEA M B

TEA M C

TEA M D

TOTAL

PROPOR-

(18

(7

(7

(7

EXPENSES

TION OF

MONTHS)

MONTHS)

MONTHS)

MONTHS)

Rent $8,292.00 Utilities $672.10 Moving $369.62 Emergency $53.85 housing Medical $0 Transpor$115.50 tation Home $514.53 supplies or home repair College $214.00 Tuition misc. $813.94

$570.00 $241.68 $402.07 $0

$1251.50 $781.93 $273.49 $0

$216.00 $0

$20.87 $351.06

$296.00 $10.00

$532.87 $476.56

2% 2%

$0

$176.84

$532.99

$1224.36

7%

$0

$0

$0

$214.00

1%

$120.00

$161.00

$338.28

$1433.22

8%

$1549.75

$3016.69

$2367.15

$17,979.13

30

12

18

14

6

6

6

6

TOTAL

$11,045.54

TOTAL

$1001.18 $11,114.68 $152.80 $1848.51 $35.90 $1081.08 $0 $53.85

62% 11% 6% <1%

SU BSI DI ES

Consumers Assisted Avg. monthly transactions

crisis. Adding up rent, utilities, moving, and home supply expenditures (86 percent) illustrates that most monies were used to secure, maintain, or move residents from one location to another. The data for this period show that twelve to twenty consumers faced eviction; thus, about every six months, the pool of those at-risk of eviction turned over, as a new group moved through the cycle of need, assistance, and ﬁnally, rent stability. To keep those who were unable to pay rent from losing apartments, case managers used the ﬂexible fund as a de facto homelessness prevention program.

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On average, each team assisted thirteen clients every six months. Of the ﬁfty-six served, nine consumers received approximately 50 percent of all ﬂexible monies. I found that Team A (table 7.1) allocated $5,000 of its $8,292 rent expenditure to just two individuals. It was not customary to subsidize rent for more than one month. Therefore, the distribution of half the ﬂexible fund monies to just nine consumers resulted from the undesirable team decision to subsidize rent for several months. Discretionary team spending created an unenviable practice question: who gets how much and why? The aggregate analysis of ﬂexible fund spending, moreover, does not indicate how onerous the task became. Managers and consumers depended on ﬂexible monies to meet needs. Staff developed expectations about manners, while consumers expected help on demand. The resulting dynamics weighed heavily on daily tasks. Below I present the oral narratives of ﬁve cases and analyze how strengths and situated knowledge work to tightly bind money to manners. CASE 1 : cm1 :

I think José saw her. He said that the apartment badly stunk and she had fresh scratches on her arms. I don’t know what to do. She wants a med [medication] drop, but she has not told us about her medical card. What is sad is she’s very likable. There doesn’t seem to be anything that gives her happiness, even her animals. I talked with her about being a client driver. cm2 : How about a peer supporter? Maybe if she worked with someone like her, she would respond. The outpatient people see her as dissociative, not borderline [personality disorder]. They don’t think we can work on the dissociative part. cm3 : She is borderline. She is requesting $100.00 for clothing from our ﬂexible funds. We could do it for her at Goodwill for $35. cm1 : This is difﬁcult. It doesn’t feel good to me when they ask for money but don’t invest themselves in CSS. Well, maybe she could work it off like a loan. We could use it as an incentive to get her active outside the apartment. cm3 : Her priorities are in a different place. She buys pet supplies and cigarettes.

Meds, money, and manners are coupled by a single expectation of the case managers: “incentive to get her active outside the apartment.” A manager reported fresh scratches, but the recent ﬂesh wounds did not become the object of clinical observation and conversation. The case record, moreover, listed “getting out of the apartment”(i.e., meaning social interaction) as a primary goal; the team’s expressed desire to leverage a desired outcome with

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money was not recorded. The team weighed the cost of “doing for” her. Money was viewed as a loan, which must be paid back by the consumer investing “themselves in CSS.” And even though the consumer’s apartment wasn’t clean and she smoked cigarettes, which intensify apartment odors, was cleanliness the only or the right priority? The team decided to honor the money request but such desires became morally complex. CASE 2 : cm1 :

She has requested $30 from our ﬂexible fund. She is overdrawn at the bank and owes $100 to the phone company. cm2 : Does she owe us anything? cm1 : No. I feel comfortable with it. We turned her down before because she was not following through. I am a little concerned with her getting into a cycle of always getting behind on her bills. That’s her pattern. She is agreeing now to do money management, and she has never agreed to do that before. She recognizes that she needs to break the cycle. cm2 : But you don’t break the cycle by borrowing money. I don’t feel comfortable with this. cm3 : I guess I want to give her some support, since there are so many good things going on. We can tell her, this is a one-time thing. We can tell her we will not do it again. cm4 : We are looking for consensus here. cm2 : I would be okay if there is a clear agreement that she will follow through with money management. And give her the stipulation that it goes for the overdraft.

Borrowing money could become a habit and was to be discouraged: “it’s a one-time thing.” The decision to give her the cash advance was based on the case manager’s opinion about “many good things going on.” Thus, the inability to balance a checkbook was weighed against her positively viewed attributions. Managers used the crisis to teach money management skills: “give her the stipulation that it goes for the overdraft.” CASE 3 : cm1 :

He wants ﬂex monies to pay for a bus pass to High County Community College. We could buy one and see if he would use it. Do we write the check to the bus company? cm2 : Yes. I have mixed feelings about this. He has money in savings. He has money. So I’m not sure why we should pay for it.

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cm1 :

Yes, but for whatever reason, social security told him to save money so he could build it up and then start on PASS.3 cm3 : The last I heard he has unrealistic goals. I don’t know if he should be saving. He will not be happy about our decision to decline his request.

Did this consumer have realistic goals? It was recorded in the chart that “he wanted a car,” and the PASS program was a step toward this goal. But in the oral narrative, managers doubted the consumer’s ability to make the PASS program succeed, and since the consensus was that he can’t (case managers were skeptical of the consumer’s ability to work), then, they reasoned, he should use his “savings” to buy his own bus pass. CASE 4 : cm1 :

We got a call from After Hours [the emergency crisis center] this morning. She was screened at Medical Center last night and then hospitalized. She lost her job Friday because of missed days. I am starting to have doubts about her apartment. I think after Medical Center, she should go to Residential House for respite care. If she can’t keep a job, she can’t keep her other goals, like getting a car. She was offered a job at Osco and Venture. She puts in half days and quits. cm2 : Are we giving her the message not to work? Is there a message that we will bail her out of her apartment? cm1 : Yes. We told her that we would cover her rent for six months. But I have doubts that this cycle will stop. cm2 : What about Andover House [a semistructured residential home]? It is cheaper. Now I know she doesn’t like to live with others, but what if after the hospital we take her to Andover House and then discuss home sharing. Remember when we talked about what percent we can cover? Now we’re doing 99 percent for her! I think it is okay for us to say we can’t subsidize it anymore. I think it is okay to give her one option and take away one. cm3 : Have we promised her six months in the apartment? Did we ever give her the message that subsidizing is contingent upon her working? cm2 : No. I don’t think so. I just feel like this could go on and on and on. It’s good for us to tell her that this arrangement is not working. It’s not punishment for losing her job and going to the hospital. cm3 : Yeah, but she will not see it that way. Telling her that we are going to no longer subsidize her apartment while she is in the hospital is a good idea. I don’t want to be the only bad guy. cm2 : No, I agree. cm3 : Do we want to eliminate the option of coming back to the apartment?

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cm2 :

This is our opportunity to read her message and take it into our hands. Her defeatist attitude is going to go on. I think she will see this as punitive because that is just who she is. cm1 : I agree. Structure is the key. But will she use the Andover House structure? I brought this whole discussion up because I am clueless about what to tell her. Legally, where do we stand? cm3 : We [High County Mental Health Center signed the apartment lease] are on the lease. And she is on the lease. She has a legal right to be there. cm4 : Perhaps we need to bring attendant care into the apartment? I don’t want to reinforce that she is a victim of her roommate or us. I don’t know what to say. cm1 : Okay, this is what I will do. I will go to the hospital and tell her that if she can’t work, then Andover House is her option. I will acknowledge that her current roommate is not a good match and that we will help ﬁnd a substitute. If she wants to stay in the apartment, I will write it up as a contract that includes our willingness to pay the rent if she works and continues making progress on her goals. cm4 : Yes. Okay.

If the consumer was willing to work, it was appropriate to use ﬂexible funds to encourage working manners. Team members, however, feared the consumer’s dependency upon the money grant (e.g., “doing for”). From a strengths point of view, the oral narrative implies that dependency is a problem and should, therefore, be coded as a misapplication of the model. The oral narrative, moreover, shows that case managers were very uncomfortable with their use of money, but their situated language became constrained by strengths’ focus on goals, work, and dependency. There are reasons for the constriction of the situated knowledge/power; the consumer’s history of work was extremely episodic, and she had many roommate conﬂicts and periods of homelessness. I do not believe that the evident frustration of the case managers was misapplied strengths management. Instead, their disciplinary and situated knowledge was unable to perceive the many ways in which money had insinuated itself into the helping relationship. Given that money had colored their intervention, how was it to be explained and handled? Case managers’ situated language was stuck in a worry language about consumer dependency. No one commented upon the clinical transference issues that complicated the case. CASE 5:

[The case manager had just reported on a visit with a consumer.]

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cm1 :

He was talking yesterday about his money very sensibly. He told me, “maybe the way I spend money doesn’t match your ideas, but it’s what I want.” He is trying to pay off collection agencies with any extra money. I am feeling better about where he is. Maybe he will get some help from his parents. He seems to know that he has made bad choices about his money at times. cm2 : Yes, but he doesn’t seem to get it. He will buy U-2 concert tickets but then he wants us to pay his dental bill. cm1 : Well, he seemed to get it, but it’s hard to know.

Flexible fund monies were provided in concert with moral expectations. All case managers expected consumers to work on goals, manage money, and work if able. Managers wondered whether or not consumers understood (or “get it”) that ﬂexible fund money was reinforcement for goal-oriented behavior. And team members would “do for” someone if they “invested” in CSS. Although the effect (preventing eviction) of ﬂexible fund spending kept individuals out of hospitals and in apartments, case managers used economic support to reinforce goal accomplishment; they also wanted to discipline impulsive or “irrational” spending habits. One manager summarized what many had conveyed to me: Well, being in the business as long as I have and knowing that there are times when you are just at the end of your rope with some people, then you are going to look for anything. We cannot make a consumer take medicine, we can’t even if they are on a court order. All you can say is you are on a court order, if you don’t take it, we have no choice but to try to revoke your outpatient treatment order. But, if there is a little leeway, then . . . . For example, I had a client last month that had, and this is a worst case scenario, not washed and combed his hair in months. I couldn’t see how water could even penetrate it because his hair was very long and it was matted up into a ball. What I did was call him up and I said we would go and get his spending money. I arrived later at his apartment and said that before we get the money, we are going to get a haircut. Bang. He was right out the door. He sat quietly and got his haircut. When we left the shop, I gave him his money. End of story. Sometimes if you can maneuver it that way, it’s a good way to do it. I don’t think it’s always good to say, if you don’t do this, you won’t get your money, rather it is best to maneuver it to work the best you can.

Without adequate cash transfer programs, lacking safe affordable housing and transportation, lacking reasonable job opportunities, and without med-

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ical insurance that pays 100 percent of the costs of medication, case managers will be bound to consumer spending. Literally, every penny of the consumers counted. The case manager’s statement that “I can ﬁx my schedule on their money needs” makes practical and situated sense. Social workers have often used money in helping relationships. It was one of the central welfare debates in the 1950s and 1960s. The 1930s ADC “budget” approach, Linda Gordon argues, instructed social workers to integrate money assistance with “holistic counseling about [the] personal, moral, and social” (Gordon 1994:103). A change in 1956 welfare policy ofﬁcially added social service assessment and intervention to cash assistance programs (Coll 1995; Wickenden and Bell 1961). Alvin Schorr, a welfare policy analyst and historian, argues that integrating social service with cash assistance has its own problems, however. It is virtually impossible to regard the guidance given by social workers as separate from their decision to give cash assistance or not. . . . My own view is that separation is not better than integration in principle, or at all times. It is better or worse in the light of what we are trying to accomplish; and the overriding social need of the 1960s and 1970s (and the 1980s and early 1990s) was to establish that law, not a worker’s discretion, determines eligibility. (Schorr 1997:69–72)

Winifred Bell and Elizabeth Wickenden contrasted the arguments on both sides of the controversy over separation versus integration, and they quote a social work educator in their classic report, who clearly states the nonintegration view of that period: I am skeptical about the validity of using economic means for meeting emotional and social deprivation—that is, to use money or the aid to the client as a tool in serving or treating the social or emotional disorganization. (Wickenden and Bell 1961:85).4

In a different time but closely related in function, strengths management advocates have unreﬂectively brought an old practice question into the present. I have shown that strengths case managers are skilled at separating the functional role of money from its pervasive symbolic meanings. Managers’ situated practice is deployed to make up for the symbolic silence in strengths management, and as a consequence situated practice became a moral economy of case management. Practitioners drew upon their own social and cultural sensibilities about money. What else could they do? When illness made

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bargain shopping temporally (or permanently) inefﬁcient and irrational, someone in the community had to “do for” the inefﬁcient shopper. Like Alvin Schorr, I am not absolutely against separation or integration of therapeutic intervention and money management, although whatever position a case management theory takes up, case managers will need at least two additional disciplinary knowledge/power schemes. First, they need psychodynamic theory to understand how money complicates helping relationships. They also need psychodynamic theory to explain how money becomes internalized as a cherished want or desire. And second, a manager needs sociodynamic theory (e.g., anthropology and sociology) to see how money, commodities, and meaning are also culturally insinuated into our most everyday wants. Strengths management works fabulously on the surface level and functional portion of money: who will do what when? But for consumers of mental health services, I am skeptical that strengths money management alone will produce meaningful spending.

C HAPTER 8

Meds

S

ince the mid-1950s treatments for schizophrenia and manic-depressive illnesses have been revolutionized by a kind of chemical warfare. In 1952 Delay and Deniker reported in the Congrès des Médecins Alienistes et Neurologistes de France the results of their research on Thorazine, sometimes called chlorpromazine. Soon, others were reporting on the beneﬁcial effects chemicals could have in treating intractable mental illnesses (Swazey 1974). By 1960 Thorazine, a neuroleptic drug, was being widely used in our state mental hospitals (Gelman 1999). This particular chemical and others to be discussed below, researchers argued, acted on the “positive” symptoms of schizophrenia—especially delusions, hallucinations, and disorganized behavior—to reduce, though not eliminate, their debilitating effects. By 1990 George Bush had signed a resolution declaring this the Decade of the Brain, and though this was not the beginning of biopsychiatry, it certainly showed the weight given to exploring the biological bases for behavior and the powerful ideological, political, and economic forces at work in promoting the research and associated industries (Glenmullen 2000; Valenstein 1998; Lewontin 1991; Lewontin et al. 1984; Breggin 1991). We now take for granted the presence and power of drugs in treating schizophrenia and mental illness, some serious and some commonplace. And for the many who work or live every day with the chronically ill, numerous chemicals seem a natural part of life and even necessary to the project of supporting people in communities. For others, talking psychotherapy is no longer relevant to the project of deinstitutionalization (Torrey 1992, 1988:220). In this

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chapter, however, it is not my intention to consider the controversial literature that attempts to explain how medications caused deinstitutionalization (Scull 1984:79–94) or how relevant psychotherapies are to the project. Yet I do understand that this literature is important to the extent that it helps me explore the situated practice of case managers. I consider instead what in the everyday practice of managers is called meds (medications), the new division of labor and spaces produced by meds, the case managers’ relationships to psychiatrists, nurses, and consumers, and the situated practice of meds, what I will call “effect interpretation.” This cannot possibly be accomplished without ﬁrst considering the drugs themselves as they produce for consumers, CSS, and the case managers indeterminate effects well beyond those attaching to neurons. I argue that the limits and potentials of these powerful drugs are realized in the activities and situated knowledge produced at the practical level and in the day-to-day practices and interactions among the practitioners involved. Forty years after their introduction and proliferation, medications do not liberate every patient from the watchful gaze of professionals, nor are they likely to do so. Indeed, if drugs produced all desired effects, case management and CSS would not be needed.

COMMUNITY SUPPORT SERVICES MEDICATIONS

I am concerned in this analysis with the kind, the number, the combinations, and the patterns of use; I do not use these data to test hypotheses. Instead, as a rough indication of biopsychiatry’s disciplinary power, I have studied the type and frequency of “prescriptions” at High County CSS. Targeted behaviors and emotions are windows into the desirable effects of biopsychiatry. I interpret the patterns in drug usage and argue that disciplinary and situated practice produces a group of high and low quantity drug users. For low users, I speculate that a single antipsychotic produces the effect of reducing symptomatology. And I show how CSS practitioners in their daily work use a trialand-error situated practice, especially for those consumers taking three or more medications (high users). Biopsychiatrists and psychopharmacologists assume that speciﬁc categories of drugs affect targeted behaviors and emotions. Yet often no one knows why drugs and speciﬁc dosages produce unique effects. “The same dosage knocks one person out and doesn’t come close to arresting aggression in others,” reported a CSS psychiatrist. I examined the normative statements found in the case manager training manuals, which managers use to study for

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an in-house examination on medication. Case managers are taught that drugs are divided into ﬁve categories: antipsychotic, antimania, anti-anxiety, antidepressant, and antiparkinsonism. In table 8.1, I present the drug categories, as they are described in the manual,1 according to their expected effects, called “target symptoms.” I have italicized the behavioral and emotional indiTABLE 8.1 DRUG CATEGORIES AND TARGET SYMPTOMS ANTI PSYC HOTIC

Hostility

Agitation/anxiety Insomnia Hallucinations Loose associations

Delusions, suspiciousness, preoccupations

ANTIM AN IA

Irritability assaultive threatening Increased motor activity Sleep disturbance Hallucinations Loose associations, distractibility Sexual delusions, persecutory delusions, religious delusions, grandiose delusions

A NTI D E P R E S SA NT

Irritability

Irritability

Anxiety

Restlessness

Insomnia Self-reproach, guilt Poor memory and concentration, slowed thinking Suicidal thoughts, hopelessness, sadness, pessimism

Insomnia Paresthesia Decreased concentration

Social withdrawal Expansive hypersexuality Poor self-care Manipulative habits Constipation, weight change Inappropriate Pressured speech affect

Anorexia

Mutism

Slowed movement, fatigue

Labile

ANTI-ANXI ETY

Trembling or shaking, dizziness or faintness, chest pain or discomfort, shortness of breath Hot ﬂashes or ﬂushing, sweating

Muscle tension

No enjoyment, Fear, palpitations decreased sex drive Exaggerated startle response

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cators that appear in more than one category. Although in theory drugs target speciﬁc symptoms, several contain, delimit, control, or mitigate the same symptoms: hostility, irritability, insomnia, hallucinations, delusions, and poor concentration and thinking processes. The qualiﬁer “anti” denotes the medication’s desired opposition to both positive (thought-related symptoms) and negative (behavioral and emotional) symptoms. My early and cursory examination of the categories along with their target symptoms led me to speculate on how practitioners attribute powers to any speciﬁc drug when anticipated effects overlap and consumers take drugs from more than one category. I wondered, in other words, whether drugs in different categories produce the same behavioral and emotional effects. If so, where one or more drugs are used, a kind of indeterminacy is present, where at best practitioners could only speculate about the effects of speciﬁc drugs. This question prompted me to examine “the prescription,” its frequency, and its various combinations. I wanted a rough indication of how much indeterminacy case managers confronted in monitoring the behavioral and emotional effects of medications. In table 8.2 I provide a list of the forty-seven CSS medications and the frequency of their use.2 The most commonly prescribed drug (10 percent of all prescriptions), Cogentin, an antiparkinsonism medication, is given to one in four consumers. Frequent use of Cogentin suggests that practitioners observed side effects3 and took chemical action against them. Cogentin counters the effects of pseudoparkinsonism, a chemical imbalance (acetylcholine and dopamine) produced in the basal ganglia that simulates Parkinson’s disease. Lithobid (antimania) follows Cogentin in frequency of client usage (9 percent of all prescriptions). In October 1996 the Food and Drug Administration approved the third most prescribed drug, Zyprexa, produced by Eli Lilly and Company. By the time I began my ﬁeldwork in 1997 it had become the single most popular atypical, antipsychotic drug (one out of ﬁve clients received the drug). Unlike older antipsychotic neuroleptics, Zyprexa can be administered in one daily dosage, and according to its makers, it has fewer interactions and no requirements for blood monitoring. Its remarkably rapid adoption at CSS indicates the medical team’s experimental approach to new antipsychotics and the pharmaceutical industry’s astonishing marketing success and intense activity. Though Lithobid (antimania) and Cogentin (antiparkinsonism) are the most commonly prescribed, I show in table 8.3 that they represent the third and fourth highest categorical use; antipsychotics and antidepressants are

TABLE 8.2 MEDICATION TRADE NAME AND PRESCRIPTION FREQUENCY MEDICATION

P R E S C R I P TI O N

% OF TOTAL

% OF TOTAL

TR ADE NA ME

F R E Q U E N CY

P R E S C R I P TI O N S

CONSUMERS

N = 808

N = 808

N = 329

Anafranil Antabuse Artane Atarax Ativan Benadryl Buspar Clozaril Cogentin Corgard Cylert Depakene Depakote Desyrel Effexor Elavil Eskalith Haldol Inderal Klonopin Lithobid Loxitane Luvox Mellaril Navane Pamelor Parnate Paxil Pertofrane Pondimin Prolixin Prozac Risperdal Ritalin

6 2 21 1 15 1 13 43 81 2 1 1 43 24 7 2 7 58 9 18 72 6 5 30 19 4 1 21 4 1 40 37 42 2

3.0 < 1.0 2.0

< 1.0 < 1.0 6.4 < 1.0

2.0 < 1.0

5.0 < 1.0

2.0 5.0 10.0

< 1.0 4.0 13.1 25.0

< 1.0 < 1.0 < 1.0 5.0 3.0 1.0

< 1.0 < 1.0 < 1.0 13.1 7.3 2.1

< 1.0 1.0 7.0 1.0 2.0 9.0 < 1.0 < 1.0 4.0 2.0 < 1.0 < 1.0 3.0

< 1.0 2.1 18.0 3.0 5.5 22.0 2.0 2.0 9.1 6.0 1.0 < 1.0 6.4

< 1.0 < 1.0 5.0 5.0 5.0

< 1.0 < 1.0 12.1 11.2 13.0

< 1.0

< 1.0

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TABLE 8.2 CONTINUED MEDICATION

P R E S C R I P TI O N

% OF TOTAL

% OF TOTAL

TR ADE NA ME

F R E Q U E N CY

P R E S C R I P TI O N S

CONSUMERS

N = 808

N = 808

N = 329

Serzone Sinequan Stelazine Symmetrel Tegretol Thorazine Tofranil Trilafon Valium Wellbutrin Xanax Zoloft Zyprexa

6 1 7 2 25 13 8 2 2 11 5 23 64

< 1.0 < 1.0 < 1.0 < 1.0 4.0 2.0 1.0

2.0 < 1.0 2.1 < 1.0 7.5 4.0 2.4

< 1.0 < 1.0 1.0 < 1.0 3.0 8.0

< 1.0 < 1.0 3.3 1.5 7.0 20.0

used more frequently. Like the antiinﬂammatory medication that ﬁlls home medicine cabinets, Lithobid and Cogentin are psychopharmacological mainstays. Pharmaceutical companies have produced newer antipsychotics and antidepressants because over time no single one—unlike Lithobid for manic depression—dependably produces the desired effects. Consequently, newer antipsychotics and antidepressants are always marketed, so even though as a category these are given to more clients, no single antipsychotic or antidepressant exceeds the frequency of a mainstay medication like Lithobid. For example, table 8.2 shows that CSS used eleven different antipsychotics: Clozaril, Haldol, Loxitane, Mellaril, Navane, Prolixin, Risperdal, Stelazine, Thorazine, Trilafon, and Zyprexa. In contrast, there are only ﬁve drugs that target antimania symptoms: Depakote, Eskalith, Klonopin, Lithobid, and Tegretol. And three of the most recent atypical antipsychotic drugs, Risperdal, Clozaril, and Zyprexa, account for nearly half (149) of all antipsychotics in use at CSS! Unlike with the antimania drugs, the unpredictable effects of antipsychotics apparently cause new generations of medications to rapidly displace older ones, while Lithobid continues to produce the effects practitioners and patients desire.

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TABLE 8.3 FREQUENCY MEDICATION CATEGORY MEDICATION CATEGORY

# OF

% OF

CONSUMERS

CONSUMERS N = 329

Antipsychotic Antidepressant Antimania Antiparkinsonism Anti-anxiety Stimulant Misc.

278 140 139 105 33 4 13

84.5 42.5 42.2 31.9 10.0 1.2 3.9

I then counted (table 8.4) how many medications were prescribed for each consumer; consumers received between one and seven medications. Two in ten (19 percent) consumers were prescribed one medication, whereas 39 percent of all consumers were prescribed two drugs. And I found that 25 percent received three and approximately 16 percent of all consumers took four and ﬁve medications each. The majority of consumers took an antipsychotic, namely, nearly 85 percent of them (table 8.3). However, suspecting that among consumers who took more than one medication a difference might emerge, I divided the medication population into three user groups—greater than or equal to three drugs, two drugs, and one drug. Table 8.5 shows that consumers taking one drug, as a percentage of their group, take fewer antipsychotics (68 percent) than others (87 percent and 90 percent). A person who was prescribed two medications had a nine-in-ten chance of receiving antipsychotics. To learn more about apparent differences, I reshufﬂed the groups and examined the data from a different angle. The high-user group (41.6 percent of all consumers, N = 137) was deﬁned as taking three or more drugs and low users as taking two (see table 8.6). In comparing these groups, I thought more critically about drugs that have overlapping target symptoms (see table 8.1). In table 8.6 I examine the relationship (frequencies) between drug combinations and the high and low users; both regularly used three types of combinations: (1) antipsychotic and antimania drugs, (2) antipsychotic and antidepressant, and (3) antimania and antiparkinsonism medication. Thus, practitioners routinely aimed two or more drugs at the same individual because, apparently, psychosis, mania, depression, and drug side effects were equally manifest. I

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TABLE 8.4 FREQUENCY OF MEDICATIONS PER CONSUMER # OF MEDICATIONS

F R E Q U E N CY

% OF TOTAL

CUMU L ATIVE

N = 329

CONSUMERS

P E RC E NT

63 129 83 36 15 2 1

19.0 39.0 25.0 11.0 4.5 <1.0 < 1.0

19.1 58.4 83.6 94.5 99.1 99.7 100.0

PER CONSUMER

1 2 3 4 5 6 7

compare the combination ﬁnding with the description of target symptoms in table 8.1, and this largely illuminates the amount of indeterminacy that insinuates itself into the work of a practitioner’s “effect interpretation.” The antipsychotic and antiparkinsonism combination was expected; that is, when consumers were prescribed a second drug, practitioners most often countered the side effects of the antipsychotic with antiparkinsonism medications. The pattern of double prescriptions listed in table 8.6 also suggests that two distinct groups emerged. And their distinguishing characteristic is the likely contradictory combination of medications: antimania with an antidepressant and antidepressant with anti-anxiety. Consequently, it is signiﬁcant that high-using individuals were more likely to receive a drug combination targeting similar symptoms. My analysis suggests that a situated practice in the medical team emerged. One group, high users, was not only taking more drugs but also received combinations with more overlapping effects. For low users—low users represent most of the CSS population (58 percent)—however, it appears that antipsychotics and antiparkinsonism drugs worked speciﬁcally enough so that no other drug was necessary. With high users (42 percent), where a drug’s speciﬁc action on a target symptom does not correspond to a desired effect, a tendency developed in situated practice to experiment with various combinations. Where one drug did not produce the desired effect, a double or triple combination might. Blending antimania drugs with antidepressants seems contradictory, yet for the practitioner who hopes for an effect contradiction is not particularly worrisome, especially when the desired effect is produced. Chemical mixtures

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TABLE 8.5 MEDICATION CATEGORY BY TYPE OF DRUG USER MEDICATION

CONSUMER

CONSUMER

CONSUMER

CATEGORY

PRESCRIBED

PRESCRIBED

PRESCRIBED

≥ 3 DRUGS

2 DRUGS

1 DRUG

N = 137

N = 129

N = 63

CASES

% ≥ 3

CASES

GROU P

Antipsychotic Antimania Antidepressant Antiparkinsonism Anti-anxiety Stimulant Misc.

119 97 87 64 26 1 11

87.0 71.0 63.5 46.7 19.0 0.7 8.0

% 2

CASES

GROU P

116 35 43 40 6 2 2

90.0 27.1 33.3 31.0 5.0 1.5 1.5

% OF 1 GROU P

43 7 10 1 1 1 0

68.2 11.1 16.0 1.5 1.5 1.5 0.0

lead to indeterminacy, suggesting that no practitioner could scientiﬁcally (or otherwise) assess which drug is producing which effect. Consequently, among medical practitioners, it seems the high user group is the object of a situatedmedical knowledge/power and practice. But why would one group become the subject of an ad hoc experiment? What makes high users different from others? Though I collected no data with which to conﬁdently address these questions, I show in table 8.5 that regardless of the type of user (one, two, or more than three drugs), nearly everyone is prescribed antipsychotics (68 percent, 87 percent, and 90 percent). I speculate that 42 percent of all consumers—the high-using group—do not respond favorably to antipsychotic medications; therefore, to accomplish a desired effect, psychiatrists and nurses experiment with various combinations. Though speculative, my interpretation is consistent with the fact that users of two medications are routinely prescribed an antiparkinsonism remedy as a second drug; for this group, then, the desired effect is achieved with a single antipsychotic and an antiparkinsonism drug. The data warrant further interpretation. If the volume of prescriptions indicates conservative use of medications, the data suggest that the medical team was not recklessly throwing drugs at consumers; that is, when a single antipsychotic drug mitigated the negative and positive symptoms of illness, practitioners stopped writing prescriptions. On the surface—I have not ana-

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TABLE 8.6 DOUBLE MEDICATION COMBINATION BY HIGH AND LOW USER DOU B LE MEDICATION COMB I NATION

# OF ≥ 3

% OF ≥ 3

# OF 2

DRUG USER

DRUG

DRUG USER

DRUG

DOU B LE

USERS

DOU B LE

USERS

COMB I NATION

Antipsychotic & N = 111 Antimania Antipsychotic & N = 102 Antiparkinsonism Antipsychotic & N = 101 Antidepressant Antimania & N = 62 Antidepressant Antipsychotic & N = 35 Antipsychotic Antipsychotic & N = 20 Anti-anxiety Antidepressant & N = 20 Anti-anxiety Anti-anxiety & N = 19 Antimania

% OF 2

COMB I NATION

82

73.9

29

26.1

63

61.7

39

38.3

70

69.4

31

30.6

57

92.0

5

8.0

25

71.5

10

28.5

16

80.0

4

20.0

19

95.0

1

0.5

18

95.0

1

0.5

lyzed dosage amounts—there seemed to be no overreliance upon medications. Only four in ten consumers took three or more drugs, while the majority were prescribed two or fewer. Psychiatrists and nurses saw no need to add further categories of medication, unless of course a single antipsychotic failed to accomplish a desired effect. Although my interpretation of medication prescriptions at CSS may be construed as an apologia for the pharmaceutical industrial complex and biopsychiatry, I have serious reservations about the many combinations and apparent experimentation on those in the remaining 40 percent. When the target symptoms of each drug category overlap, there is no easy way of determining which drug is producing the desired effect, and this leads to much speculation. Though experimentation is not intrinsically unacceptable, it is not clear from my research that consumers and practitioners understood it this way or approached the matter systematically. Social projects that use medicine to produce behavioral and emotional

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effects can potentially overmedicate. Mental hospitals were particularly sensitive to such charges, and whereas custodial care did not require rational, goal-oriented and motivated patients, overmedication at CSS clearly can become counterproductive. Although heavily tranquilized bodies may have contributed to ward harmony, at CSS former “patients” have to meet scheduled appointments, write checks, balance checkbooks, arrange for and plan transportation. In short, because CSS requires self-directed subjects, chemicals must not impede daily living. Unwittingly (unlike hospital-based psychiatry) the policy of deinstitutionalization produced a safeguard against the tendency to overmedicate. One should be cautious with this argument, however. If programs lack case management resources, they may need to tranquilize; there may be no practitioners responsible for monitoring outcomes. For sure, where the actions of chemical agents leave off, human agents must take over. CSS needs case managers to produce effects that chemical combinations fail to provide.

THE CASE MANAGER IN THE MEDICATION DIVISION OF LABOR

Prescribing medication and assuring compliance require more than watchful eyes. As with most systems of surveillance, the surveillant’s everyday behavior is organically connected to the object of the gaze—monitoring medication creates inseparable bonds between consumers and case managers. Assessing, prescribing, and delivering also requires the full deployment of CSS workers. Though psychiatrists, nurses, case managers, and attendant care workers are primary providers, secretaries must record and drivers must move consumers across the exurban landscape to and from medication and other appointments. For everyone, and particularly for the case manager, the division of labor originates and unfolds in the med room.

TH E MED RO OM AN D COMPLIANC E MON ITOR I NG

About any kind of medication, psychotropic or otherwise, the user often asks: How often? Are they working? What are the side effects? How do I recognize a side effect? Can I depend upon myself to take them regularly? How do I get a reﬁll? How long before the medication starts to work? If I am offered alcohol, do I accept it? There are numerous permutations in medication management. And even for those not suffering from severe mental illness, following

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drug regimens presents formidable challenges. In sum, for those with severe mental illness, taking medication is a litmus test for daily living. Wherever psychotropic drugs are used, consumers are caught in a web of supervision and a complex division of labor called CSS. At CSS, the med room was at the center of this project. An entombed, windowless, and isolated eight-by-eight square, the med room embodies the history of the present. It is both a reminder of the power that medicine and psychiatry once had in the “total institution” and a signiﬁer of the project of deinstitutionalization. It is a space of contestation, where one is at once reminded of the continued authority of the medical model and the simultaneous displacement of that authority with new forms of discipline and power—medication management. The med room is also a conﬂicted crossroads where CSS and the community work out the quotidian and often contradictory tensions between dependence and independence. At CSS this powerfully symbolic space was also a crucial crossroads in the daily work of practitioners, case managers, psychiatrists, and nurses. It was a place where the “prescription” began its journey from the institution to the community, a place where the disciplinary knowledge of psychiatry and medicine joined with the disciplinary and situated knowledge of case managers. The med room had few of the trappings of the “total institution.” It was virtually out of sight. This was not a space as Foucault might have imagined it to be; the space of the panopticon was superseded by a mobile division of labor. The med room, for example, opened at 8:30 a.m. and was locked at 5 a.m. There were no discernible “patients” queuing before the watchful eyes of the nurse; most of the time, consumers were at home, completely out of sight. Although the med room was not open 365 days a year, monitoring occurred continuously and was diffused to hundreds of sites in the community where drugs were delivered, consumed, or resisted. Nevertheless, the epicenter of medication management was the med room. The timelessness of medication, its inevitability, was underscored for me when, on one of many visits (July 25, 1997) to the med room, I noted that the monthly planner on the wall was still that for June. I wondered how medical personnel could not pay strict attention to the days and weeks of the month. Surely, consumers needed to know precisely when to start and end medication regimens. But here, where one never imagined a time without medication, inattention to the actual month symbolically represented the med room as a space of chronicity where medication was a reality of everyday life. A nurse captured for me the room’s essence: “Mental illness is chronic and to be chronic is to need meds. If they don’t need meds, they don’t need to be here.”

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On a bulletin board opposite the storage cabinets a nurse posted medication instructions for visitors’ perusal; these remained unchanged during the time of my study: (1) tips for dry mouth, a side effect of many medications; (2) a list of drug companies that provide CSS with sample medications; (3) a list of managers’ phone numbers; and (4) a list of pharmacy phone numbers. Near a small cabinet next to a desk, a clipboard, a red basket, a plastic folder, a 3 × 5 ﬁle box, and plastic cups rested. A form was attached to the clipboard and used to register the names, times, and medications dispensed in the med room. Mixed in with pharmaceutical literature describing Prozac and Zyprexa it was common to ﬁnd empty prescription bottles and med boxes ﬁlling the red basket. Med boxes were used by nurses and managers to distribute daily (a fourreceptacle container) and weekly drugs (a twenty-eight-receptacle container); a consumer’s morning dose was placed in the AM box and afternoon medicines in the PM box, and so forth. Case managers made and justiﬁed requests for free drug samples by ﬁlling out a 3 × 5 card and placing it in the red basket. One manager wrote that the “consumer’s divorce became ﬁnal last week with no warning. Her insurance has subsequently run out. Medicaid application and indigent med request pending. Need medication immediately.” A request for free drug samples resolved various daily crises that disrupted drug regimens: the unplanned (e.g., the consumer fails to alert the case manager) medication reﬁll, an emergency change in medication, and unaffordability. Two large storage cabinets housed plastic tubs, distinguished one from the other by the last names of team leaders. Managers found consumers’ medication in the team leader’s tub, where Ziplock bags contained up to a half dozen bottles. I often saw managers riﬂing through these bags and carrying them to and from cars and ofﬁces and to and from consumers’ apartments. The med room was a functional space for several kinds of monitoring. For self-directed medication users, the room had little meaning. Those less capable of self-monitoring, however, found the room crucial to the organization of daily living. Injectable drugs were the easiest to monitor for the CSS worker; there were no bottles, bags, tubs, and med boxes to deal with. And although shots reduced the reliance on pills, they did not eliminate them. Consumers took an average of 2.5 medications and one of these was administered daily, by mouth, to reduce side effects. The majority of the injectable drugs were antipsychotics requiring Artane or Cogentin to counter drowsiness, parkinsonism, tardive dyskinesia, pacing, and dry mouth. Some consumers simply used the med room as a repository; they came only to ﬁll med boxes under supervision. Between the extremes of self-regu-

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lation and practitioners’ monitoring were many variations, about as many as possible permutations. For example, according to my ethnographic notes, case managers talked in a team meeting about a hospital discharge. The consumer had made a suicidal gesture by overdosing, and weighing suicidal threats against self-monitoring, a manager asked: cm1 :

Is she going to be on a med box or med drop? Will she get a three-day sup-

ply? cm2 :

Well, we are aware that if she wants to overdose, she will ﬁnd a way. Let’s start out with a med drop, and if that goes okay, then switch to a weekly med box.

At home, in this instance, the consumer ﬁlled her med box with medications delivered by the case manager. This visit, called a med drop, can only be done by case managers certiﬁed for the task; otherwise it was not legal for a case manager to ﬁll a med box. However, because the law does not stipulate how drugs were to be moved from one site to another, anyone was eligible for this task. Inside a consumer’s apartment, inside the med room, or inside the car, the manager gave the medicine bottle to the consumer, then monitored the consumer as he or she ﬁlled the med box. In short, for consumers who needed compliance monitoring, the CSS division of labor assured that consumers received one, two, or three weekly med drops. Some had daily drops. Although numerous consumer characteristics and daily events called for variations in the way the system worked, the med room was central to the medication division of labor. Every day and for many reasons case managers made several trips to the room. In one two-hour period, I recorded the following medication-related events: 9:30 a.m.: CM (case manager) had purchased meds yesterday and was placing them in the consumer’s bag. This consumer gets nightly med drops. 9:40 a.m.: CM picked up daily medication for two consumers. 10:25 a.m.: CM is returning a med box and setting up two med boxes for weekend delivery. 10:30 a.m.: CM picked up the consumer’s bag of medications and returned ten minutes later with the bag. 10:35 a.m.: CM is looking in a small ﬁle box to see if her client received Loxatine from the indigent program. Her consumer has not met his spend-down and needs meds today. 10:50 a.m.: CM is checking to see if her consumer’s meds are in the box. They were not. So, maybe, she says, “they are still in my car.” The CM

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is arranging a med drop along with a money management session, “so I do not have to duplicate a visit.” 11:05 a.m.: CM looks in the locker and discovers that her consumer’s med box is missing. She wonders where it has gone. 11:10 a.m.: CM is picking up medications for daily med drop. 11:15 a.m.: CM is ﬁlling a med box for a consumer who temporarily does not want to keep her meds at home because of suicidal feelings. 11:30 a.m.: CM is picking up meds for a daily med drop. The med room, the med box, and the med drop are at the heart of the languages, spaces, and activities that constitute the medication division of labor. Just as the body must break down synthetic substances, then circulate chemicals to neurotransmitters, the human effort outside the body must work. The strengths management (goal setting) system breaks down the different parts of a medication goal; it then moves medicines from the site of assessment and prescription, to the pharmacy, to the medication room, to the med box, to the med drop, to the case manager’s desk and car, and ﬁnally to the consumer’s apartment. At each point along the medication circuit, participants exchange chemicals for desired effects. For example, on a routine home visit, a manager was completing a new monthly goal plan: case manager:

How about meds? Well, eventually I want to take them myself and be in charge of it myself. I am happy with these meds. I’ll take them. I am not crazy anymore. case manager: Is that a long-term goal? consumer: Yes. case manager: The side effects aren’t bothering you? What is the difference on these meds? consumer: It makes me gain weight. case manager: Perhaps you need to increase exercise? So, in February, do you want daily med drops? Or maybe we could do a med box? consumer: What’s that [med box]? case manager: Twice a week we ﬁll a med box that you keep at home. consumer: That sounds good. I don’t want to put you out. case manager: Maybe we can start on Monday. I’ll check with the nurse and the team. consumer:

In this oral narrative, driven by strengths management, the manager wanted to produce self-reliant monitoring. The consumer wanted medica-

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tion, and back at the ofﬁce the manager wrote into the case record a new (monthly) medication goal. Med drops and boxes were part of the work of monitoring for compliance. The body, in effect, does the rest of the work: transporting the substance to the brain. The outcome, however, is unpredictable. A wait-and-see attitude prevailed. Once in the body, cross-checking the medicine’s intended effects with the actual requires a different kind of medication work, effect monitoring or interpretation: “I am happy with these meds.” Three more examples illustrate the overlapping work of compliance and interpretation. cm1 :

She called this week and reported that she is sleeping too much and can’t get out of bed sometimes. Maybe we should do a med check. cm2 : He had an ER [emergency] med check yesterday. He was really frightened. When he hears voices, they are usually violent and aggressive. I think it was due to a decrease in his Haldol. It looks like he will need both medications [Haldol and Lithobid]. cm3 : A week ago she pushed a resident. She pushed and cursed her in the hallway. I think she heard voices. It is just too stimulating sometimes around here. I think she is taking her meds. I mean, I stay with her and watch her take it.

As long as medications are deployed, the interventions and system I describe, or some comparable substitute, must be in place. Although CSS systems vary widely in the monies allocated to medication services, the division of labor no doubt must include some combination of the monitoring of effect interpretation. The latter constitutes a system of power with a single hopedfor effect: reducing the perceived negative or behavioral and emotional (e.g., apathy) and positive or thought-related (e.g., hallucinations) symptoms. These may be depression and anxiety (i.e., negative) or disruptive, disorganized, and delusional thinking (i.e., positive). What starts as a simple activity, taking medicine, results in complex compliance monitoring, effect monitoring and interpretations, power relations, and actions. Unlike money management, which did not require a complex division of labor, with the CSS pharmacopoeia case managers moved through a web of activities: scheduling daily and weekly med drops, transporting consumers for shots and med appointments, and making numerous trips to pharmacies. In this division of labor, the work had to be regularized and routinized. A single case manager with a caseload of ﬁfteen had an average of nine consumers taking two or fewer medications. Six were taking three or more. A daily case-

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load included 108 events, assuming each medication was taken three times in twenty-four hours; thus, staff were responsible for monitoring several thousand events each day. Case managers, however, worked eight-hour days. It was probable, then, that in every ﬁve-minute period a medication event unfolded. Yet many consumers followed instructions without their case manager’s interpretation or intervention; they were not visited, watched, or telephoned, nor were they asked about compliance. Others required daily assistance. Consequently, managers worked between the poles of consumer self-compliance and CSS monitoring. And they always had to work alongside the psychiatrist and nurse. Two psychiatrists provided four important services at CSS. First, there were the obvious medical assessments and prescriptions. Second, case managers relied on their psychopharmacological knowledge. Third, insurance billing often required a physician’s signature, and they also approved and signed treatment plans devised by case managers and consumers. And, ﬁnally, courtordered evaluations required the authority of the psychiatrist.4 Psychiatrists and case managers routinely consulted on medication evaluations or “med checks.” Clinical meetings between managers and psychiatrists often focused on effect interpretations: case manager:

You see Ned on August 19th. He is doing OK. He is moving ahead on his driving goal and calls the driving school on Tuesday, and hopefully he might make a decision next week. He is saying the meds aren’t doing anything—maybe nothing. He is still, I’d say, about the same as far as medicine. Still doing as well as he has been doing. When I saw him this week, he talked a little bit about the nervous demon. But he won’t tell me too much more because he says it sounds crazy. And I said, “well, you’d be surprised at the things I’ve heard.” And he just wouldn’t do it. But he is still convinced that, I mean part of him, that it’s bizarre and crazy. Most of him still thinks that it’s not delusional, it is real. psychiatrist: Good. He’ll be O.K. I’ll probably have to think about how to do two things. One is increase his Zyprexa and the other is to start scaling back on his Mellaril. case manager: Boy, when you mentioned that at med check, he almost choked. He is going to be a nervous wreck. psychiatrist: I would like to be able to get some kind of an impact on him from the Zyprexa. I’d like to be able to demonstrate some, uh, effect where he would say, “I feel different,” or “I feel calm,” or “I feel something.” Because of the stance that he has right now, it is like, “What medicine? Or, what Zyprexa?

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Four nurses scheduled intakes for medical evaluations, they read and wrote medical notes, reﬁlled prescriptions, gave some eighty consumers weekly or bimonthly shots, and operated the makeshift on-site pharmacy, stocked with samples from pharmaceutical companies. Case managers often depended on nurses for samples to ﬁll the void while other resources and ways to purchase medicines were being explored. Nurses oversaw the med room and ﬁlled daily med boxes. For consumers who came to the center to get daily meds—a practice that was discouraged—nurses often dispensed the meds, always watching and carefully recording. Most medical questions were directed to nurses. They were routinely queried about possible adjustments in meds and schedule, if needed, a med check with the psychiatrist. Aside from the manager, Attendant Care Workers (ACW) also handled medications; most were part-time employees who worked at residential programs and, among other duties, monitored medications, where they were instructed to encourage consumer self-reliance. Often it was through conversation with the ACW that case managers learned about medication compliance. The ACW also assisted with med drops. On any given day, medications (one episode is called a med drop) were delivered to approximately twenty-four consumers (approximately 6 percent of all CSS consumers), and some got as many as three visits a day. In a sixmonth period, I was told that 7,000 med drops had occurred. In sum, selfmonitoring requires that medicines be swallowed and bodily systems process and move the chemical to neurological sites. In the absence of self-regulation, case managers played a crucial role in delivering drugs. But their most important role was in monitoring effects.

MONITORING FOR EFFECT INTERPRETATION

I routinely observed one central management function, irrespective of the degree of self-monitoring. I call it effect interpretation. Managers constantly surveyed and reported on how medicines affected daily living. Constant monitoring and interpretation overlapped with medicine. I use my ethnographic data to show how managers’ situated effect interpretations, along with strengths management’s goal-oriented work, constituted a system of medication management. To convey a sense of how effect interpretation is central to medication management, I ﬁrst provide examples from a team meeting. Finally, I queried managers about their perceptions of the medicines and their effects in the

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body. Throughout, in order to highlight the work of situated practice, I have italicized examples of situated language.

TEAM CASE MANAGER MEETI NG

In a daily team meeting, typically twenty-three consumers were discussed; nine required medication management and usually a related effect interpretation. The following examples are taken from a single team meeting. CASE 1 : cm1 :

We were just talking about him. I saw him last Thursday. There was an open beer can on the coffee table. He needs some kind of substance abuse treatment, and it seems his refusal of meds is precipitated by his drinking. He doesn’t come in for med checks. cm2 : Should we get him in for an emergency med check? Then we could do med drops. cm1 : Yes, but what happens is, we start med drops, he stabilizes, then we stop med drops, he starts drinking, and then the cycle begins all over. cm3 : I wonder why he is drinking? Do you think he is self-medicating? He has classic symptoms: hallucinations and paranoia. Does he drink when he takes meds? cm1 : He drinks quarts [of beer]. cm2 : Could his wife watch his meds? cm1 : He is very open to suggestions, so I think we should have a chat with him about his drinking and his wife checking on his meds. cm3 : Let’s get more information from him. Maybe he doesn’t even recognize his drinking problem. Instead of us setting up a medication appointment for him, ask him if he wants us to do an emergency med check with him.

Home visits served to gather information for the work of compliance monitoring: “an open beer can on the coffee table.” Drinking, the manager suspected, is the possible outcome of noncompliance. Yet, is drinking the cause of noncompliance or is drinking the result of noncompliance? The manager’s identiﬁcation of a “cycle” suggests that compliance was perceived as having more than a single cause. Strengths management, however, does not provide a language for understanding complex motivations for drinking; the case record, in this example, noted “I want to stop drinking,” while the step toward

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this goal was written as “take meds as prescribed.” Had the manager tried to write a more complicated goal, for example, “my goal is not to want to drink,” strengths management would have limited the assessment and intervention to the surface level of everyday life. Why? Because it can only rewrite a positive desire into a negative one. Yet the case manager’s oral narrative sought a deeper explanation: “Why is he drinking” and “Is he self-medicating?” In Case 1, case managers also raised doubts about self-compliance and discussed med drops as a mechanism for delivery and monitoring. A strengths perspective manifests in the query about the wife’s surveillance powers, an example of a “naturally occurring resource”; in short, with someone at home to monitor, the case manager was free from this burdensome task. Then there was the effect interpretation: was drinking an antipsychotic home remedy? Although this incident was fraught with the strengths and pharmacological disciplinary gaze, case managers used a situated language to reconcile the difference between hoped-for self-compliance and worker monitoring: “Instead of us setting up a medication appointment for him, ask him if he wants us to do an emergency med check with him.” I often experienced and observed in medication management the situated use of “doing for” and “doing with.” While setting up an appointment and starting med drops “for him” was considered in the above case, the decision to encourage self-reliance was given equal weight. In the subtext there was a practice ambivalence over too little self-directed behavior on the part of the consumer and too much assistance from the manager; the ambivalence in Case 1, evident in the situated language of “doing for” and “doing with,” was not entered into the case record. CASE 2 : cm:

He is ﬁne. He is very high functioning. His shot is today and I didn’t even know it.

Although this was a brief and subtle interjection during a routine team discussion and in response to a case manager’s request regarding the consumer’s well-being, this kind of oral narrative was common to medication events. Here, self-directed behavior was stronger than the managers’policing:“I didn’t even know it.” Medication management had regulated both the manager’s and the consumer’s time; thus “high functioning”was a situated interpretation that coded consumer behavior as self-reliant and, in turn, produced decreased monitoring on the part of the manager.

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CASE 3 : cm1 :

Did they [van drivers] get him in for the shot? cm2 : He usually runs about a day or two late. cm1 : I wonder if we could close him and reopen later if necessary? Is everyone okay with Teddy going to meds only? Mom is payee. He does everything on his own. He hasn’t been in the hospital for two years. He sets up his own goals. He changes his goals when he wants. With the goals he sets, he does not need case manager assistance. cm3 : He qualiﬁes for meds only status.

A similar effect interpretation was made in Case 3, though it went one step further than the previous case. It linked self-reliance to termination. This consumer was so independent (“He sets up his own goals”) that the team hoped to end case management by changing his status to “meds only.” Although during my intensive study of one team “meds only” transfers were rare, it was the most desired effect of case management. Moreover, a “high functioning” consumer was a candidate for a “meds only” status. The latter, however, was tenuous: “we could close him and reopen later if necessary.” I do not interpret this as case managers seeing deﬁcits by acknowledging the possibility of failure. It is, instead, a recognition that consumers rarely or straightforwardly moved from medication noncompliance to total self-reliance. Case management reality was more like an ongoing roller coaster ride. CASE 4 :

I am picking him up today for his shot. He is doing ﬁne. He doesn’t need much help with meds. CASE 5:

She stood me up on Friday. We already had rescheduled once. As usual she was tentative about the appointment so I called before leaving and she did not answer. She is taking her meds. She reports doing ﬁne.

The case manager’s comments in Cases 4 and 5 were meant to update other team members regarding a consumer’s capacity for self-monitoring. “He is

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doing ﬁne” correlates to managers’ situated understanding that this consumer is “low need.” “Low need,” in this case, referred to injectable medication because shots limit the time case managers spend monitoring. Even though the consumer depended on a Prolixin shot, case managers concluded that he was “doing ﬁne” because “he doesn’t need much help” with medication compliance (again, it was coded in situated language as “low need.”). The consumer in case 4 was also considered “low functioning” because injectable drugs were not valorized as much as oral medications. Oral medications were used when acceptable consumer compliance was anticipated, i.e., high functioning. Consequently shots signiﬁed dependency and erratic self-compliance, thus the situated language of “low functioning.” Case 5 shows how medication compliance became the litmus test for the case managers’ estimation of consumers’ self-reliance; despite the fact that she missed appointments, “she is taking her meds” meant that she is sufﬁciently self-monitoring to be “doing ﬁne.” The manager did not interpret missed appointments as meaningful because she assumed that medication produced a “doing ﬁne” outcome. These effect interpretations show that case managers handily used neurobiology as a shorthand for understanding clients’ capacity. In contrast, in Cases 6 and 7, managers believed “doing ﬁne” was associated with not taking medication or with decreased dosages. CASE 6 : cm1:

He wanted to go out Friday, so I took advantage of this and we went to Denny’s. He is doing ﬁne. He talked about his taking Prolixin. He talked so loud that I think we lost some of the other customers. It was kind of comical. He talked about going back on Prolixin if he gets real nutty. cm2: Nutty! Is that what he calls it? Does he recognize when he goes nutty? cm1: I think so. CASE 7:

Doing very well once his meds were decreased. He wants to take classes. He reports that he sleeps too much. He wants to decrease to 2 mg a day. His symptoms seem pretty much gone.

Managers constantly read and coded consumer actions, feelings, and thoughts (i.e., “symptoms”) in order to draw conclusions about the medication’s power to produce self-directed behavior.

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And, ﬁnally, Case 8 shows the complex relations between money, medication, and manners. These life domains are linked by a careful weighing of the consumer’s self-initiative, self-responsibility, and self-understanding. CASE 8 : cm1 :

We need to make a decision. His apartment looks awful. Trash is everywhere and he spills coffee everywhere. I don’t know if he gets it. cm2 : We are using $200 a month of our ﬂexible money to subsidize his apartment living. I don’t have a problem with $100 a month. I would like to write him a letter. cm3 : I wonder if it is time to sit down with him and talk about this. I think we could tell him we would not subsidize a substandard apartment. He is never going to pursue working a little if we do not cut him off. cm2 : What about meds? Did he do his labs? cm1 : I think he did, but I don’t know for sure. He likes Clozaril but if he isn’t going to follow the protocol, then maybe we should change it. cm3 : Maybe we should have a team meeting at his apartment. There are so many issues. Meds, money, and housekeeping—there are at least three issues. Let’s talk to him, but separate the times and the issues.

With the statement, “We need to make a decision” the case manager acknowledged that the consumer’s housekeeping was below the team’s standards, which was especially irksome because the team subsidized his rent. A quid pro quo was expected: we ﬁnance your apartment, and in return we expect it to be clean enough to avoid eviction (the case study, chapter 6, shows that eviction was not avoided). In this instance, no effect interpretation linked medication compliance with wellness. Rather, unpredictable adherence was evidence of the consumer’s lack of understanding (“I don’t know if he gets it”). The consumer did not “get” that case managers wanted him to see a relationship between compliance and “doing ﬁne.” In the query, “did he do his labs,” managers commented on self-reliance. Intervention was considered when it was suspected that the consumer had not followed instructions; that is, Clozaril required weekly laboratory analysis to rule out serious side effects. Thus, when blood was not drawn for two weeks, Clozaril should be terminated. But before termination was considered, the team would “do for him”— change in medications—to prevent medication noncompliance. In Case 8, the team feared relapse and hospitalization.

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CASE 9 : cm:

He had put one of his mattresses outside, and it got wet from the snow and rain. It was ruined. I asked him, “Why didn’t you tell us? We could have found a home for it [the mattress].” It didn’t cross my mind what might happen next. After I left, he went to the trash bin, got the wet mattress, and put it back on his bed. It was soaking wet! He is having a difﬁcult time keeping the place clean. I chatted with him about his personal hygiene because he is getting a little stinky. In the way he was describing his routine, I do not think he is taking a shower. He told me that he doesn’t want to take a shower because of the mirror in the bathroom. He may be getting paranoid. He’s so high need and so low functioning at times. Well, his shot is due soon.

It is irrational to place a wet, ruined, and foul-smelling mattress on a dry bed; this was aptly read as a sign of disorganized thinking. A “high need” and “low functioning” consumer received help to clean, shop, pay bills, do laundry, and get medications. For team members this consumer was sometimes unable to understand or “get it.” The bathroom mirror caused in this consumer paranoia, which prevented him from taking showers. The desired effect was captured in a typical case manager oral narrative,“his shot is due.” She hoped that an antipsychotic injection would reduce the consumer’s disorganized thinking—irrational thinking and paranoia—and lead to a “cleaner body and apartment.” Case managers often condensed complex observations such as these into a single medication interpretation. Here it was hoped that with the injection the consumer would take showers, clean his apartment, and demonstrate clear thinking. Body odor and “irrational” action were among the several common signs pointing toward failure of the medication. Increased manic behavior, pressured speech, and exaggerated displays of anxiety made case managers wonder, “are you taking meds” or “perhaps there isn’t enough in his system.” Are the medications working or “kicking in?” For example: CASE 10 cm1 :

On Tuesday I did groceries and Thursday laundry. I saw him on the porch yesterday yelling and screaming and no one was there. His meds may be going the way of the stool.

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cm2 :

He is doing very, very poorly, extremely symptomatic. He takes Lithium, but I am not sure it’s working. cm3 : I was there two times Monday. He met me at the door with a ﬂashlight and an Ouija board. He was refusing to take the meds he had at home because he felt they had been tampered with. I called in some ER [emergency] meds. I’m trying to avoid hospitalization. I want him to take oral Haldol. cm1 : He always ends up in the hospital in March. cm2 : Maybe it’s some kind of cycle. In the past, we thought it was the result of stopping his meds, but not this year. I offered him an attendant care worker, but he turned it down. Yesterday I asked him if he wanted to see the psychiatrist. He said, “yes, I want to ask him if he knows of a good doctor.” [laughter] cm3 : Well, he still has his wit. Continue monitoring. Hopefully his Haldol will kick in.

To demonstrate how observations accumulated from many sites, my next illustration is a composite of events that occurred over several weeks and shows how effect interpretations change relative to consumer behavior. A resident of Residential House, Clara, was “decompensating,”“paranoid,”“unmotivated,” and was “isolating herself in her room.” The case managers found little evidence of self-directed behavior and after many attempts their efforts to engage Clara failed. After nearly eight weeks of steady decline the team was exasperated. Perhaps a medication change was necessary: “Clara is isolating herself in her room. Hygiene is bad and she doesn’t look good. I guess the doctor wants to change her meds. I don’t think she can make it until Thursday.” At the clinical meeting the psychiatrist began with a report on his med check with Clara. “Replying to my inquiries, Clara said to me, you’re the smart guy, you ﬁgure it out. The session did not go well, it was very negative.” He summed up, “you know, I thought I was making a change in her meds when I reduced them, but no change occurred.” The psychiatrist and the team wrestled with possible interventions. Although not desirable, hospitalization seemed inevitable. The psychiatrist said: I am not sure short-term hospitalization will work with her. I think her eating disorder is a symptom of psychosis. I know our mission is not to put someone in long-term hospitals, but it is also our mission to meet the client’s need. I feel depressed when I see her. She is ill and needs treatment.

While involuntary hospitalization was considered, no one reported the “dangerous behaviors” necessary for committal. A new drug regimen seemed

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the only hope. Then a manager asked: “Do you think injectable Prolixin would work?” The psychiatrist thought it might, but “it would take awhile to have an effect.” He was hesitant. Recalling that Clara experienced severe tardive dyskinesia as a result of past regimens, he sent for the medical chart. We all waited patiently while the chart was reviewed. To his surprise, she never was “above a level three on the scale” that measures the severity of tardive dyskinesia. “Oh,” he discovered, “I remember what it was. When she came to us, we tried Depakote, and she experienced hair loss.” The psychiatrist traced Clara’s route to CSS to discover that She has been going at this [schizophrenia] since age sixteen. She was ﬁrst hospitalized in northern California. The chart notes that when we got her she looked real good. She was in a battle over the custody of her child and we decreased her Prolixin. It seemed to work for her. She was able to tolerate the side effects with Cogentin. In 1995 she was still on 10 mg of Prolixin. Then, in 1996, we switched to Risperdal, and it was downhill from there. If she is willing to go back on Prolixin, it is worth a try.

After a short voluntary hospitalization and a change to injectable Prolixin, Clara was released to Residential House. She steadily improved. “Attendant Care Workers report she does not stay in her room and that she increasingly wants to interact with others.”“Yes, I know, I saw her yesterday and she wants to make plans to move.” Managers noted that she was now “following through with goals” and “clear about what she wants.” “On Prolixin,” one manager reported, she is “very high functioning and low need.” This composite illustrates dramatically how strengths management and situated language combine in written texts and oral narratives to do the work of medication management. For several weeks I had no opportunity to see the change discussed in team meetings. Then I visited Clara at a congregate-care facility together with a case manager. I was curious to see the change. I hardly recognized her. She was charming, forthcoming, inquisitive, and thoughtful. The terms used to describe her illness before Prolixin—“unmotivated,” “paranoid,” “hostile,” and “delusional”—were now inappropriate. She remembered my previous visits and felt compelled to apologize: “I am a little embarrassed because I was so crazy before. I can’t even remember all that I did.” On the day of my visit transportation was the central management concern; Clara was taken to CSS for a Prolixin shot. By concatenating these observations of Clara over several weeks, I understood why the radical change in her behavior was attributed to Prolixin. Case managers’ interpretations (i.e., “doing ﬁne”) focused on the

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concrete effects drugs appear to produce. Moreover, their observations often corroborated and afﬁrmed psychopharmacology and the medical model. In many cases desirable effects were barely detectable and disorganized thinking persisted. But for Clara the contrary held true; she had improved. And although her “reasonable” state may not have lasted, the fact that Prolixin was connected to improvement (self-directed behaviors) provided sufﬁcient concrete evidence. With the enormous indeterminacy associated with knowing what drugs actually do, the slightest evidence of their positive effect was enough to assure case managers’ support of a regimen. I was not concerned with the accuracy of the managers’ interpretations. Instead I sought to document their effect interpretations and show how these were mediated by the disciplinary knowledge of biopsychiatry and the managers’ situated knowledge. To a manager, the slightest change in walk, tone of voice, and daily routine could signify the efﬁcacy of medication. In sum the managers’ situated contribution to the medication division of labor was the knowledge of the particular: I think it’s very individualized. There are folks that cannot take their meds and do quite well for some time and I might not even notice that they’re not taking their meds. But then, sure there are things that you learn over the time that you have worked with someone that if certain things are coming up, or if they’re saying certain things, or acting a certain way, then chances are they’re not taking their meds. It’s not always cut and dry.

MEDICATION IN THE BODY

Below I examine managers’ perception of drug effects. What do medications do in the body? My queries suggest that case managers did not utilize a sophisticated medical language or imagery to describe the bodily work of medicines. They were more interested in desired effects. In particular, it was “clear thinking” that was most hoped for. Managers saw themselves as auxiliary memory for consumers; they brought the past into the present by recalling for the consumer, “without medications you may very well end up in the hospital.” I begin with how they perceived medicinal effects on the body: cm1:

In years of seeing mentally ill people and from experience of taking medication myself for high blood pressure, I think medicine really works on the brain, chemicals in the brain, slowing down all patterns, helping to make patterns a little clearer. I do believe that medicine . . . is doing something in there.

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cm2 :

I don’t see medication as ever getting rid of symptoms of mental illness. I see remission being created primarily because of the medication, but what it’s doing is creating a buffer. My idea is that some of those symptoms stay active . . . and the medication is creating a buffer or a wall. This sounds like a fantasy, but I see it as the medication creates a wall and blocks voices and symptoms and hallucinations from coming through. I think the individual can still hear voices, but they’re not so bad because there is a buffer between the symptoms and what actually comes out. I don’t think any of the symptoms completely go away. cm3 : Medicine is a replacement for something that is naturally lost. If a person has a broken leg, medicine can help heal it. It may not be the same leg, but it will be better. cm4 : It [medicine] mixes with the chemicals in your brain and sets off the endorphins to do something, something. I don’t know. cm5 : Well, actually they [medicines] are supposed to work on the liver . . . in my mind, it goes to the liver stream, which absorbs it, and its supposed to help clear their thoughts or stabilize their mood. A lot of times when clients have a lot of questions about medications, I refer them to the nurse. cm6 : By the things I’ve heard when listening to doctors is that some of them [medicine] inhibit certain, I think its called dopamine. Things like that. As far as I know, they affect the way the brain works in some capacity. I’m not real up on meds to tell you the truth. cm7 : Reduce the uptake of neurotransmitters. They reduce the total number of brain pathways that are employed at any given moment so that thought can be more organized and coalesce into sensibility. Seize up the muscles, damage the liver, medications are a trade-off. Many people honestly ﬁnd the medications worse than the disease. cm8 : I think any medication, I don’t care if it is aspirin or a psychotropic, it helps the natural resources of the body cope with whatever it’s dealing with. cm9 : Hopefully it’s messing with the brain to get it to do what it is supposed to do.

Most apologized and some were embarrassed by their lack of technical, scientiﬁc, and pharmacological knowledge. Many qualiﬁed their answers with an honest “I don’t know.” It was in the realm of desired effects that common perceptions were shared. I then asked, “What effects do you hope the drugs have?” cm1 :

Medication can decrease how often symptoms occur and the intensity of the symptoms: compulsive behavior, hearing voices, and depression. cm2 : Probably more than anything it gets their reasoning power and their insight good enough to where they can work on some of the issues that would make them happier.

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cm3 :

The ﬁrst thing is for thought processes to clear up so they can actually concentrate. cm4 : I want it [medicine] to help them think clearly and be less fearful. If they are depressed and they can’t function normally, I want it to elevate their mood. cm5 : . . . decrease the voices, decrease the paranoia, and decrease some of the fears. cm6 : Sometimes the term, it’s called “making them clearer” is used. I think sometimes the meds can help with decision making, it clears up their heads . . . takes away some of the voices . . . so that they are able to concentrate more on doing things. cm7 : I have a client right now who hears voices all the time. The voices tell him not to go to work. I thought at ﬁrst, well, maybe he just doesn’t want to go to work. But he would get up, get dressed and be on his way to work and that’s when the voices would tell him that he would die if he went to work. So, for that particular client, I would hope that there is a medication that would be able to alleviate the voices. cm8 : I hope it makes them think, though realistically it may not be the way I think, more able to concentrate on what they’re doing, what they want to do.

The perception that “meds make things clear” was accompanied by an assumption that I found summarized in one statement: medicine “has enabled them to suppress the symptoms” (see Rhodes [1984] for a similar discussion). Managers believed that medication enabled. As a result, the consumer could, perhaps, concentrate and know more about “what they want to do.” Medication enabled strengths management to work on consumers’ wants and goals. With medicines case managers hoped that consumers would be given the preconditions—clear thinking—for action. Not just any action, however, but those that would contribute to satisfactory “community” living. Medications, for example, helped in removing thoughts (“voices”) that prevented remembering the date and time of an appointment with a social security ofﬁcial. Working in the medication domain would not be so difﬁcult if (1) the drugs always produced the desired effect, and (2) the consumers understood, with the same understanding of practitioners, the relationship between medication and effects. Unfortunately, neither of these circumstances was always given. They were, in fact, true only part of the time, and no case manager could predict for his or her caseload how drugs would work. Thus, medication management required a situated knowledge of consumer particulars. Regarding the second possibility—connecting drugs with improvement— case managers tried to be the consumers’ memory. The idea that event B followed from A required a sense of time and recollection. To know that time had passed required memory. And interestingly enough, concentration and

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increased memory were often the medication effects the case managers hoped for most. Managers, in lieu of a medication miracle, acted as auxiliary memories, recalling for consumers the reasons for taking medications: cm1 :

They stop taking their meds, their symptoms become so increased that they cannot think straight. They hallucinate. Become delusional. We put them in the hospital. They get medication whether they like it or not. They start to think clearly. They get out of the hospital and start to work. They start to make friends and say, “heck, I’m doing so good, I don’t need these meds.” And for the life of me, I don’t understand that. They cannot remember what it was like when they were off the medications. cm2 : I think you have to use past examples in their life to make them think, “Oh yeah, she’s right. If I stay on my medication, take it daily I won’t be like I was a year ago.” . . . I think you have to bring someone into their past. “Look, remember what happened a year ago when you attacked the police ofﬁcer, they threw your buns in jail.” It’s trying to get them to remember that this is what will happen if you do this [not take medication]. cm3 : I often say, “Remember how well you were doing? Remember how the voices weren’t bothering you as much?” I draw back on that.

In the life domain of medication case managers steered a delicate course between self-directed and professional monitoring of medications. Because deinstitutionalization required that prescriptions spread throughout the community, the case manager became the key ﬁgure in monitoring their effects. In constantly performing effect interpretations, they worked at making the disciplinary knowledge/power of medicine effective by bringing to it the situated knowledge of the particular. “It goes back to knowing your client,” said one manager, “I know if the medicine doesn’t work with this one client the minute he starts talking about bizarre things at work.”

C HAPTER 9

The Helper Habitus: Situated Knowledge and Case Management The power to analyze a human situation closely, as distinguished from the old method of falling back upon few general classiﬁcations, grows with the consciousness of power to get things done. —Mary Richmond, Social Diagnosis.

F

or Mary Richmond subjective classiﬁcations were among the practices to be purged from the emerging profession of social work. Yet they remained and are today embedded in the situated knowledge and practice of case managers. Richmond, central to the project of developing social work’s disciplinary knowledge in the early part of the last century, was Roy Lubove’s (1965) ideal “Professional Altruist.” She was not alone, however. Others among the early architects of social work sought to bury the intuitive knowledge and practice of the “friendly visitor” beneath the language of positivist science. By way of the casework method, most sought to replace the “subjective opinions” of volunteers with objectively trained observers. In this chapter I argue that case managers embodied “friendly helping” in their situated practice. In contrast to Richmond, I do not oppose “friendly helping” to scientiﬁc case management. Nor will I extricate once again the “old method” of a “few general classiﬁcations” from the new, modern, scientiﬁc one. Instead, I argue here that situated knowledge often taps the helping, enabling, teaching, parenting, and assisting sensibilities found in the life experience of case managers. I have argued that case managers’ situated practice cannot be explained by reducing it to a simple misapplication of strengths management or to a lack of scientiﬁc rigor. Some situated practices, moreover, performed work that strengths management could not do. And because I have argued that the situated was not reducible to the disciplinary, I face two related questions: (1) why did I not ﬁnd a different situated language for every case manager, and

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(2) for case managers with no common education (except for strengths training), where did the situated come from? In chapters 5, 6, 7, and 8, I have shown how case managers deployed situated knowledge. From my ethnographic data, I constructed a semistructured, open-ended interview (see appendix C) and queried managers about their use of situated language. I was curious about how managers perceived the work of situated knowledge, and I wanted to validate whether or not my coding was consistent with their perceptions. I coded their responses (e.g., responsibility, choice, teaching, linear thinking, and dependency), and then, using a single voice to represent a general theme, I constructed the following narrative and interpretations. I use the interview data to argue that situated practice aids in the allocation of case management time. My aim is ﬁrst to understand the perceptions and meanings of managers’ situated language, and second, to use Pierre Bourdieu’s concept of habitus to understand situated practice. Here, I present the results of this second methodological step and in the last section of this chapter, I use interview and additional socioeconomic data to argue that case managers transpose parenting and teaching ideals to the relationship between manager and consumer.

“DOING FOR” AND “DOING WITH” 1

Case managers were always weighing when and how to “do for” and when to “do with” consumers. Meds, money, and manners necessarily create the conditions for intimate helper/recipient relations: There are times when consumers have a tendency to look at you as their personal servant. At times, you just have to say “Whoa, stop! I am here to advocate for you. I don’t do your errands for you. You are capable of doing everything you’re asking me to do. I will do them with you, but I won’t do them for you.”

Too much “doing for” was thought to produce the unhealthy effect of a dependent person: The ﬁrst time you do something for them that they can do themselves, you build a dependent relation. Why should I call SRS (Social Rehabilitation Service) for them, when they should be able to call themselves? You must be on

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guard if they are the type that take advantage of you. Some, however, are eager to do for themselves.

Assessing responsible action and averting dependency were, in part, the desired effects of applying situated concepts; at the same time, they alerted the case manager to be careful of the boundary between practitioner and consumer. Situated language reminds managers that saying “no” is permissible. And between consumers and workers there are perceived boundaries, not always sharply drawn, but when crossed, they could produce the “dependent” or “rescued” consumer: “Doing for” is doing all the work and I feel it’s how a lot of case managers get burned out. . . . Let them [consumers] do some work. They have two legs, they have two hands, they can hear, and they can speak. They are very, very able and know what is going on. And, you know, I’ll be honest with you, they can play the system, they know who they can get to and who they can’t. And, I just think that when you say “do for” or “do with,” it’s like okay, you need to control your boundaries.

Deploying a “doing for” action was appropriate when deciding to catch someone before a crash: When it comes to being a safety net for consumers, we are going to have that feeling of wanting to help. Oh, I’ll be there for you, and I’ll do this for you. Doing for consumers can show them that we care.

Some workers saw “doing for” as an act of charity: I love the idea of genuine acts of kindness. Doing for someone is a genuine act of kindness to show them that you just want to help because you appreciate who they are as a person, instead of as a consumer of service. I don’t believe in doing for a person as a rule of thumb. I would basically go with what works.

Managers used teaching analogies and metaphors. Through “doing with,” consumers learned the skills and manners to live comfortably in suburbia. Conceptually, by “doing for” and “doing with,” case managers modeled responsible behavior in the hopes that consumers would learn by doing: You give a person a ﬁsh, he’ll eat one day, but if you teach that person how to ﬁsh, he’s going to eat for the rest of his life. I’m a big promoter of the second.

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For example, I like very much to have enough time to go with someone to pay bills. From the moment that we pull up to a bank, I want that person to experience everything, including opening the bank door, going up to the teller, and asking for money orders. Then, take the money order, go sit down, take the bills that need to be paid, and go at it. Have them write out the money order themselves. Sometimes they need reminders to put their account numbers on the money orders. Then, fold that money order, put it in the envelope, lick it, put the stamp on it, and get back in the car. We ride to the post ofﬁce, and then mail it.

I asked why it was so important to “do with.” Because you and I pay bills everyday, and if I die tomorrow, then he [the consumer] would know how to pay his bills. I did that with him. I sat with him. I sat next to him. There is no point for that person to ride in the car with me and have me go into the bank for them, buy the money order, come back to the car, ﬁll out the money order, while they sit in the car observing me. If he doesn’t do that himself with my assistance, I’ve just wasted an hour, an hour and a half, of my time.

Practitioners saw progressive movement from “doing for” to “doing with.” These situated concepts organized in their minds the importance of an intervention that produced independent behavior: cm1 :

Doing with, an example comes to mind from just a week ago. A woman who had been in the hospital for twenty years was at one of our group homes. I helped her with her breakfast dishes. I did a dish, and then I asked her to rinse it and put it in the tray. We worked together, we worked with her. And the idea that I have is that the next time I do it, she may take on more responsibility and fully learn the skill. cm2 : . . . it’s necessary to progress from doing for—because the person can’t or won’t competently perform—with an eye toward performing with, with a gradual introduction of performing with.

Case managers were always scanning their caseloads to determine who needed “doing for” and who needed “doing with.” Below (table 9.1) I excerpt from one manager’s weekly planner a day of work. Five home visits later— including trips to banks, grocery stores, convenience and discount stores, and round trips to and from CSS—she had not only met the scheduled obligations. She had also driven 112 miles through the snarled trafﬁc of High County’s suburban landscape. During these outings, she was “doing for”

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TABLE 9.1 A CASE MANAGER’S DAY

7:45 a.m. 9:00 a.m. 10:00 a.m. Noon

1:30 a.m.

2:30 a.m.

3:30 a.m. 4:15 a.m.

5:00 a.m.

HV (home visit) . Then, to CSS for corning lab, wbc (white blood cell). Dropped off at work. CSS team meeting. HV . Taken to food pantry, dropped off for groceries. Appointment at hospital for med check. Dropped off at apartment To CSS, picked up , who ate lunch at CSS and washed dishes for reps. We stopped at Q-trip to get pop. Dropped off at apartment. Back to CSS, picked up and dropped him off at apartment. He talked about wanting a job. Will refer to vocational case manager. Back to CSS, helped ﬁll out a Section 8 (HUD) form: a re-certiﬁcation process. Meet with Section 8 ofﬁcer, then off at RH (Residential House). dropped HV . Applied at job service. Phone credit check. SSDI veriﬁcation: $470 month. HV . To bank to pay bills: phone 41.73; KCPL 90.39; to post ofﬁce to mail bills. Then, a stop at Cigarette Outlet and Price Chopper (groceries). HV . Just a quick hello.

(providing transportation) and “doing with” (banking or shopping together). Case managers juggled these home visits daily, often assisting ﬁve to ten clients with various needs; they attended administrative and clinical meetings and did paperwork, all requiring serious time management. Managers had to learn to constantly anticipate: how much time will an event or task consume? Strengths training, however, does not prepare social workers to make difﬁcult decisions about time: Sometimes it’s easier to do things for the client because you can do them faster and you can, therefore, do more things that you have looming over your head. But “doing with” gives the consumer more ownership over whatever you’re doing, and its just a more natural thing; it is more of a teaching thing by demonstrating, or by helping. So yea, ideally we do everything with, but I don’t, I don’t always do that.

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Thus, “doing for” and “doing with” are situated concepts organizing case managers’ time. For me, sometimes it is a matter of convenience. I have a consumer that would prefer to go to the bank with me, withdraw the money, and then go to the grocery store. She is very suspicious of how her money is done, but she doesn’t really want to get involved in the actual transaction. So sometimes, instead of having to go all the way to the bank and then go all the way back to where the grocery store is, I will go to the bank and just hand her the money and say, “here is your grocery money.” Because sometimes when I do try to save myself steps, it is for me, like it doesn’t matter if I do it for them. She could do it with me, but I could use that time in a more constructive way with that person, rather than just being their errand runner, or whatever.

Managers were not alone in perceiving that “doing for” and “doing with” are about time. Administrators and supervisors also understood the work situated language performed. One said that “there’s so much time that goes into ‘doing for’ that there is not a whole lot of time to ‘do with.’ It’s a real blessing some days to hear case managers say, ‘God, I got to do this with my consumers. We did these things.”’ In sum, “doing for” and “doing with” were workhorse situated concepts pulling the case manager through experiences that are speciﬁc and contextual. In contrast, strengths textbooks do not prescribe what should be done about setting boundaries, teaching skills, modeling responsibility, preventing dependency, and showing occasional acts of kindness. And perhaps above all, situated knowledge answered the question: “do I have time today to ‘do with?’”

“LOW AND HIGH FUNCTIONING” AND “LOW AND HIGH NEED”

In disciplinary schemes of case management one expects conceptual coherence, and this is true for situated concepts as well: Low functioning and high functioning help you make decisions. Say, Natalie [case manager] is working with a client and she believes that she is high functioning. And, if I have an interview with this client and they’re telling me, “Well, I need this, I need this, I need this, but I can’t do it on my own,” I would remember what Natalie said and would think, how can I show this person how

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to do it on their own? Whereas if Natalie said this person is a low functioning person, I would be more apt to “do for them,” but have them with me so they could know how to do it in the future.

What does high and low functioning mean? What kind of work were these designations intended to do? Basically, these binary concepts act to establish types or categories. Low and high functioning correspond closely to the notion of low-need and high-need consumers, and by establishing a two-bytwo matrix, four possible types emerge: low need and high functioning, low need and low functioning, high need and high functioning, and high need and low functioning. No formal diagnostic tools produced this matrix or how consumers ﬁt into it. This was informal knowledge dependent on case managers’ perceptions. Below I ﬁrst examine what these terms meant to case managers, and then I show how they performed a function similar to that of “doing for” and “doing with.” For some, the low/high binary correlated with the consumer’s ability to self-identify needs and wants: A lot of times they [consumers] have hidden needs and wants, I don’t profess to know. Sometimes they know what they want. A client I had in here today comes in every Monday to ﬁll her med box and is very high functioning. She has held a competitive job and is director of a program. A few of them are high functioning and I think they know what they want. But some of the others, no, I don’t believe they really know what they want.

Yet, I asked, why does a low functioning person not know what he or she wants? They have been told what to do and how to do it for so many years because of their mental illness and lack of functioning in the community. If you are institutionalized, you are going to get up, take a shower, eat breakfast, go to an activity, eat lunch, do more activities, eat dinner, do another activity, and then go to bed. So when we [CSS] get them out here in the community, consumers ask themselves: “What the hell am I going to do?”“What am I supposed to do?” and “What am I supposed to eat?”

For one manager a low-need and high-functioning consumer was “an independent person who happens to have a mental illness,” and those consumers were “people who do not demand much from a manager’s time.” High

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functioning was equivalent to being “close to normal.” Low need and high functioning meant that consumers were independent enough to “meet most of their basic needs.” Low functioning, on the other hand, referred to someone who is “really, really incredibly ill and simply cannot do life tasks, so they need assistance.” In fact, a low functioning person was often a “high need” person. A high need and low functioning consumer would need a great deal of assistance with meeting their basic needs. Paying their bills, doing their shopping. They would need a lot of direction, assistance, and encouragement. They might need a lot of assistance with medication. They might need three med drops a day.

Although the categories low need and high functioning and high need and low functioning identiﬁed most consumers, case managers also used two others: high need and high functioning and low need and low functioning. The ﬁrst (high need and high functioning) included those individuals who accomplished most everyday tasks without assistance. Yet they needed help “getting a few resources in place.” And then once the resources were in place, they were no longer high need. A low functioning and low need person was someone who for various reasons made few demands on time. Some may need more (high need) but because of their low functioning, they make few demands (low need). Thus, they were low functioning and low need: I think Johnnie is high need and low functioning, but he only allows us to do the minimal, low need. You have to base it [the binary] on what they are willing to allow us to do, or what you are willing to take on, because they are the one who ultimately does the work. We want them to do things because of what they are likely to become, but if they don’t want it, well, that’s their choice.

It is clear that these binary situated concepts provided a great deal of practical ﬂexibility. Consumers slipped in and out of categories. Although I found consensus on managers’ perceptions of low need clients, regarding the decision to place someone in the high need category, I found differences. I asked one team of managers to rank consumers as low or high need. This exercise was possible because a continuous management team shares work with all of the very high need and low functioning consumers—I’m sure this is a learned strategy that prevents burnout. All case managers agreed that of eighty-one consumers thirty-nine were low need; in contrast, in only three cases did they reach consensus about high need. Four managers considered twenty-one

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consumers high need, while two scored the same consumers as low need. Concerning the remaining seventeen consumers, four managers thought the individuals were low need while the other two saw them as high need. Thus, on one team (in about half the cases) managers’ perceptions about low need were remarkably convergent. One explanation for this is that needs vary daily, weekly, and monthly, so a high-need person tends to slip in and out of categories more often than lowneed individuals. A case manager explained: In a meeting my team leader asked me: “how many high need people are on your case load?” Well, I just kind of said, it depends on the week. I mean there are certain persons that need more attention consistently over time and space. Everybody needs help sometime so I don’t necessarily think the categories mean much. There is a core group of people that I have that I will likely be working with until I quit. . . . It’s more about what is the task that we need to do this week and what are the things that are approaching.

Low-need consumers have more stable needs over time—transportation, for example. A high-need person, in contrast, in managers’ perceptions, has continuous needs, but they vary from one week to the next: one week it may be food, the next, rent, and the next, medications. It is hard to predict where a high-need consumer will fall on the scale, whereas a low-need person is predictable. And since case managers juggled dozens of appointments each week, predictability is necessary to their efﬁcient use of time. I argue that managers constructed a situated knowledge/power of consumer experience because strengths and CSS disciplinary knowledge require ongoing assessment. Managers were hired to assist and meet wants and needs. And even though the model provided the tools of the Strengths Assessment and Personal Plan, these only name wants and identify “who does what by when.” For practitioners, naming wants was only a halting ﬁrst step. Meeting needs was a task far more complicated than merely assessing desires. Practically, then, case managers developed a situated scheme to measure how much need, as helpers, they could meet. Situated concepts are in part about allocating management time; thus, a case manager assesses how much time is involved. Time, after all, is the case managers’ most cherished resource. And while these situated concepts may appear crude—they are certainly not objective measures—they accomplished an important piece of the daily work. No Kansas mental health policy required case managers to place consumers in a low or high need category. Nor was this a language that satisﬁed

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a Medicaid prerequisite. CSS does not mandate its use, and the idea ran counter to basic strengths training. Moreover, many managers were not particularly fond of the scheme. They often saw it used pejoratively: I see it [low need and low functioning] used sometimes in appropriate ways that are helpful and sometimes as a slam. Like, oh God, so and so is a low functioning and high need person. I think some people have said, “that person is low need, I’ll keep them on my caseload.” That kind of perspective to me is real irritating.

Another manager agreed: “I hate those terms to be honest with you. I think they are meaningful, but I think it points more toward the case manager.” Why were managers deploying a subjective classiﬁcation of their own making? I return again to time constraints. It was their way to “reason the need” for dispensing various amounts of management time. Together with other parts of the situated scheme (“doing for” and “doing with”), the low/high binary rationalized speciﬁc modes of assistance. Case managers would “do for” someone because he or she was low functioning; in contrast, they would more likely say no (set boundaries) to those they thought high functioning. Still, a consumer could be high functioning but have speciﬁc “high needs” because he or she has a regularly occurring contingent need (e.g., he or she knows how to grocery shop but lacks a mode of transportation). The needs of the mentally ill, like the needs of those not mentally ill, have hundreds of permutations. And given that mutual knowledge between a helper and recipient develops over time—about (managers’) ability to give, (managers’) ability to meet needs, (consumers’) ability to do, and (consumers’) felt need—meeting every new request unprejudiced was impractical. To expect unprejudiced judgments would be to ask both parties to deny the role history or time plays in forming our attitudes, determinations, and conclusions. Thus, the low/high situated binary classiﬁed consumers so that case management time was “rationally” distributed across a caseload. Like Shakespeare’s King Lear, we may wish to “reason not the need,” but it will remain, as with King Lear (Ignatief 1984), a mad wish because the CSS social ﬁeld demanded such rationalizations. In practice, needs must be met. When social assistance is arrayed along service continuums, need assessment necessarily follows. Managers’ situated concepts were performing the work that the CSS and strengths disciplinary knowledge required but could not deliver. Statements about the principles of helping—for example, strengths management’s emphasis upon realization of wants—failed to recognize that

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actual helping was bounded by time. Managers triaged wants that were inﬁnite and unbounded for the same reasons that emergency medicine triages patients: to prioritize the distribution of work time. My argument about the low/high classiﬁcation system is strengthened here by the case managers’ own understanding: cm1 :

. . . the lower functioning people consume more time, more energy. Well, low need is someone who I see once a month, twice a month, once every other month. A low-need person is someone who can manage their own money, can basically take their meds on their own, can get to their appointments on their own, but they just need some maintenance and support every now and then. And sometimes those people end up being transferred to meds only because they don’t need case manager services. A high-need person is someone who needs everything. You see them two to three times a week, they have problems managing their money, they have problems getting to the grocery store, so we provide that. cm3 : Basically, it [low and high functioning] has more to do with how much time is involved with serving them. cm4 : Low functioning is one that’s always seeking out their case manager—I need $5.00 today, I need this, I need that. Low need is one you very seldom see. They don’t seek you out. But for the lower functioning it seems like they have a higher need for comfort, even if they decide to buy a hamburger for lunch, they wonder: is it all right that I buy a hamburger? Your high-need person is here every day; they seek out their case manager every day, and sometimes it’s just imaginary because often the case manager will say, “What do you think?” And then they will go ahead and make the decision, but they need somebody to just bounce it off. cm2 :

These excerpts were remarkably similar across my interviews. The CSS director also acknowledged the work of the binary scheme: Oh, it helps them organize their time. It’s like this is where I place priorities. But I also think it causes some stress when we [administrators] talk about human potential and growth because, it’s like the case manager thinks, “yeah, we’ll do that, when there’s time.” And there will never be enough case management time. I know if we asked KU [University of Kansas, Strengths Training Assistance] to come and consult with us [thought trails off]; I mean, I was working with a small group of case managers and they kept saying,“You know, it’s [human potential and growth] all just academic ﬂuff.” “We’ve got work to do, we just need to do it.” “That’s [human potential and growth] just making it sound pretty.” And I think sometimes you do it [apply disciplinary knowl-

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edge] to make it sound pretty, so that people have a way to articulate a vision for what we do. I mean, it’s not just about deﬁning people in terms of functioning and need, that is not very humane, but I think all case managers do it.

“NATURAL CONSEQUENCE”

Much of situated case management would not make sense without the companion concept of natural consequence. The notion that effect B follows from A is a common-sense epistemology afﬁrmed by our experience. When my alarm clock goes off (A), I get out of bed (B). Asked if my getting out of bed was the natural consequence of the irritating buzzing of my alarm clock, I would readily say yes. Why? Common-sense epistemology says so. This logic applies particularly in teaching life skills. Waking and rising each morning is part of being self-directed. When consumers do not get out of bed, there are consequences: (1) they won’t take their medication, (2) they won’t keep appointments, (3) they won’t shop for groceries or pay bills, and (4) without social interaction, they won’t have a meaningful existence. In reminding consumers of these consequences, managers strove for one hoped-for effect: linear (causal) thinking. In sum, if a consumer perceives that medication does not produce helpful effects, then the case manager may have to do that thinking “for” him or her. In utilizing natural consequences, managers focused on the power of choice: I ﬁnd that people in general respond well to illustrations. I did as a kid. If someone doesn’t understand, for example, that if he does [illegal] drugs, the police may come to his door. There’s a natural process in life. I’ll use an example. If you choose to put your hand in a ﬁre, regardless of whether or not you want it to burn, it doesn’t make any difference. It’s going to burn. I don’t care if you say, “No, it won’t.” Whatever reason you might give, that hand is going to burn and that is a natural consequence to a choice you made to put that hand in the ﬁre. I ﬁnd that’s part of the teaching role CSS pays me to do. I can’t watch someone twenty-four hours a day. My job though is to explain to the consumer that if you make certain choices in life, there are going to be natural consequences that follow.

Deciding to allow a natural consequence to unfold was about learning failure and gaining insight:

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To me it basically is don’t rob the human being of failures. I mean I have failures so why shouldn’t some of my folks that I work with; otherwise, I really feel like they get robbed of something in life. The beneﬁt would hopefully be that they would gain some insight. I just don’t think you can rob somebody of that. I mean it’s just like a parent, at a certain point you have to let go and let kids make mistakes.

Some perceived the use of natural consequences as a necessary tool for teaching responsibility: If we [managers] wrote bad checks, what would happen to us? I mean, we would have to be accountable for that. What we mean by the claim [natural consequences], is to make consumers feel natural consequences and not always be rescued. There are repercussions out there if you break rules.

To rescue someone was contrary to the idea of natural consequences: Natural consequences to me are a chain of events. We can’t really rescue anybody. There are choices that people make, and there are reactions to add to choices, and it is just a chain reaction. Maybe we’ve tried different things and a behavior still continues and you know we’ve done this, tried this, everything; and then sooner or later, natural consequences need to happen. If we’ve done all we feel that we can, and I don’t want to say natural consequences are necessarily the last choice that we have, but if behavior that is not very appropriate continues to happen and it is against the rules, then we have little choice.

The “natural” in natural consequences was about learning the art of linear thinking, the power of choice, and “natural” also identiﬁed the party initiating the action: Natural consequences mean that you accept whatever comes of a particular behavior. You know, if I make a decision on a behavior or whatever I choose, what comes after is a natural step. For example, if I choose not to eat, I’m going to get sick. If I choose not to take my medications, I’m going to probably have symptoms. But if you choose not to take your medications and I choose to bring you to a med check, then that is not a natural step. I made that step, not the consumer; I, as the case manager, made the decision.

In other words, it is not natural if the case manager “does for” the consumer.

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A few case managers thought the use of natural consequences was lacking at CSS; thus, there was too much “rescuing.” Others believed natural consequences were sometimes used punitively. This attests to the strategic, personal, and contingent aspects of situated knowledge. Answers to my queries about natural consequences were often prefaced with “it depends.” No hard and fast rules applied. There was consensus, however, on their use being intended to teach a rule of life: choices have personal and felt effects.

“GET IT”

In my ethnography I observed that managers often thought that consumers “don’t get it.” I learned more about the use of this situated term and its meaning in examining its relationship to natural consequences. Natural consequences should not be deployed when workers reasoned that consumers’ illness caused their need. After so many attempts at cleaning Robert’s apartment, it was thought, “he doesn’t get it.” Doubting someone’s comprehension (“get it”) was a situated concept that referred to understanding cause and effect. Through practice experience managers were often led to believe that some consumers do not see relationships linearly; for example: I have one consumer that is like, she just doesn’t understand. She thinks people just call the police on her and take her off to the hospital. She can’t remember and she gets really manic—in people’s faces and really scary out in the community—when she stops taking her meds. We can tell her and tell her, but she just doesn’t get it that we don’t just call the police on her. So, I mean, I think truly some people just don’t get it. I think that is part of their illness.

Perceptions that consumers “don’t get it” underscored managers’ decisions to act as a safety net. And in situations where consumers were unable to think rationally it was considered appropriate to rescue them. “I don’t believe in the idea of natural consequence for someone who is experiencing a lot of symptoms of an illness.” In cases where situated knowledge assesses “don’t get it,” managers will then “do for.” Situated concepts are coherently related; one by one each concept provides situated answers to work-generated questions. And it is here, at the juncture of acknowledging that some consumers “don’t get it” and the apparent reason, illness, that my research reveals the presence of situated knowledge.

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Strengths case management does not provide social workers with assessment knowledge and tools sufﬁcient to address some very difﬁcult questions. First, when case managers determined that a consumer “doesn’t get it,” how did they decide to “do for?” Second, when did they let natural consequences unfold? Third, did they do so based on their perception of the consumer’s illness? And if so, how did they know that the consumer’s behavior was either (or both) a product of illness or a product of pychodynamic factors and personality? Case managers were quick to answer: “I often don’t know.” Donald Schön (1983) calls the ground between theory and professional practice a swamp. Identifying either illness or the personality as causing mental difﬁculties is a deep and messy swamp for managers: I have heard case managers say, “oh, that’s just his illness, he’s playing with his illness,” you know,“he does it all the time.” And sometimes I wonder, well, how do you know if he is actually playing the game with you? It could be something really severe, or he could just be upset. How do you know?

“It’s a thin line, sometimes you don’t know.” “Sometimes, you just take a guess; it’s a big guess.” These were typical remarks. I found these doubtful answers to be honest responses to practical demands. And in the case managers’ search for answers, I see the reason why situated knowledge arises. I pushed for clariﬁcation: “Okay, you often don’t know, but you still have to make decisions, the issue is there, and it won’t go away; what do you do?” You have to use good judgment and common sense. Most of this job, to me, had nothing to do with training. It did some. Most of this job had to do with the desire that I have to work with people and help them have a better life. And most of that has to do with exercising good judgment. You spend time with them and you get to know them. You develop a friendship, and we get to the place where there is trust. It goes back to putting your hand in a ﬁre. Do you know how many times it took my children to ﬁgure it out? I got three kids. At the age of three or four, they all wanted a drink from my coffee cup. I kept saying, “it’s hot, it’s hot,” but all three of them had to ﬁnd out for themselves what hot meant. For two of them, sticking their ﬁngers into the cup for two seconds was enough. They knew what hot meant and they wanted no part of it. For the other one, it took ﬁfty times. He would stick his ﬁnger in the cup, burn it, and then he would cry. The very next day he did it again. I don’t know why! I remember thinking, all these kids have the same parents. I’m bringing up my children the same way. I love all three of them the same, yet for two it took one

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time, and the other ﬁfty. Maybe my method was different, I thought. And with the clients it is the same. I had to ﬁgure out a different way, or maybe through experience, no matter what you do sometimes, it’s going to take a certain amount of experience.

Yet an important part of practical epistemology would be lost if I failed to point out that case managers reported that identifying illness or “stubbornness” as causal was also based upon (1) “knowing my client,” (2) “having a good relationship with my client,” and (3) “spending time with my client.” Managers acted to do “for them” or experience consequences “with them” by pulling out of the theory/practice swamp a consumer’s particularity. Although the situated language was ordinary, what was accomplished with it was often extraordinary. In sum, unquestionably, case managers used trial and error. Yet was it random? Was it just a guess? There was much at stake for the consumer in the manager’s use of situated knowledge. To answer this question I introduce the concept of habitus. This sheds light on the question of where the helping language derives from.

HELPER HABITUS

Social work projects like CSS need workers with altruistic sensibilities. I call this sensibility the helper habitus: a common and everyday embodied understanding and disposition to help or assist. Twentieth-century United States— its politics, market economy, and culture—has produced a speciﬁc kind of helping habitus; other cultures and historical moments produce different ones. Because altruism is so commonplace, the habitus appeared to Roy Lubove (in The Professional Altruist, 1965) as “natural.” Two core features of the habitus guided case managers’ situated practice: (1) “rational choice” as a means to assess and distinguish independent from dependent behavior, and (2) the use of general classiﬁcation schemes to hierarchically deﬁne needs. Situated language (e.g.,“doing for,”“doing with,”“natural consequences”) assigns responsibility to consumers for actions and encourages the creation of rational subjects. The United States (capitalist) social formation is one heavily steeped in and committed to the notion of independence through self-improvement—in Pierre Bourdieu’s terms, the constant addition of cultural capital. It comes as no surprise to me, then, that social workers bring self-improvement schemes into various helping contexts,

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CSS being one among many. For example, newspapers across the country are brimming with workfare testimonies like the one from Carlous Aldridge: “I had become dependent,” said Ms. Aldridge, a 29-year-old single mother. “Now I look forward to getting up every day and being independent, being able to pay my bills and being able to do what we want to as a family.” (The Dallas Morning News, March 27, 1998, 36A)

Carlous made the news because she was a new graduate of a public and private job skills training course. Identiﬁed as a “single mother” by the reporter, as if such a being might be naturally dependent, Carlous negatively deﬁned dependency as (1) not paying bills, (2) not getting up every day, and (3) not getting what she (her family) wants. Ms. Aldridge’s deﬁnition is strikingly similar to the case managers’ perceptions of consumers’ dependency. The similarity between “welfare dependency” and mental illness dependency is not the product of chance. Western societies are inextricably bound to schemes of self-improvement and are generally suspicious of people who are not socially mobile. For social welfare projects, the end product of selfimprovement is ideally the independent and self-directed person. As a society we valorize change, movement, and “personal” growth.2 I have used socioeconomic and demographic data to argue that managers do not require textbook knowledge to perceive that consumers’ lives are arrayed along a selfimprovement continuum.

SOCIOECONOMIC STATUS

Compared with all other CSS workers, case managers were in the sociodemographic middle (see table 9.2). Their median income ($34,382) placed them in the middle of the overall CSS salary range. Although they were more educated than most employees, case managers lacked a master’s degree, which positioned them at the middle of the educational ladder. Even their age, coincidentally, deﬁned a midrange. As a summary, this demographic proﬁle is not an absolute measure of a case manager’s socioeconomic status, but I do think it signiﬁcantly contributes to a particular helper habitus. By occupying the middle, case managers looked below to see the effects of less education, experience, and related salary gradations. At the same time, for those eager, able, and willing to set and act on goals of higher education, the socioeconomics of CSS supervisory, administrative, and nursing positions (N = 17) pointed upward to higher incomes and prestige.

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TABLE 9.2 CSS EMPLOYEE DEMOGRAPHICS

Age Gender Salary Education

Years of CSS experience

CASE M ANAGERS

ALL EMPLOYEES

ALL EMPLOYEES

N = 34

N = 97

R ANGE

median, 36 11 male, 23 female median, $34,382 5 have more than 2 years of college; 29 have bachelor’s degree median, 5

median, 38 34 male, 63 female median, $33,072 45 have 2 years of college or less; 33 have a bachelor’s, 17 have master’s degree median, 4

21 to 62 $17,000 to $66,000 High school to master’s plus.

1 to 26

Even if they were not particularly goal-oriented, at the very least their middle position permitted them to imagine the prospect of upward mobility. And I argue this sense of mobility was crucial to their helper habitus; when case managers encouraged consumers to believe in progress and goal-oriented achievement, they were speaking from their life experience and from their class position. Ethnicity, gender, and sexual orientation also inﬂuenced their helper habitus. Seven of the thirty-four case managers (20.5%) were from minority backgrounds, ﬁve times the percentage of minorities living in High County, which was 4 percent. Sixty-seven percent were women who earned wages equal to those of their male counterparts.3 Several case managers were gay or lesbian. Given the white, politically conservative, suburban character of High County, Kansas, the case managers were a remarkably diverse group. Consequently, they had actual workplace referents for a “progressive”perspective on women’s and minority’s earnings. From gays and lesbians, moreover, I heard of no workplace discrimination. The CSS work environment clearly valorized diversity and heightened hopes for acceptance and inclusion. The principle behind deinstitutionalization, normalization, is isomorphic with minorities’ desire for cultural acceptance and economic parity. Managers of a particular gender, ethnicity, class, or sexual orientation were sociohistorically prepared to empathize with the differences that severe mental illness cause for their consumers. This does not mean that middle-class white males cannot also be good strengths case managers.

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Indeed, just the opposite is true. White males, in general, come ready-made with cultural assumptions about earning higher incomes and status. Consequently, for case managers at High County Mental Health Center, socioeconomic and cultural progress was real; I believe their experience was embodied, then, in their subjective helping dispositions. Their personal experience was proof that movement, social change, and personal growth are possible. The knowledge contained in a strengths textbook was not needed to persuade case managers of the value in self-improvement; rather, our culture, politics, and economy delivers to schools of social work embodied (habitus) notions of the importance of progressive change and self-improvement.

PROFESSIONAL DEGR EES

In table 9.3, I compare case managers’ professional degrees and associated disciplines. Administrators and supervisors have not privileged a social work background in employment decisions; eleven of twenty case managers have bachelor of science degrees. This suggests that schools of social work do not exclusively provide a helper’s disposition. Policymakers and administrators can draw upon a larger pool of workers because the helper habitus does not have its central origin in a professional school or a college degree. The data in the third column of table 9.3 provide part of the explanation. In semistructured interviews I asked, “If someone wanted to know what you did for a living—and you did not want to say ‘case manager,’ because it seemed too ambiguous—what among the many social roles in life would you pick that would describe what you actually do?” Case managers rarely identiﬁed with professional degrees; they perceived themselves as teachers, parents, counselors, and advocates. Nor did they see themselves as social workers. They identiﬁed, instead, with work tasks: teaching, parenting, guiding, advocating, counseling, navigating, and coaching. By transposing values from their parent /child and teacher/student relationships to case manager/consumer relationships, situated knowledge tapped a sensibility stronger than what could be described by a particular college degree. Although case managers were hesitant to admit that work often felt like parenting, they did perceive the similarities: And see I’m a parent, and I know they are not children, but sometimes you feel like it because you are constantly teaching, supporting and maintaining; that is part of the job of being a case manager. People call us case managers, but see,

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TABLE 9.3 CASE MANAGERS’ EDUCATION DEGREE

Bachelors of Arts Bachelors of Science Bachelors of Science Bachelors of Science Bachelors of Science Bachelors of Science

DISCIPLINE

I D E NTI F I E D S O C I A L RO L E

English Education Psychology Rehabilitation Sociology and psychology Physical education

parental coach teacher guidance counselor some sort of therapist community specialist I help people with severe mental illness Bachelors of Science Psychology advocate Bachelors of Science Psychology teacher Bachelors of Science Psychology counselor Bachelors of Science Psychology counselor Bachelors of Science Health care administration teacher Bachelors of Science Psychology teacher Bachelors of Social Work Social work psychiatric social worker Bachelors of Social Work Social work parent\educator\lawyer Bachelors of Social Work Social work parent Bachelors of Social Work Social work teacher Bachelors of Social Work Social work social worker Masters in Counseling Psychology mental health social worker Masters of Science Gerontology social worker Masters of Social Work Social work navigator Masters of Social Work Social work social worker

I think it does not deﬁne what it means; I’m not here to “do for” you, I’m here to “do with.” I’m here to help, support, and assist. . . . If you keep doing something for a kid, how are they going to learn to do it on their own?

In response to my question about using money to encourage consumers to take medication, for example, a manager replied: You know, I feel like a parent . . . [laughter] . . . giving out an allowance, and I just don’t feel comfortable with that. I mean I do it because that’s just part of the job.

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Still, when asked how she knew it was time to end the management relationship, another case manager said: I think people need it all the time, I really do. There are times I need it . . . it’s ongoing . . . you know, it’s like your children, even though biologically they can be forty to ﬁfty years old, they still might ask: “Mom, I need ten dollars.” So, it’s like, how do you say no.

Asked in what instances they would “do for,” one manager responded: When I ﬁnd that I am paying more consequences as a worker than the beneﬁt they would get by teaching them a million times. . . . I really liken this job to working with teenagers. It is kind of like they have so many different inﬂuences around them and they don’t know who they are yet. They hear mom’s voice, dad’s voice, a friend’s voice, and a teacher’s voice . . . and when they get to be sixteen years old, they have to decide whose voice they really want to hear, and which one they are going to follow.

With the many needs of consumers that case managers confronted daily, it is understandable that they transposed—from sources other than textbooks— ways of reasoning about helping, assisting, and teaching. These transpositions were drawn from the everyday and accessible: parenting and teaching. Strengths management asks managers to reason about wants, not needs. Because wants are more abstract, they are less burdensome to managers. Recall the workshop example in chapter 4: “a consumer wants to be president of the United States.” Participants were told to translate wants into achievable tasks. A want makes no demand on the manager. “You may want something, but you may not need it,” was a typical response to my inquiry about the difference between want and need. Converting the desire to be president into reality, however, is a demand. In translating wants into concrete needs, the helping relationship—“how much do I get” (consumer) and “how much do I give” (helper)—was negotiated. In a case management relationship, translating want into need is not done through strengths language; it takes more than goal-setting to deﬁne relationships. For example, in negotiating needs, boundaries are set, crossed, and maintained: I had an experience last week with a consumer who was really used to her old case manager, who apparently was quite strict with her and . . . I am still testing the waters. She walks into my ofﬁce and asks me if I have time to see her and, you know, I did spend quite a lot of time with her; out of twenty-two days

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in a work month, I probably saw her like ten times. And she was not a highneed person. I think she was just testing me. She told me she wanted to see if I would always be available for her.

How do case managers reason about limits and boundaries? Strengths management’s philosophy does not make the manager/consumer relationship complex. Although I suspect that the workshop presenter was aware of the conﬂicts and issues in the helping relationship, it would have been a slippery slope indeed had her trainees been led toward alternative clinical knowledge/power schemes.4 Case managers mainly borrowed (transposed) from parenting and teaching relationships and overlaid those onto the manager/consumer relationship. Several noted that religious convictions and experience provided them with a language for thinking about work: “You give a person a ﬁsh and he’ll eat one day, but if you teach that person how to ﬁsh, he’s going to eat for the rest of his life.” When the power of strengths failed to explain consumers’ behavior and feelings, case managers drew upon a helper habitus to reason about work tasks. With twenty years of strengths research to back his claims, Professor Rapp writes that The evidence is that case managers can be selected from a wide pool of people (professionals, BA-level generalists, students, consumers) but need high-quality supervision . . . from a seasoned professional, and easy access to medical personnel and other experts. Considerable pre-service and in-service training and technical assistance has been recommended. A beneﬁt of this stafﬁng conﬁguration is that it would be less expensive than requiring case managers to be fully credentialed. (Rapp 1998:187)

I think that Rapp can draw managers from a “wide pool of people” because strengths management draws from culturally embodied (helper habitus) selfimprovement schemes. To practice in a strengths language is to practice what most take for granted. Situated concepts are commonplace because they come from the commonplace and the everyday culture. This need not be the case, however. Case managers could import other knowledge paradigms. At present, though, it seems such “stafﬁng conﬁgurations” are “less expensive.” Costconsciousness should not be the basis for foreclosing upon case managers’ capabilities. Yet, as long as strengths management focuses merely on surface goals, the situated case managers will draw on their helper habitus to do the rest of the work.

C HAPTER 10

Conclusion

I

have demonstrated that the study of case managers requires multiple research methods and a view of practice power that includes the disciplinary and the situated. In this ﬁnal chapter I summarize my ﬁndings for the purpose of drawing attention to the implications for research and practice. I argue that strengths case management suppresses theories of the self, and this compels case managers to aim disciplinary power at the surface level of the mental health reality. In addition, I discuss a perplexing irony: deinstitutionalization and normalization of mental illness did not preclude the need for monitoring by practitioners. Instead, the eyes of the automobile-centered case manager replaced the hospital panopticon. And ﬁnally, I discuss what this study contributes to our understanding of situated knowledge and practice. My research has not disputed the robustness of strengths management: case managers were handed strengths disciplinary knowledge/power (DKP), and with it they efﬁciently produced the effect of the independent suburban apartment-dweller. Yet, when strengths management’s shortcomings were realized in practice, managers’ situated knowledge/power (SKP) made up the difference. In short, to discover situated power I analyzed what strengths management was unable to accomplish.

ERASING THE SELF: THE LIMITATIONS OF STRENGTHS MANAGEMENT

Strengths management did not produce the social ﬁeld called CSS; the ﬁeld sets the conditions in which strengths management can realize its practice

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power. I have shown that an ad hoc policy of deinstitutionalization alongside an intentional policy that produced CSS displaced the hospital social ﬁeld in Kansas. Boundaries were redrawn. A reorganized landscape, an unintended consequence of deinstitutionalization, required former patients to access services and necessary commodities, and suburban High County was a space that produced unique management needs. I have shown that transportation was critical. By moving from one point of commodity exchange to another, peripatetic consumers and managers located, acquired, and moved through “naturally occurring resources.” Case managers, supervisors, and administrators also created new social spaces ﬁlled with consumers: group homes, transitional homes, crisis units, drop-in centers, and med-check, psychosocial, and multipurpose rooms. I have shown that monitoring occurred along a continuum of commodity exchange and service provision, which constituted the internal logic of CSS. In turn, consumers’ mobility meant that workers had to be freed from the ﬁfty-minute hour and the clinic. Thus, administrators and policymakers joined strengths case management with CSS to deﬁne the relationship of manager and consumer as resource acquisition and goal attainment. Federal, state, and private research monies have contributed to the creation (and current legitimation) of ﬁve case management models: psychiatric rehabilitation, broker, assertive case management, recovery, and strengths. Depending largely on state departments of mental health, case management models have become regionally differentiated and institutionalized. Although each model has a slightly different philosophy of helping and related practice, ultimately the policy of deinstitutionalization (or community reintegration) requires case managers to produce consumer self-monitoring. And the need to teach self-monitoring creates the case manager/consumer power relationship. I have shown that Kansas case managers ﬁrst used a “learning by doing” management method, and later strengths architects—produced and legitimated by scientiﬁc research processes—organized workers and institutionalized a full-ﬂedged disciplinary power. While the Kansas CSS social ﬁeld created the conditions for case managers’ actions, strengths management produced the practice effect: self-directed consumers. I have shown how CSS and mental illness confronted case management with three intractable and enduring life domains: medication, money, and manners. Practitioners worked by recursive exchange; they hoped to exchange medication for target symptoms in the consumer: confusion, lethargy, paranoia, hostility, agitation, and depression. Yet the exchange of the practitioners’ medical knowledge (medicine) for consumers’ psychiatric symptoms was not straightforward; it entailed interpretation and contextualization on the part of the workers. Money and manners were similar. I found

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situated knowledge/power in the social exchanges of managers and consumers. When medicine, for example, failed to produce the desired effect, managers used “effect interpretations” to resolve indeterminacy. Those “irrationally” using money were confronted not with strengths management but with a situated moral economy of case management. I have shown that strengths worked on the management or surface level of the mental health reality to engage and motivate consumers. Strengths management privileged the work of acquiring “naturally occurring resources” external to consumers. By reorganizing a person’s relationship to his or her “natural” environment, strengths philosophy assumed it could alleviate social and mental dysfunction. For example, instead of professionally organized recreational activities, case managers encouraged the use of a community recreation center; normalizing recreation, it was hoped, would reduce stigma, produce consumer conﬁdence, and alleviate dysfunction. By placing former patients in “naturally” occurring environments, case managers necessarily perceived those environments as natural and normal; indeed, practitioners worked to emphasize community strengths as well. For strengths architects, it was equally impermissible to think of the community as sociopathological as it was to see the individual as psychopathological. To remain consistent with its philosophy of avoiding pathologizing language, communities were seen as normal, and individuals who suffered from severe mental illness were strategically placed in “normal” commodity-privileged suburbs. I discovered, however, that case managers’ situated practice confronted consumers who did not act with acceptable market and goal-oriented manners when managing their meds and money. In explaining the lack of consumers’ goal attainment, managers could only note that a goal was improperly broken down or was incorrect. It was in this way that I perceived that strengths management could operate only at the surface level of the mental health reality. Symptoms, behavior, and feelings were all outcomes of rational choices and related goal attainment; in short, to be normal was to possess the appropriate manners to acquire meds and money. It was here that the theorist and practitioner of strengths management confronted a most puzzling question: if the goal of deinstitutionalization and CSS was to produce consumer self-monitoring, where was the site for selfmonitoring? For strengths management the site was the external community. The model provided no theory or language of the self that could account for self-observing, self-monitoring, and self-regulating practices. And this was the most troubling problem. The full or partial recovery of the self from debilitating psychiatric symptoms must be theorized and developed outside

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the strengths model. Although I believe that case managers’ situated language (e.g., “doing for” and “doing with”) tried to make up for the erasure of a disciplinary language of the self, case managers invented a moral economy of money and effect interpretations of medication. But the situated also lacked a language of the self. Still, why can’t consumers “get it”? What was the site for “getting” something? Strengths management’s philosophy and methods provided only one answer: external resource acquisition and goal attainment. In sum, case managers engaged and motivated consumers by helping them get what they wanted. The site for self-monitoring remained external to the consumer, suppressed by strengths management’s untheorized self. I found no disciplinary language that worked on internal ego functioning, for example. Strengths management, therefore, pointed the manager outward and abandoned the consumer to a sociological island of “natural resources” that lacked a psychological and self-referential point of view. Ironically, the outcome of erasing the self was that consumer monitoring became dependent on managers’ mobile eyes. And as long as strengths management erased the self, it was open to the Foucauldian criticism that normalization projects regulate, control, and monitor behavior. Consumers who have internalized a speciﬁc means to self-monitor meds, money, and manners, would not need the watchful eyes of others. I have shown that as strengths case management was conceptualized and practiced, it lacked the disciplinary power to produce self-awareness in consumers, and therefore a primary prerequisite for self-monitoring. Moreover, the strengths suppression of self accounted for the unique use of a situated language (e.g., “doing for,”“doing with,”“gets it,” and “low and high functioning”) that recovered and made visible what strengths management had hidden. Strengths management created a radical separation between the internal (i.e., psychic reality) and the external (i.e., resource acquisition) world, and by bringing a situated psychodynamic and ego function language back into practice, case managers bridged the gulf in two ways. First, situated language (e.g., “high functioning”) coded consumer ego functions that the disciplinary gaze concealed. I argued in the previous chapter that situated language also worked to allocate managers’ time. And it did. But more important, consumers were coded “high” and “low” functioning because case managers differentiated among those who can “do with” and those who need “doing for.” Managers’ situated language recovered for strengths management a way of naming self-monitoring capability. When a manager reasoned that a consumer was high functioning and low need, it was concluded that the case manager’s assistance was unnecessary. Situated language, in this study, did not

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attach consumer needs and functions to a theory called ego psychology; instead, case managers recoded ego functions with situated terms such as low and high functioning. Strengths management, therefore, identiﬁed the site of self-monitoring as resource acquisition on the surface level. Second, case managers’ use of “doing with” and “doing for” was a situated way to recover a psychodynamic language that referenced the helper’s or therapist’s subject position. Strengths management lacks concepts to deﬁne, limit, or otherwise instruct case managers in conceptualizing the hidden dynamics of helping relationships. In cars, apartments, and in clinic ofﬁces the intimate interactions between managers and consumers were extraordinary and necessary. I think that the only parallel to this kind of intrusion was the caseworker (Handler 1973) who traveled across community, family, and personal household boundaries to collect welfare data. Recall the strengths workshop leader who encouraged managers to seek and identify the behavioral and motivational clues hanging on consumers’ walls, standing on their bookshelves, and lying on their sofas. This prescriptive invitation was beyond any that most traditional psychotherapies warranted. Although I am not altogether opposed to home intrusions—for to give former patients the opportunity to live in the community often requires helpful intrusion—I am skeptical about a case management language and practice that conﬁne managers to surface levels of helping relationships. I believe managers’ situated language recovered for strengths management a language to name the psychological issues—named previously by psychodynamic theories—that lie beneath the surface of helping relationships. Deposing the dominating medical model and watchful eyes of the nurse, ward attendant, and psychiatrist was predicated on emptying hospital beds (Rhodes 1991). I have shown in this study that the monitors were renamed case managers and a new practice was deﬁned, namely, case management. Strengths management is just one version. Deinstitutionalization was the penultimate Foucauldian practice; yet, in the form of strengths case management, recycled biopower ironically supports Foucault’s thesis that modern governments need disciplinary agents (Chambon et al. 1999). Any management theory that purposefully separates external and internal realities is unethical in my judgment. While hospital practice focused on the internal and neglected the external, deinstitutionalization combined with strengths management theory—without concern for what was lost—aimed practice at the external reality alone. I have demonstrated that case managers bridged the external and internal realities of consumers with their situated power. Consequently, fortunately for practitioners, situated knowledge worked to make up for strengths management’s narrow reductions.1

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Researchers have focused on mental health case management and the efﬁcacy of system and client outcomes, and although these ﬁndings are useful, little research attention has been paid to the actual process of case management. How do managers apply theory in practice? Or, in other words, how do managers know when a model of case management is limited in applicability? Architects of management models usually write about practice as if a oneto-one correspondence existed between the prescriptive assumptions of the model (i.e., the disciplinary how-to) and the actual participant interaction. Moreover, many researchers desire ﬁdelity, that is, they hope that practitioners strictly observe and apply the model’s prescriptive rules or “critical ingredients.” For example, advocates of the strengths model have noted that “when deviation from model guidelines occurs, the consequent evaluation of program outcomes becomes a futile attempt to match program results with unspeciﬁed worker behavior” (Marty, Rapp, and Carlson 2001:215). Regardless of the model applied, what do we know about the function in practice of “unspeciﬁed worker behavior?” In other words, when a model fails to achieve all the work that its architects hope for, how do case managers make up the difference? Why did case managers rely upon a situated knowledge/power of their own making? Is their commonsense language a kind of “unspeciﬁed worker behavior” that undermines loyalty to a strengths model’s assumptions? Is this ﬁnding peculiar to strengths? I don’t think these ﬁndings are peculiar to strengths. Strengths is a robust management model that produces signiﬁcant community support outcomes, and the research pointing to its efﬁcacy is not put into question by these ﬁndings. I use this research on strengths management to demonstrate instead that community case management needs the contribution of management models like strengths and more. What these case managers made up, moreover, should not be viewed as “unspeciﬁed worker behavior,” or as practitioner deﬁcits leading to an unfaithful relationship to the strengths model. Rather, regardless of the management model employed, it is my argument that the situated knowledge/power reported here worked to recover the clinical issues that most helping relationships engender. Fortunately, since the early 1980s, a small but steadfast group of practitioner-scholars, researchers, and academics has written about the clinical skills case management involves (Hagman 2001; Harris and Bergman 1993; Harris and Bachrach 1988; Kanter 2001, 1999, 1996, 1987; Lamb 1980; Surber 1994; Walsh 2000). Harris and Bergman wrote that “while case management is frequently seen as a valuable part of treatment for chronically mentally ill patients, the focus is often on its managerial rather than its clinical elements” (Harris and Bergman 1987:296). Kanter, moreover, pointed out that

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while various models of case management . . . have emphasized various aspects of case management practice, case managers involved in personal, ongoing interactions with long-term clients implement ﬁve underlying principles: 1) continuity of care, 2) use of the case management relationship, 3) titrating support and structure in response to client need, 4) ﬂexibility of intervention strategies (i.e., frequency, duration and location of contact), and 5) facilitating client resourcefulness or strengths. (Kanter 1996:259)

Walsh noted that the power relations inherent in helping require therapeutic theory and skill in order to effectively carry out the six core management activities: assessment, planning, linkage, advocacy, monitoring, and evaluation (Walsh 2000:9–16). By studying case managers in their natural management environment and relationships, I have shown how they relied upon a commonsense use of self to set therapeutic boundaries. And in using situated terms in a complementary fashion, they were often struggling with interpreting the hidden desires of clients, and profoundly so. In doing work that strengths is not clinically designed to do, case managers acknowledged that the feelings, needs, and wants of adults with severe mental illness are not always transparent. I see this as empowering. Clinical skills empower by helping client’s name their own feelings and desires, in particular those that often lie outside of awareness and beyond our everyday functional needs. Perhaps one isn’t always aware of hidden feelings, but does that mean these feelings and desires are not real? Are only consciously stated wants signiﬁcant? When a theory of human behavior posits the existence of surface and hidden characteristics of clients, then workers need a theory and language that can access both levels of everyday reality. Strengths efﬁcacy is at the surface level of mental health community support work: identifying strengths, goals, wants, and taking action to acquire resources. In actual practice, however, by using their situated language, case managers dug deeper into less accessible clinical issues. By “deeper” I am not pointing to the psychoanalytic conception of the unconscious; rather, I mean deeper into the everyday clinical issues that helping necessarily produces; these clinical realities have been described by the many advocates who have argued for case management and clinical social work. And ﬁnally, I am not setting clinical work against case management as if it were simply a rational choice of opportunity costs and beneﬁts. The data reported here suggest that case managers need clinical social work training so that they know how to weigh a model’s prescriptive functions against every-

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day clinical realities. Thus, the need is for a reﬂective case manager, the worker who can weigh the disciplinary knowledge/power of a management model against the situated knowledge/power of clinical practice.

THE NATURE AND STUDY OF SITUATED KNOWLEDGE

What have I learned about the nature of situated practice? I discovered situated practice by ﬁrst studying how practitioners used strengths management to negotiate (structured by the CSS social ﬁeld) everyday exchanges. Second, I looked for examples of unsatisfactory outcomes. I found situated knowledge in the practice space between the outcomes of failed disciplinary power and the social ﬁeld’s hoped-for and desired effect: the suburban, apartmentdwelling consumer of mental health services. Disciplinary practice was conducted with narrative devices that described and justiﬁed professional relationships to service recipients. When used over and over, case managers’ narratives (e.g., strengths case management) assumed a durable conﬁguration. Strengths case management generated narratives to describe the resettling of former hospital “patients.” And because strengths management was standardized, I identiﬁed its imprimatur on consumers’ and practitioners’ experience by isolating the work it could not perform. In addition, I could not have seen situated practice had I not studied the oral narratives of case managers. Although the oral narratives conduct disciplinary and situated work, my study suggests that written texts record only the disciplinary. Thus, scholars must remain cautious about conclusions drawn solely from written texts. Situated knowledge is dependent on the activity involved and to the extent that practitioners’ activities unfold over time, we must have methods to study practice in process (Berlin and Marsh 1993:75). Ethnographic methods provide important research tools for the study of situated knowledge. However, disciplinary practice is also at work alongside situated knowledge/power, and the former doesn’t exist in isolation. This means that historical and sociological methods are equally important in excavating how social ﬁelds such as CSS are established. Moreover, historical methods can answer the related question about how and why social ﬁelds trap particular kinds of disciplinary knowledge, related agents, and power relations. Elizabeth Lunbeck, for example, in The Psychiatric Persuasion (1994) conducts the kind of historical research that is complementary to ethnography. Indeed, much of the recent historical work on social work practice enriches the profession.2 How-

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ever, my study challenges scholars who rely on written texts to qualify their conclusions with questions about historical methods that fail to access the oral narrative. Case managers’ textual and oral narratives combined to produce apartment-dwelling consumers. I did not privilege one type of knowledge/ power over the other. Both types of power were productive. The question is to isolate and analyze how each power produces different or similar effects. Although CSS reorganized time, space, mobility, economics, and the helper/ service recipient relationship, Kansas policymakers and legislators added the social ﬁeld’s sixth element: strengths disciplinary knowledge/power. And political and social inﬂuences independent of the six elements of the CSS social ﬁeld—which are national in scope and the reason why case management is ubiquitous—affect the implementation of particular (e.g., strengths management) or state and county level disciplinary practice. Thus, to research disciplinary and situated practices and make knowledge claims about their interrelationship, they must be studied with the methodology of ethnography, sociology, and history.3 In conceptualizing practice power as constitutive of two productive parts that form a whole, I oppose dichotomous thinking that frames a hierarchical relationship between theory and practice (Berlin 1990). I view the relationship between disciplinary and situated practice as the play of difference between the universal and the particular. On the one hand, strengths management worked hard to organize resources for goal attainment, and this was a universal activity that consumers of mental health services required. Like other case management models, however, strengths universal power did not perform all the work practitioners were confronted with; disciplinary theories are not omnipotent, ready, and willing to absorb all difference and peculiarity. Case managers’ situated practice stood alongside the disciplinary, and it should not be hidden or suppressed by any privileged alignment with government-mandated power (e.g., the mandated use of strengths management in Kansas). The situated performed work that strengths management could not do; therefore, situated practice had the potential for discovering gaps and silences that the disciplinary practice glossed over. Yet, was the relationship between the two hierarchical? I do not think case managers’ situated practice was subordinate to the state-mandated disciplinary power of strengths management. Indeed, I do not think it is possible to subdue situated practice; it always exists, whether case managers are conscious of it or not. Moreover, because it was not subdued, forced into a shadow of the disciplinary, this did not mean that case managers’ situated practice was about resistance to dominating,

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power-over disciplinary schemes. I found that situated language complemented the hoped-for effect of producing independent consumers. Case managers’ use of situated power did not resist the overall mission of deinstitutionalization or CSS. I have not, however, disputed the possibility that disciplinary resistance couldn’t be an outcome of situated practice. I deployed ethnographic and historical methods to show that situated practice existed in case management and to analyze the work it performed. It was not my objective to show in an a priori fashion that situated practice is resistance. I think situated power is a probable site for resistance, but my ﬁndings suggest that resistance to disciplinary domination would be a contingent outcome of situated power. Social work has had a long tradition of promoting empowerment perspectives (Simon 1994). The need to articulate a philosophy of client empowerment was a response to the criticism of the dominating social worker usurping clients’ power. Although often implicit, a cornerstone assumption of empowerment theory is the idea that social workers can resist government policies that are oppressive and that they can resist the idea that disciplinary knowledge has the universal power to explain away all client difference. In this study, when strengths management did not explain consumers’ behavior and when it failed to produce self-monitoring consumers, situated practice could have been coded as resistance if it had actively worked against strengths management and against the social ﬁeld’s requirement of normalizing former patients in suburban environments. In theory, situated power serves up the particular to the disciplinary, and as a result a dialogue should unfold. Indeed, this is the way most scholars have deﬁned the reﬂective practitioner-in-action (Schön 1983). The dialogue is, therefore, a potential site for resistance, but this is contingent upon a reﬂective practitioner who carefully and cleverly facilitates a dialogue between both productive powers. Social work scholars acknowledge the importance of practical wisdom (Berlin and Marsh 1993; Marsh 1983; Harrison 1987) and personal practice models (Mullen 1983). Theorists outside social work refer to local (Geertz 1983), subjugated (Foucault 1980), and situated knowledge (Haraway 1988), but we have yet to systematically interrogate or deploy these concepts in research of social work practice (see Rhodes [1991] for a notable anthropological exception to the study of mental health practice). One effect of ignoring the oral narrative is that the personal, the practical, and the situated have become invisible; that is, research often reduces situated forms of knowledge to organizational structures, policy, and disciplinary knowledge.

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Arguments that portray social workers, mechanistically, as agents of their intuition and unscientiﬁc theories—displacing social pathology onto individual psyches—are incomplete. At the other end of the spectrum, some practitioners, often naively, believe that practice intuition is superior to the disciplinary or “textbook knowledge.” I think a correction to this dichotomous thinking is long overdue (Berlin 1990). Likewise, I argue that policy, organization, and treatment research must not privilege the conditions for action; they must account for the situated, practical, and personal. Still, practitioners who limit themselves to situated knowledge must compare and contrast everyday knowledge with the power of the disciplinary. Additional studies are needed to further examine the relationship between disciplinary and situated knowledge/power. How might the situated become a site for resistance to policy and disciplinary schemes? Are the types of knowledge in a relationship of dominant and subordinate? Is there a tension between them? In what ways do institutional power relations affect the use of both types of knowledge/power? And ﬁnally, under what conditions do disciplinary and situated activities overlap? When scholars of social work practice ﬁnd that situated and disciplinary power produce social conformity, we must then wonder about the possibility of resistance, transformation, and change. But this is why one should not “preload” research with the one-sided view that practitioners produce their effects through a singular use of disciplinary knowledge/power; if theory had absolute power, then practitioners would have long ago produced the ideal subject position. Conclusions about a profession’s social control function, I argue, must be drawn from three methodological steps: (1) the disciplinary power is shown to produce an effect of social conformity, (2) the situated is shown to produce an effect of social conformity, and (3) the structural conditions—economic, political, and cultural—are shown to correspond to the disciplinary and situated production of the conformity effect in question. In my study strengths case management was limited. It profoundly foreclosed on other disciplinary explanations of severe psychiatric illnesses. Yet I found no evidence that case managers were importing other disciplinary schemes. This explains why they deployed the kind of situated knowledge I found. In saying that a client “doesn’t get it,”a foreclosure occurred that begged further questions. Why did she not get it? How did she not get it? Knowledge claims about practice are limited when either the disciplinary or situated is elided, and one form cannot be dismissed merely by failing to name it. Is the gulf between disciplinary and situated practice peculiar to the strengths model? Or are such discrepancies referencing a general theory and

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practice reality? My study does not provide the data to address these more general questions. From anecdotal and interview data and from my own practice experience, I can suggest three possibilities. First, in other policy regions and in organizations using different case management models, the same situated language is present. In particular, the language of “low and high need,” “low and high functioning,” and “doing for,” and “doing with.” Situated terms like these might be found in other social work settings: where clients have ongoing needs for social services, where there is a perceived need for workers to allocate time, and where the policy environment promotes case management models. When faced with a scarcity of resources, Michael Lipsky’s street-level bureaucrat (1980) used discretionary responses. Thus, I speculate that the policy environment, organizational needs and culture, and practice economics inﬂuence the relationship between disciplinary and situated knowledge/power, accounting for degrees of divergence or complementarity. Second, there is also a clinical explanation for the general use of situated terms such as “doing for” and “doing with.” Most theories of helping relationships require that we negotiate the use of the self (Kondrat 1999). Models of case management, including strengths, tend not to emphasize the role of transference. It is possible that the case managers I studied recovered the use of the self when they labeled interactions “doing for” and “doing with.” My data from interviews with case managers support this clinical argument. “Doing with,” in particular, was a conscious decision to relate to consumers in a manner that averted consumers’ dependence on workers. On the other hand, “doing for” permits the worker to get a speciﬁc job done even though such use of the self may promote dependency. Because strengths management does not specify a therapeutic use of the self, it is possible that case managers used these situated terms to recover a fundamental practice reality. And third, it is possible that in circumstances where the disciplinary produces the effects that practitioners and clients most desire, situated practices have no void to bridge or recover. In the case study of Robert (chapter 6) situated practice recovered his illness, chronicity, and dependency; he was a doubtful candidate for independent living. In cases like his, where case managers constantly “do for,” where consumers “can’t get it,” and where recipients get tagged “high need” and “low functioning,” we need to ask whether or not a different policy, organizational structure, and disciplinary scheme would not be more ethical and efﬁcacious. For example, situated practice aimed at some consumers suggests that around-the-clock supervised sites (organized social spaces) may be necessary, not merely transitional. At the present time, the policy of deinstitutionaliza-

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tion directs individuals to temporary spaces (short-term hospital stays, crisis units, and temporary group homes) and then moves residents to “permanent” apartments. Once the individual is returned to community support services, a disciplinary knowledge like strengths management becomes operative again. Although it is common that the science of policymaking and practice seduces us into thinking that one knowledge scheme explains all situations, situated knowledge can act as an important check on the disciplinary. In sum, practitioners’ strategic responses can be signiﬁcant clues for identifying shortcomings in policies and treatments. Finally, neglecting the study of situated practice has a serious implication for the way we undertake evaluation research. When researchers evaluate the effectiveness of treatments, they often study the (disciplinary) paradigm effects, but few have methods for studying the desired effects of situated practice. Without a methodological and theoretical strategy for testing how situated knowledge contributes to speciﬁc outcomes, we suppress our understanding of practitioners’ everyday knowledge, sometimes called practical wisdom. Most research identiﬁes the criteria for the production of disciplinary knowledge/power. We need an epistemology of the situated as well (Kondrat 1992). My study points toward such an approach, but much more must be done. The two types of practice power form a totality, and each part requires equal (and simultaneous) attention to assess its respective forces, liabilities, and potentials.

APPEN DIX A

Methods, Data, and Analysis: A Critical-Realist Perspective

A

lthough qualitative research methods are used most commonly in sociology and anthropology, in recent years they have become increasingly accepted and useful in the professions of nursing, medicine, education (Delamont 1992; Borg and Gall 1989), social work (Anastas 1999; Padgett 1998; Beeman 1995; Drisko 1997; Franklin and Jordan 1995; Sherman and Reid 1994; Reissman 1984; Goldstein 1991; House 1991; Reid 1994), and in the work of community action (Stringer 1996). In these ﬁelds there are manifold understandings of the principles and practices of the techniques, but some are in general agreement on the central features: they are holistic, inductive, and naturalistic (Creswell 1994; Lincoln and Guba 1985). Thus in this study I sought to understand the structure or totality of the CSS social ﬁeld—unfolding daily events, case management in action, and case managers as actors—in open systems. Whereas in the experimental design every effort is made to isolate and reduce social reality to closed systems or operationally deﬁned variables, I used qualitative methods and critical-realist ontological and epistemological assumptions to understand or interpret the totality (Sayer 1992, 2000). I have moved inductively from the particular to the general, from close observation or description of case managers to the discovery of general patterns (Agar 1980:194; Miles and Huberman 1984; Merriam 1988; Fraenkel and Wallen 1990; Locke et al. 1987; Marshall and Rossman 1989). Thus I have made every effort in this study of case management to avoid preloading the work of observation with assumptions, a priori theorization, or hypotheses about the nature of situated knowledge/power (Hammersley and Atkinson 1983:24).

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I am fully aware of the many and controversial debates (Reid 1994) that make problematic the assumption—not limited just to qualitative research, but for all social sciences—that survey results or statistics are untainted by concepts or theories and only subsequently interpreted, explained or predicted using some theoretical or conceptual “framework.” . . . The data we “gather” in science are already pre-conceptualized. We may have “sensations” without concepts, but we have no perception without concepts. Social scientists who treat “data” literally as “given things” (often those who feel most conﬁdent about the objectivity of their knowledge and the “hardness” of their facts) therefore unknowingly take on board and reproduce the interpretation implicit in the data: they think with these hidden concepts but not about them. (Sayer 1992:52)

My research took place in natural settings, where events and actions unfolded in necessarily open systems, and where I attempted immersion into everyday reality and made every effort to enter the case managers’ world through regular interaction and observation. From January 1997 to fall 1997 I conducted ethnography at High County Mental Health Center. One group of managers invited me to join their team. I had the opportunity to attend daily team meetings, to observe bimonthly clinical and business meetings, to observe ofﬁce talk, and to participate in the many trips with case managers and consumers to homes, banks, grocery stores, food pantries, and welfare ofﬁces. On only two occasions did consumers ask that I not be present. And on no occasion did the team ask that I be excused. Nor was any part of CSS off-limits to me. After I had established a working relationship with one team, I branched out to spend time with three others. In all, I was a companion manager with some twenty case managers on four different teams. I documented the application of Strengths Assessments, Personal Goal Plans, crisis intervention, medication evaluations, home visits, and the transportation of medications (called med drops). I often remained at CSS to experience the unfolding daily dramas and crises in the lives of case managers. Along with case managers, ﬁve days a week I arrived at 8:30 a.m. and left at 5 p.m. I paid particular attention to the ways case managers, including the researcher, experienced, perceived, and assigned meaning (Fraenkel and Wallen 1990; Locke et al. 1987; Merriam 1988). I also assumed that experience is structured in complex ways and that social reality is not singular and unidimensional, but it is instead a stratiﬁed ontology (Sayer 2000, 1992; Collier 1994; Lincoln and Guba 1985). And in apprehending the stratiﬁed reality, I

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paid particular attention to the use of tacit, local, intuitive, or felt knowledge (Zeira and Rosen 2000), the practical wisdom (Mullen 1983) of the case managers (Lincoln and Guba 1985). Although qualitative researchers seek to establish the objective bases of their knowledge claims, it is often argued that their data are not quantiﬁable. Yet knowledge claims grounded in quantitative data, as demonstrated in recent critiques of positivist social science, cannot be made on the basis of mere statistical associations. Indeed, even the strongest associations are at best mere starting points for probing deeper into how and why events, actions, and activities are often correlated with other events, actions, or activities (Collier 1994). I used ethnographic research methods to capture practitioners’perceptions, meanings, and experiences of case management. I then analyzed audiotapes and my ﬁeld notes for strengths case management and situated expressions. In sum, my technique for identifying the work of situated knowledge involved ﬁve related steps: (1) identify and describe the strengths language in a training workshop, (2) record oral narratives of actual case management activities, (3) identify the written case notes that corresponded to the oral narrative identiﬁed in step 2, (4) compare the oral and written narratives for the purpose of identifying the work of strengths and the situated language, and (5) through interviews with case managers conﬁrm whether or not the language I identiﬁed as situated is a language the case managers also acknowledge. In chapter 9 I compared self-reported data with what practitioners actually do and how they ground their behavior “in the realities of daily existence” (Jorgenson 1989:15). For example, no case manager used the concept of situated practice; indeed, no manager used the categories disciplinary and situated knowledge/power. Thus, to validate my assumptions about situated practice, toward the end of my ethnography I devised a structured, openended interview schedule (see appendix C). Twenty-ﬁve case managers were queried at length about their perceptions of the terms I had coded as situated. The managers recognized the situated language, and they all described its meaning. This methodological step allowed me to “check out [the case managers’] understanding of the phenomena under study” (Hammersley and Atkinson 1983:24) and provided a measure of validity and reliability (Reissman 1993:64–68). The situated narratives that I have summarized in ﬁgure 1 (page 219) contained expressions that all case managers recognized. In chapters 2 and 3 I relied on several primary and secondary sources. In a 1978 article written by two NIMH ofﬁcials who worked on formative policy committees between 1974 and 1979, I found data that became crucial to my

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understanding of NIMH’s role in formulating CSS policy. Written as a retrospective, almost journalistic account, the article carefully retraced the authors’ steps—including detailed attendance summaries of eight policy workshops. In chapter 2 I analyzed the original Kansas Department of Social and Rehabilitation Services and Mental Health and Retardation Services grant proposal (1980): Community Support Systems Strategy Development and Implementation Grant. This one-hundred-page document contained resumes, letters of support, reviews of local CSS programs, and lengthy discussions of policy goals. The data for chapter 3 came from dozens of quarterly summaries and reports that High County administrators submitted to state ofﬁcials between 1982 and 1989. In addition to participant-observation techniques, to understand the daily life of case managers, I used mental health center data compiled from clients’ monthly goal plans and medication prescriptions, mileage forms and budget data, team’s ﬂexible account statements, consumers’ payee account statements, employee records, and twelve months of a single case manager’s daily appointment book. In chapter 8 I analyzed the medication prescriptions of 329 consumers. I collected a snapshot sample of how many medications and the different kinds of medication consumers used. The purpose was to generate frequencies so that I could place my participant-observation medication data in a broader quantitative context of medication use. My collection and use of policy grants, administrative reports, letters, personal communications, interviews (appendix C), and participant-observation data allowed me to analyze the case managers’ use of strengths case management theory and situated knowledge/power in the context of deinstitutionalization, the rise of the community support service social ﬁeld in Kansas, the rise of the case manager, and the latter’s work in three consumer life domains: meds, money, and manners. In fact, I did not start the study with a preformed idea that three consumer domains would dominate case managers’ activity. In this way, in the spirit of qualitative analysis and grounded methodology, I let the data show me where to place emphasis in the case managers’ use of strengths and situated practices. The use of a variety of data gathering methods coincided with my criticalrealist assumptions. I see disciplinary and situated practices as constituent parts of a practice power totality and that totality ontologically exists independent of rival thoughts about it. Thus, practice reality is an object or structure, and it has causal powers to produce effects in helping relationships. In other words, researchers and practitioners can have rival theories of practice power, but these theories point to one reality (i.e., the object I call practice

APPEN DIX A

FIGURE 1

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Research Summary

power), which opposing theories compete to explain (Sayer 2000:10–16; Collier 1994). I am fully aware that theories of practice power are concept dependent, that is, we have thoughts about how to make practice interventions. Indeed, this is why strengths case management can be identiﬁed as a disciplinary knowledge/power. But practice power produces effects in helping relationships despite any particular thoughts about that power. I have sought to understand the conditions that inﬂuence the relationship between disciplinary and situated practices. One of these conditions is my corollary use of the concept social ﬁeld. Social work theory and practice is

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context dependent. The context is the particular social ﬁeld that names the problem, identiﬁes the helper, names the recipient, and ﬁnally, through policy initiatives, ﬁlls the social ﬁeld with particular kinds of disciplinary power. For example, there are child welfare, geriatric, criminal justice, domestic violence, mental health, hospital, school, health, and substance abuse social ﬁelds; each will have its own history and set of power relations. The social ﬁeld has its own causal powers to produce effects and these effects vary according to how the six elements of helping social ﬁelds (i.e., space, time, mobility, economy, disciplinary knowledge and helper/service recipient relation) are uniquely ﬁgured and reﬁgured over time. A social ﬁeld, combined with its related situated practice power, is, therefore, able to produce a new power distinct from its parts. Moreover, if one’s research methodology disaggregates these two powers (i.e., the social ﬁeld and situated practice), then their unique combined effect will be not be understood; Roy Bhaskar has called research disaggregation methodological individualism or actions but no conditions for actions (Bhaskar 1989:70–73). Thus, understanding the unique effect of a social ﬁeld and situated knowledge/power is not possible a priori; its study requires a posteriori analysis or historical study of the conditions for the activation of practice power. And it requires ethnography. The latter is necessary because the combined effects are often not activated or realized in closed systems. I assume that the case manager and consumer relationship is negotiated in the open system of daily life (i.e., in vivo practice experiences). In ﬁgure 1 I have presented a summary of my ﬁndings. A policy measurement success—portrayed at the bottom of ﬁgure 1 as the independent apartment dweller or consumer—was the individual who regulates daily meds, carefully monitors spending, and learns other self-sufﬁcient manners.

APPEN DIX B

Continuum of Services

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APPEN DIX C

Interview Schedule

NAME DATE PERSONAL HISTORY

1. 2. 3. 4.

What is your degree? Tell me your work history as case manager. What kind of training have you had in case management? What was the most signiﬁcant source of information/book/workshop on case management that inﬂuenced your style? 5. What are your long-term personal/professional goals? What are your short-term professional goals? 6. What do you need to be a good case manager? 7. If someone wanted to know what you did for a living—and you did not want to say “case manager,” because it seemed too ambiguous—what among the myriad social roles in life would you pick that would describe what you actually do? NEEDS/GOALS

1. How do you conceptually organize a consumer’s needs? 2. I have noticed that case managers use the term “low need” (“low functioning”); what does that term mean to you? Have you used it? Examples? 3. Same question as #2 but for “high functioning” and “high need.”

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4. When is case management appropriate, and when should it be refused or terminated? 5. In your mind, is there any difference between a goal and a need? I have heard consumers say: “I want to feel safe”—is that a goal or a need? “I want to stay in this apartment”—is that a goal or a need? “I want to stabilize my ﬁnances”—is that a goal or a need? 6. As a case manager, do you assume the consumer knows what he wants? Do you sometimes try to interpret what consumers want? Examples? 7. What assessment tools do you use to assess your clients’ needs? 8. In your experience, what are consumers’ most important needs? 9. Are some needs ongoing and some temporary? Examples? 10. How do you track your consumers’ needs? 11. In your experience, what determines whether or not someone is moved to meds-only status? 12. I have heard case managers use the term “natural consequences” when describing a consumer; for you, what is meant by “natural consequences,” and how do you use them? Examples? 13. Should the case manager be a safety net and catch someone before he or she crashes? 14. Can a consumer ask for too much? If so, then what? 15. I have heard case managers talk about doing for and doing with; what does this mean to you? Examples? 16. You assess monthly goals and collect the information in monthly goal sheets, but in your experience how often do consumers stay with that goal? 17. How do you use money to inﬂuence behavior? When does it work to use the removal or giving of resources to inﬂuence behavior? 18. How do you use meds to inﬂuence behavior? 19. How do medicines do their work in the body? 20. What behaviors do you hope meds will have an effect upon? 21. Do you complete a money management worksheet on every consumer? How often? Why some and not others? 22. How do you use the strengths assessment tools? 23. What models of case management do you tend to use? 24. How much prompting do you have to do when writing monthly goal sheets? 25. If the consumer does not ask for anything, do you tend to leave him or her alone assuming that no news is good news? 26. In your experience what is a success? Examples?

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27. How do you know when it is the illness that causes behavior and when it is the consumer’s personality, temperament, or initiative that inﬂuences the outcome? 28. When should someone be discharged? Or when should case management services be pulled from someone? Give me examples. 29. On your team or caseload, who would you say became as self-directed as anyone could ever hope? Give some examples that come to mind from your experience. 30. On your team or caseload, can you give me some examples where you think someone was helped too much? Enabled, perhaps? 31. How much change is necessary to be a success? Give me examples. 32. What cases come to mind that you closed? Why? 33. Do you know of cases where natural consequences did not work as hoped? 34. Is it your responsibility to go to med check? 35. How do you engage consumers? 36. How do you assess that the self-directed project doesn’t work for consumer X? Examples? 37. What are our basic needs? Are these the same as the consumers’?

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Notes

1. INTRODUCTION 1. I have not tested the effectiveness of a case management model in this study. According to standard measures, case management works to keep people out of hospitals. For my purposes it is not important to review this now extensive literature; there are many excellent summaries. The best source for a quick overview of case management is the 1999 Surgeon General’s Report (chapter 4): http://www.surgeongeneral.gov/library/mentalhealth/chapter4/case and the report is also available in hardcopy (Mental Health: A Report of the Surgeon General, 1999). For the most recent and comprehensive reviews of case management research see Mueser et al. (1998), Bedell et al. (2000), and Gorey et al. (1998). There are numerous articles and books that compare and describe six models of case management: broker, clinical case management, assertive case management, intensive case management, strengths, and rehabilitation. Although most comparisons include the broker model, there is very little written about it; scholars typically portray it as a primitive form of case management. And it is often contrasted to other models in order to underscore linking as singularly insufﬁcient and backward. Like the broker model, clinical case management is not popular; its lack of use, however, is due to reasons different from those that devalue the broker model. Joseph Walsh (2000) has articulated a version of the clinical model that is the most detailed. Other important supporters of clinical perspectives are Harris and Bergman (1987, 1993), Kanter (1989), and Lamb (1980). Clinical case management combines psychodynamic theory and practice

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3. 4. 5. 6.

I NTRODUCTION

with everyday management functions. I think the cultural and professional skepticism about psychodynamic theory acts to silence advocates of clinical case management. Taken together, the remaining models make up the bulk of the literature and research. For a comparison of the models highlighting the strengths version, see Rapp (1998). William Anthony et al. (1993, 2000) and the Center for Psychiatric Rehabilitation (Boston University) are leading proponents of the rehabilitation model. The intensive case management model is well articulated in Borland et al. (1989). Assertive case management (ACT) has been highly visible both in the literature and in research; Stein and Test (1980, 1985; see also Stein and Santos 1998) are among its architects. See Thompson et al. (1990) and Scott and Dixon (1995) for good reviews of ACT principles and research evaluations. Pescosolido et al. (1995) show how the dominant models aim interventions at organizing formal and informal social supports. Using case records to describe and explain social workers has been a social science preoccupation in the 1990s. The following authors are exemplary in their use of case records: Karen Tice (1998), Tales of Wayward Girls and Immoral Women: Case Records and the Professionalization of Social Work; Leslie Margolin (1997), Under the Cover of Kindness: The Invention of Social Work; Mary Odem (1995), Delinquent Daughters: Protecting and Policing Adolescent Female Sexuality in the United States; Elizabeth Lunbeck (1994), The Psychiatric Persuasion: Knowledge, Gender, and Power in Modern America; Linda Gordon (1994), Pitied But Not Entitled: Single Mothers and the History of Welfare, 1890–1935; Regina Kunzel (1993), Fallen Women, Problem Girls: Unmarried Mothers and the Professionalization of Social Work, 1890–1945; Theresa Funiciello (1993), The Tyranny of Kindness: Dismantling the Welfare System to end Poverty in America; Beverly Stadum (1992), Poor Women and their Families: Hard-Working Charity Cases; Lori Ginzberg (1991), Women and the Work of Benevolence: Morality, Politics, and Class in the Nineteenth-Century U.S.; Andrew Polsky (1991), The Rise of the Therapeutic State; and Peggy Pascoe (1990), Relations of Rescue: The Search for Female Moral Authority in the American West, 1874–1939. Adrienne Chambon and others (1999) recently translated one of the few essays by Foucault dealing speciﬁcally with social work practice. Jerome Wakeﬁeld has provided a comprehensive critique of Margolin’s Foucauldian approach to the study of social work (Wakeﬁeld 1998). See appendix A for a detailed description of my research methods. In order to protect the identity of the institution and individuals studied, I will not refer to the actual mental health center, the address, or the community. I have assigned ﬁctitious names to the mental health center and to all research participants.

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7. The Kansas Mental Health Reform Act required that every mental health center appoint at least one consumer and one family member to its governing board.

2. FORMATION OF COMMUNITY SUPPORT SERVICES 1. Council on Social Work Education. 2. Policy studies of implementation are an exception; see Brodkin (1990) for a discussion of the importance of investigating policy implementation. 3. Thresholds, a not-for-proﬁt group, was organized in the 1960s by practitioners who rejected the medical model. Its founders believed that rehabilitation models and other normalizing interventions would better serve the long-term mentally ill. Chicago-based Thresholds and New York’s Fountain House organized services long before community mental health services; the latter needed the inducements that occurred in the early 1980s. 4. Double funding tended to increase mental health budgets (Lerman 1982), thus savings occurred only if hospitals closed. 5. Let me provide anecdotal evidence for this argument. In the 1994 Kansas election a Republican governor, senators, and representatives were swept into ofﬁce. The new legislators lacked even the most basic knowledge of mental health issues. Some, for example, were not aware that Kansas had passed a mental health reform bill (1990) that mandated the closure of state hospitals and the transfer of patients to local community mental health centers. Advocates for community support services lobbied and not to my surprise, they used a “cost-savings” discourse. On most matters social workers ﬁnd themselves in opposition to Republican initiatives. Here, however, they can all agree that community support services are ﬁscally prudent. 6. Kansas Department of Social and Rehabilitation Services, Division of Mental Health and Retardation Services, personal correspondence (1995). 7. For summary discussions of the body, disability, and mental illness, see Lowe’s The Body in Late-Capitalist USA (1995, especially, pp. 149–171) and Susan Wendell’s The Rejected Body (1996). 8. Their benchmark article, “The NIMH Community Support Program: Pilot Approach to a Needed Social Reform” (1978), is often cited by community advocates. The article provided me with important insights into the formation of the CSS social ﬁeld. 9. For recent examples of this genre of work, see: We’ve Had a Hundred Years of Psychotherapy and the World’s Getting Worse by James Hillman and Michael Ventura (1992) and Therapy’s Delusions by Ethan Watters and Richard Ofshe (1999).

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10. I have abbreviated the reference: Kansas Department of Social and Rehabilitation Services and Mental Health and Retardation Services (1980),“Community Support Systems Strategy Development and Implementation Grant,” Department of Health, Education, and Welfare, PHS-5161-1, program number (13-242) and state application number (8910-13).

3. THE RISE OF THE CASE MANAGER 1. The data here and throughout chapter 3 were taken from High County Mental Health Center quarterly reports, letters, and documents. In order to assure conﬁdentiality, I have disguised the actual name of the mental health center. In the reference section, I have listed all reports and documents under High County Mental Health Center. 2. The staff hours reported here reﬂect those tabulated on daily event forms. Between 1983 and 1989 the number of staff averaged sixteen. 3. The calculation was as follows: client time (192,504 hours) multiplied by the proportion of their group time (67 percent), divided by the total staff time (52,088 hours) multiplied by their proportion of case management work (63.4 percent). Thus, 128,977 divided by 33, 023 equals 3.9, or approximately one staff hour to 4 client hours. 4. CSS would later (1990s) expand downward into the younger population (below eighteen) and upward into the over ﬁfty crowd. 5. The idea that clients are at different levels remains a vexing problem for case management models and programs. The newest management paradigm, the recovery model, for example, has four levels: dependent/unaware, dependent/aware, independent/aware, and interdependent/aware. What instrument instructs participants that they have moved a level up or down? Movement among levels, case managers will conﬁrm, can vary daily, depending on the life task at hand.

4. STRENGTHS CASE MANAGEMENT 1. The University of Kansas School of Social Welfare homepage (http://www. socwel.ukans.edu) links to a strengths perspective site that states: The KU School of Social Welfare has devoted 13 years to the development and testing of a strengths perspective for social work and other helping professions. The strengths perspective is drawn from social work’s commit-

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ment to building on people’s strengths, rather than focusing on their deﬁciencies, problems, or disabilities. As an orientation to practice, emphasis is placed on uncovering and reafﬁrming people’s abilities, talents, survivor skills, and aspirations. This approach assumes that an unswerving focus on strengths found in individuals and communities will increase the likelihood that people will reach the goals they set for themselves. (University of Kansas School of Social Welfare, Strengths Perspective, online at http://www.socwel.ukans.edu/htdocs/strength.htm, June 25, 2000)

2. For example, I am currently conducting research on an Ohio Department of Mental Health initiative to introduce (statewide) a new case management model called recovery. 3. Rapp’s recent book, The Strengths Model: Case Management with People Suffering from Severe and Persistent Mental Illness (1998), is the most comprehensive discussion of the model. 4. During my ethnography, I never heard a case manager use this phrase.

5. LANDSCAPE FOR A CASE MANAGER: THE CARLESS MENTALLY ILL 1. See Elizabeth Lunbeck (1994) for an excellent historical discussion of the role of social work in creating outpatient treatment within the context of the Boston Psychopathic Hospital. 2. The economic data reported in this chapter is from the “High County Demographic Update,” High County Planning Ofﬁce, November 1992.

6. ORAL AND WRITTEN NARRATIVES OF CASE MANAGERS 1. The only texts that do not appear in sequence are the February progress notes. Other progress notes, not concatenated in the case record, I gathered and reordered chronologically with the oral accounts of the same management event. 2. In his study of school professionals, Hugh Mehan makes a similar argument about written reports and “learning disability” subjects (Mehan 1996:276). 3. For ﬁfty of approximately four hundred clients I found this same monthly goal, written in similar fashion: “I want to stay out of the hospital.” 4. I have used the abbreviation CM to mean case manager; CM1, CM2, etc., refer to speciﬁc case managers.

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7. MONEY 1. A med drop is a delivery of daily medication. 2. Ted has a federally supported Section 8 voucher. 3. Program for Achieving Self-Sufﬁciency (PASS) is a social security program that eligible consumers use to buy automobiles. The program requires strong evidence for work capability, however. 4. See Eveline Burns (1962), “What’s Wrong with Public Welfare?” Social Service Review 36 (2): 111–122, for a period analysis of the separation and integration debate.

8. MEDS 1. Antiparkinsonism drugs are not included in table 8.1; they are for side effects. 2. These data represent a synchronic view. At a single point in time, I counted the number of prescriptions among 329 consumers. 3. Commonly reported side effects are: dizziness, drowsiness, weight gain, constipation, headache, akathisia (restlessness), tremors, neuroleptic malignant syndrome (high fever, muscle stiffness, rapid heart rate or breathing, sweating, and seizures, sometimes fatal), tardive dyskinesia (uncontrollable movement of the muscles, especially repetitive motions of the tongue and mouth or involuntary ﬁnger or hand motions). 4. Although the establishment of a CSS social ﬁeld did not undermine psychiatry’s authority over medicine, it was compromised. Physicians dominated in gatekeeping roles in hospitals. Not at CSS. Consumers were admitted to the program with the diagnostic consent of social workers. And for the ﬁrst time, the 1990 Kansas Mental Health Act empowered both psychiatrists and master’s level social workers to authorize emergency hospital admissions. Psychiatry was a necessary part of the medication division of labor, and it was a precondition for the circulation of drugs.

9. THE HELPER HABITUS: SITUATED KNOWLEDGE AND CASE MANAGEMENT 1. Ann Dill (1995:106) noted that “doing with” and “doing for” are common case management terminology that she feels has cultural determinants.

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2. Anthony Giddens (1992) argues in The Transformation of Intimacy that Western society produces the need to continually improve the self. 3. In fact, females had a slightly higher average salary ($34,617) than males ($33,922). They had exactly the same median salaries ($34,382), however. 4. For a similar criticism, see Joel Kanter (1988), “Clinical Issues in the Case Management Relationship.”

10. CONCLUSION 1. In contrast to strengths management, by combining ego psychology with everyday management functions, “clinical” case management offers a way to bring a theory of the self back into management work; in particular, I am thinking of the work of Joseph Walsh (2000), Maxine Harris and Helen Bergman (1993), and Joel Kanter (1995, 1989). 2. See chapter 1, note 2 for a list of these works. 3. Elizabeth Townsend (1998), Deborah Connolly (2000), Michael Rowe (1999), and Lorna Rhodes (1991) have used ethnography to examine both written and oral narratives of occupational therapists, social workers, nurses, and psychiatrists. Gerald A. J. de Montigny (1995) studied child welfare workers in action and used both kinds of narratives in his analysis. Dorothy Smith’s (1987) method of institutional ethnography is well equipped to study disciplinary and situated practice; Townsend and de Montigny, for example, produce signiﬁcant contributions with Smith’s method. Although Smith is not using the language of disciplinary and situated knowledge/power, I think her theory could enhance our understanding of how social work power is articulated with dominant, extralocal social relations.

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Index

Abbott, Andrew, 18, 19, 42 ACT model, 65 ACW, see Attendant Care Workers (ACW) ADC, see Aid to Dependent Children (ADC) Age distribution of consumers, 48(table) Aid to Dependent Children (ADC), 125, 148 Alcohol, 168–69 Aldridge, Carlous, 196 Almshouses, 17, 85, 125 Anafranil, 154(table) Andover House, 145–146 Andover, KS, 88–89, 101(table) Antabuse, 154(table) Anti-anxiety medications, 152(table), 157, 158(table), 159(table) Antidepressant medications, 152(table), 157, 158(table), 159(table) Antimania medications, 152(table), 153–60, 158(table), 159(table)

Antiparkinsonism medications, 152(table), 153, 157, 158(table), 159(table), 232n1 Antipsychotic medications, 152(table), 153–60, 158(table), 159(table), 162 Artane, 154(table), 162 Assertive case management (ACT, PACT models), 65–66 Assessment and diagnosis: biopower and, 3; colligation and classiﬁcation as steps of, 18; early lack of assessment instruments, 55; as a modality of social work, 18–19, 42; in psychiatric rehabilitation model, 64–65; relation to treatment and inference, 18; in strengths case management, 64–65, 69, 73–82, 76(table) Asylums, 20, 23, 26 Atarax, 154(table) Ativan, 154(table) Attendant Care Workers (ACW), 167

250

Beard, John, 30 Bell, Winifred, 148 Benadryl, 154(table) Bergman, Helen, 207 Biopower, 3, 27–28, 63, 109, 206 “Blaming the victim,” 117 Bloch, Maurice, 126 “Body” (term use), 25–26 Boston University, 64 Bourdieu, Pierre, 7, 16, 181, 195 Brodkin, Evelyn, 27 Broker model of case management, 66–67, 227–228n1 Buspar, 154(table) Carless mentally ill, 89, 97–107; contrast to homelessness, 99–100; and naturally occurring vs. segregated resources, 99–100; see also Landscape for case management; Mobility; Transportation Cars: car-speciﬁc interactions between social workers and consumers, 97–98, 105; money and, 136; as private spaces, 89; see also Mobility; Transportation Caseloads, 11–12 Case management: assertive case management (ACT, PACT models), 65–66; best practices, 1, 73; broker model, 66–67, 227–228n1; clinical skills and, 207–9, 233n1; “clinical” vs. “case management” terms, 32; constraints on, 67, 102, 106, 109–10, 183–85, 188–90; deﬁcit models, 64–65, 74, 135; functions of, 15, 32–34, 73–74; helper habitus and situated knowledge, 180–201; homeless mentally ill and, 27; levels of service, 55, 230n5;

I N DEX

life domains supported (meds, money, manners), 15, 49, 50(table), 51; monitoring mobility as the core of community support services, 48–56; moral economy of, 126, 128–49; NIMH reform proposals and, 32–34; psychiatric rehabilitation model, 64–65; recovery model, 230n5; rehabilitation model, 228n1; relationship between linking, monitoring, and driving, 102–7; requirements of successful case management, 12, 73; routinization of, 55–56; structuring community time, 48–49; time management needed for, 183–85, 188–90; transition from group-based to individual services, 45–48; transition from situated case management into disciplinary knowledge, 52–56; trial and error in, 194–95 (see also Medications); see also Landscape for case management; Monitoring; Research; Strengths case management Case managers, 2, 5, 9(table); demographics of, 197(table), 198; division of labor, 53, 93, 160–67; education and training of, 13, 43, 73–82, 198–99; emergence of “learning by doing” practice, 13, 42–45; medications and, 160–67; need for reﬂective case managers to balance disciplinary and situated knowledge, 208, 211; recommended caseloads, 11; as representative payees, 129–37; rise of, 42–60; salaries, 11, 196; selfperception of, 198–201; socioeconomic status of, 196–98; as “speciﬁc” and “universal” intellectuals

I N DEX

(Foucault’s concept), 5, 6; statistics on staff activity, 47(table); theoretical and methodological considerations in study of, 2–7; “unspeciﬁed worker behavior,” 207; see also Disciplinary knowledge/power; Landscape for case management; Narratives, oral; Narratives, written; Relations between helper and service recipient; Situated knowledge/power; Transportation Catchment area, 85, 102, 107; deﬁned, 38–39 Categorical institutions (orphanages, homes for unwed mothers, homes for the aged, etc.), 17, 19, 20, 85, 125 Child abuse, national agenda setting and, 20 Choice: clients’ desire for help and services valorized by term “consumer,” 59, 70; natural consequences and, 191–93; strengths case management and, 79, 120–21 Chronic nature of illness, 33–34; “doing for/doing with” expression and, 121; funding and, 56; lack of language in strengths management, 118 Classiﬁcation, 24; helper-service recipient relationship framed by categorical labels, 25; NIMH reform proposals and, 31; rights and privileges determined by categories, 25–28; as step in diagnosis process, 18 Client, as name for service recipient, 56–60; see also Consumers (former hospital patients) Clinical skills, 207–9, 233n1 Clipboards, 78, 84 Clorazil, 172

251

Cloward, Richard, 2 Clozaril, 154(table), 155, 172 Coercion, mental hospitals and, 8–9 Cogentin, 153, 154(table), 155, 162, 175 Community Mental Health Center Act (1963), 31, 32 Community Support Program Implementation Group, 31 Community support services, 17–41, 209–214; deﬁned/described, 26; disciplinary knowledge/power and, 42; elements of mental hospitals and community support services compared, 9(table), 24; historical roots, 12, 17–34; “in vivo” methods deﬁned, 33–34; jurisdiction and, 19, 42; life domains supported (meds, money, manners), 15, 49, 50(table), 51; monitoring mobility as the core of community support services, 48–56; naming of service recipient as “client” or “consumer” and, 56–60; NIMH Community Support Systems Strategy Development and Implementation program and, 34; NIMH ﬁndings on funding and need for leadership, 30–31; NIMH reform proposals and, 31–34; obstacles to establishment of, 40; politics of categories focused on “illness identities,” 24–26; politics of location, 24, 26–28; review of studies on deinstitutionalization, 20–24; rise of the case manager, 42–60; services and functions listed, 32–34; as social ﬁeld replacing mental hospitals, 7–8, 12, 19–28, 37, 40, 56–60; spatial enclosure of social relationships of helping and, 87; see also Continuum of

252

Community support services, (Cont.) care; Funding; Landscape for case management; Normalization, principle of; Outcomes; Transportation Community Support Services (High County): background information, 10–12; catchment area, 38–39; consumer drop-in center, 90–91; continuum of care and, 54–55; de facto living spaces in CSS buildings, 89–91; division of labor, 53, 93, 160–67; early years, 43–45; freedom of consumers to negotiate space at, 94–96; funding of, 12, 35–38, 44, 52; levels of service, 55; location and spatial arrangement of ofﬁces, 87–93; med room, 160–67; move to Andover, 88–89; move to Harrisville, 90; naming of service recipient as “client” or “consumer” and, 56–60; origins of, 34–41; perspective from inside the ofﬁce looking out, 86–97; PHP sector, 53–54; residential sector, 53–55; space allocation in contrast to hospitals, 90, 92–93; structure of, 11, 93–94; transition from group-based to individual services, 45–48; transition from situated case management into disciplinary knowledge, 52–56; vocational sector, 53–55; see also Landscape for case management Community Support Systems Strategy Development and Implementation program, 34–36 Community time, 21, 48–49 Conferences, 29–31 Coniglio, G. C., 36 Consumer drop-in center, 90–91

I N DEX

Consumers (former hospital patients), 9(table); “body” as term, 25–26; carless mentally ill, 89, 97–107; empowerment theories and, 211; failure to connect drug compliance with improvement, 172, 178–79; illnesses acknowledged by, 25; “illness identities” and perception of worthiness for aid, 24–26, 28; life domains supported (meds, money, manners), 49–51, 50(table); naming of (“client” and “consumer”), 40, 56–60, 70–72; need for employment, 28, 40; need for housing, 28, 39–40; need for money, 24, 26 (see also Employment; Money); oral narratives and language about need, dependency, and illness, 109–10; practical categories “low/high need,” “low/high functioning” (see “Low/high need,” “low/high functioning” expression); progression to a normative state, 51, 54; services for chronically mentally ill subordinated to the “worried well,” 11, 12, 32; statistics on client activity, 46–47(tables); structuring community time through surrogate life activities, 48–49; target population deﬁned, 38; transition from group-based to individual services, 45–48; variable movement within a life domain, 49–51; written texts and the production of goal-oriented, self-directed subjects, 116–17; see also “In vivo” methods; Choice; Daily living skills; Desires of consumers; Medications; Mobility; Money; Relations between helper and service

I N DEX

recipient; Target symptoms; Transportation Continuity of staff, 12 Continuum of care, 37–38, 49, 221(ﬁgure); mobility and, 38; monitoring changes in life domains and, 54–55 Corgard, 154(table) Criminality: “illness identities” in contrast to, 24; spending sprees and, 137 Crises: medications and, 162; money and, 133–36, 141–42, 145; ofﬁce spaces and, 94–95 Critical-realist perspective, 215–220 Cyclical nature of mental illness, 26, 124, 168 Cylert, 154(table) Daily living skills, 33–34; medications and, 160–67; partial hospital programs and, 44; statistics on time spent on, 47(table), 49; see also “In vivo” methods; Manners Decarceration, 22–23 Deﬁcit models of case management, 64–65, 74, 135 Deinstitutionalization, 1, 20–28; advocates vs. critics of, 10–11; beneﬁts of personal vs. institutional time, 9; community support services as a new social ﬁeld and, 19, 20–28; consumer advocacy and, 57; cyclical nature of mental illness and, 26; early projects, 17; economics of, 22–24, 229n5; effects on space allocation, 92–95; needs of former patients, 28 (see also Employment; Housing; Medications; Money; Transportation); NIMH-CSP con-

253

ferences on early policies, 29–31; overmedication and, 160; politics of location, 24, 26–28; review of studies on, 20–24; rise of categorical institutions, 17, 19; temporary living situations and, 213–214; see also Transportation Delusions, 152(table), 153, 178–79 Demographics, 100, 101(table), 102 Depakene, 154(table) Depakote, 154(table), 155 Dependency, 117; cultural signiﬁcance of, 194–95; “doing for” and, 181–82, 213; money and, 132–37, 145–46; natural consequences and, 192–93; see also “Doing for/doing with” expression Desires of consumers: emphasized in strengths case management, 65, 68–75; hidden motivations off-limits in strengths case management, 135, 168–69, 208; money as incentive, 143–44; symbolic component of, 139–40, 148–49; wants distinguished from needs, 74, 80–81, 121–22, 200–1; weighing desires and needs, 139–41; see also Goal planning Desyrel, 154(table) Diagnosis, see Assessment and diagnosis Dincin, Jerry, 30 “Disability,” rights and privileges determined by, 25–26, 28 The Disabled State (Stone), 25 Disciplinary gaze, 6–7, 90–91 Disciplinary knowledge/power, 6, 42, 219(ﬁgure); deﬁned/described, 2, 4–5; disciplinary language, 219

254

Disciplinary knowledge/power, (Cont.) (see also Goal planning); domestic violence shelters and, 85; economics of deinstitutionalization and, 22; examples of, 21; medications and, 175–76, 179; mental hospital compared to community support services, 9(table); monitoring and, 24; relations to situated knowledge, 6, 14–15, 123–24, 175, 179, 206–7, 209–214; routinization of case management, 55–56; self-directed behavior and, 67–68, 122–23; suppression of language of illness, 117–18, 122–23; time management and, 190–91; transition from situated case management into disciplinary knowledge, 52–56, 63; written texts as copies of, 116; written texts as empirical site of, 7, 109; see also Strengths case management Dispositions, teacher/student and parent/child, 16, 198–200 “Do him” expression: examples of use, 118–22; language of needs and, 121; meanings deﬁned/described, 122, 137; recognition of chronic nature of illness and, 121 “Doing for/doing with” expression, 149; consumer’s “investment” in CSS and, 144, 147; dependency and, 181–82; examples of use, 118–21, 145; medications and, 169; money and, 133–36, 144, 145; recognition of chronic nature of illness and, 121; recovery of language of self and, 213; relation to “gets it,” 122, 193; relation to natural consequences, 192, 194; self-monitoring capability and, 122,

I N DEX

205; situated knowledge/power and, 121–22, 181–85, 205–6; teacher/student or parent/child dispositions and, 199–200; time management and, 183–85 Domestic violence shelters, 85 Double funding of hospitals and community support services, 22, 23 Drug dealers, 2–3 Drugs, see Substance abuse Economics, 21; double funding of hospitals and community support services, 22, 23; economics of deinstitutionalization, 22–24, 229n5; mental hospital compared to community support services, 9(table); need for former patients to have money, 24, 26, 28 (see also Employment; Money) Education and training of social workers, 13, 43, 73–82, 198–99 Effect interpretation, 15, 151, 157, 165–76, 204 Effexor, 154(table) Elavil, 154(table) Eli Lilly and Company, 153 Employment, 33, 50(table); baseline behavior, 51; de facto living spaces in CSS buildings and, 91; discretionary money and, 145–47; former patients’ need for, 28, 40; monitoring and, 49, 50(table), 104; moral economy of case management and, 145–47; strengths case management and, 103; see also Vocational and prevocational training Empowerment theory, 211 Engagement ring crisis, 133–36 Eskalith, 154(table), 155

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Estroff, Sue, 24 Ethnography, 13, 15, 109–10, 209–214, 216–217, 220, 233n3 Foucault, Michel, 3–6, 206; biopower concept, 3, 27–28; on coercion, 8–9; “consumer” as term and, 57; pervasive power vs. power-over, 127; pessimism about progress in liberal social projects, 24; “speciﬁc” intellectuals concept, 5, 6 Fountain House, 21, 30, 229n3 Fragmentation of mental health services, 10, 12; Marmor and Gill’s fragmented polity thesis, 22, 24; NIMH ﬁndings on, 30 “Friendly visitor,” 16, 180 Funding: continuum of care and, 40; CSS (High County) funding, 11, 12, 44, 52; double funding of hospitals and community support services, 22, 23; economics of deinstitutionalization, 22–24, 229n3; naming of service recipient’s illness as “chronic” or “long-term” and, 56; NIMH ﬁndings on shift from state to federal funding, 30–31 Gaze, disciplinary, 6–7, 90–91 Geopolitical space, 85, 100–2, 107 “Gets it” expression: examples of use, 118, 120, 147; lack of explanations for not “getting it,” 212; meanings deﬁned/described, 110, 193–95; medications and, 172–73; money and, 133, 147; natural consequences and, 122–23, 193–95; possible alternate disciplinary schemes for consumers who don’t “get it,” 213–214; recogni-

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tion of illness and, 122; site for selfmonitoring and, 205; strengths case management and, 194 “Getting underneath,” 75–77 Gill, Karyn, 22 Girl, Interrupted (Kaysen), 7 Goal planning: consumer’s ability to understand goals, steps, and actions (see “Gets it” expression); deﬁned/described, 75–81; failure to achieve goals, 116–18, 121–22, 204; “getting underneath” and, 175–77; medications and, 121–22, 164, 169, 178; money and, 132–37, 139–40, 143–46; relationships and, 200; Robert and (case study), 112–14, 113(table), 116–17, 121–22; suppression of language of needs and, 80–81, 110 Gordon, Linda, 125, 148 Graebner, William, 20 Gramsci, Antonio, 5 Gregory, Dick, 80, 81 Habitus, deﬁned, 16; see also Helper habitus Haldol, 154(table), 155, 165, 174 Hallucinations, 152(table), 153 Handler, Joel, 2 Hannah, Jerry, 35–40, 54 Harris, Maxine, 207 Harrisville, KS, 90, 101(table) Helper habitus, 15–16, 180–201; deﬁned, 195–96; “doing for/doing with” and, 181–85; “low/high need,” “low/high functioning” and, 185–91; “natural consequences” and, 191–93; socioeconomic status of case managers and, 196–98; teacher/student and parent/child dispositions, 16, 191

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Helping relationships, see Relations between helper and service recipient High County, KS: demographics of, 102; lack of affordable housing, 99, 102; naturally occurring resources in, 100; see also Landscape for case management High County Mental Health Center, 10–12; see also Community Support Services (High County) A History of Retirement (Graebner), 20 Homelessness, 10, 27, 99; contrast to carlessness, 99–100; discretionary money used to prevent, 142; relation between wants and needs, 81 Home visits, 4, 96, 103–6, 206; see also Narratives, oral Hopper, Edward, 92 Hospitals, see State mental hospitals Hostility, 152(table), 153 Housing, 28, 33, 101–2; broker model and, 66; changing client needs, 50(table), 50–51; CSS’s move to Andover and, 88–89; early programs in Kansas, 39–40; home visits, 4, 96, 103–6, 206; lack of affordable housing in High County, 99, 102; money and, 141–43; residential sector of CSS, 53–55; Section 8 vouchers, 102, 104; see also Living situation Hygiene, 98, 147, 172, 173 ICF-MH, see Intermediate Care Facility for Mental Health (ICF-MH) “Illness identities,” and perception of worthiness for aid, 24–26, 28 Income levels in High County, 101(table), 102 Inderal, 154(table)

I N DEX

Inference/reasoning, as a modality of social work, 18–19, 24 Insomnia, 152(table), 153 Intellectuals, speciﬁc and organic, 5, 6 Interdependency, 69 Intermediate Care Facility for Mental Health (ICF-MH), 53–54 Interviews, 217, 223–225 “In vivo” methods, 33–34, 47, 49, 77, 116 Involuntary commitment, 11, 78 Irritability, 152(table), 153 Jackson, John Brinckerhoff, 106–7 Jurisdiction, 19, 42 Kansas: community support services and, 34–41; deinstitutionalization in, 10–11; demographics of High County, 102; economics of deinstitutionalization in, 23; Living, Inc. program, 39; mandated strengths case management, 67, 109–10, 210; Partnership Agreement for Continuity of Treatment, 39 Kansas Case Management Act (1988), 62 Kansas Mental Health Reform Act (1990), 8, 11, 27, 62 Kanter, Joel, 207–8 Kaysen, Susanna, 7 Klonopin, 154(table), 155 Knievel, Evel, 80–81 Lamb, Richard, 30 Landscape for case management, 83–107; boundaries and, 106–7; carless mentally ill, 89, 97–107; carspeciﬁc interactions between social workers and consumers, 97–98, 105;

I N DEX

convenience and, 106; crises and ofﬁce spaces, 94–95; de facto living spaces in CSS buildings, 89–91; deﬁned/described, 83–86; driving time, 97–98, 100, 106; ﬂuid boundary between social workers’ and recipients’ space, 96; income levels in High County and, 101(table), 102; need to adapt low incomes to high-income landscape, 102; perspective from inside the ofﬁce looking out, 86–97; perspective from outside looking in, 97–107; privacy (see Privacy); relationship between linking, monitoring, and driving, 102–7; see also Constraints on case management; Home visits Language: “body” as term, 25–26; choice and, 70; classiﬁcation as syntax of political rhetoric, 20; “clinical” vs. “case management” terms, 32; helper-service recipient relationship framed by categorical labels, 25; hospitalization framed as the critical problem, 27; “illness identities” and perception of worthiness for aid, 24–26, 28; labeling illnesses, 71–72; language about need, dependency, and illness, 109–10, 118–24; language of wants vs. language of needs, 74–75, 127–28, 135; money and, 127–28; naming of service recipient, 56–60, 70–72, 127; NIMH reform proposals and, 31; “A Person and a Patient” (poem), 71; “rehabilitation” as term, 65; rights and privileges determined by categories, 25–26; situated language (see “Do him” expression; “Doing for/doing with”

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expression; “Gets it” expression; “Low/high need,” “low/high functioning” expression; Natural consequences; Situated language); suppression of language of illness and need, 117–18, 122–23; suppression of language of self, 202–6; voluntary participation and “consumer” as term, 59; written texts and the production of goal-oriented, selfdirected subjects, 116–17; see also Narratives, oral; Narratives, written Learning by doing, 42–45 Least restrictive environment, 33, 36, 49, 51 Lerman, Paul, 23 Life domains (meds, money, manners), 49–51, 50(table); progression to a normative state, 51, 54; in strengths case management, 74–75; variable movement within, 49–51, 54; see also Manners; Medications; Money Limitations of strengths case management, 202–9; failure to achieve goals and, 116–18, 121–22, 204; hidden motivations neglected, 135, 168–69, 208; lack of language for consumers who don’t “get it,” 122–23, 194 (see also “Gets it” expression); management conﬁned to surface level of helping relationships, 206, 208; medications and drinking and, 168–69; money and, 132–37, 148–49; suppression of language of self, 202–8; time management considerations neglected, 183–85, 188–90 Linking, 102–7, 125–26 Lipsky, Michael, 213 Lithobid, 153, 154(table), 155, 165

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Living, Inc., 39 Living situation: baseline behavior, 51; behavioral and motivational clues, 77–78, 103–5, 206; monitoring and, 49–51, 50(table), 96, 104; natural consequences and, 123–24; residential supervisors, 53–54; Robert and (case study), 110–12, 115–16, 118–24, 213; see also Homelessness; Housing Location, see Space “Low/high need,” “low/high functioning” expression, 213; examples of use, 118, 121, 169, 173, 175; meanings deﬁned/described, 186–88; medications and, 169–71, 173, 175; as names for self-monitoring capability, 110, 205; situated knowledge/power and, 185–91; strengths case management and, 188–90; time management and, 188–90 Loxitane, 154(table), 155 Lubove, Roy, 195 Lunbeck, Elizabeth, 209 Luvox, 154(table) Manners: as ability to follow a routinized schedule of daily activities, 55; baseline behavior, 51; complex relationship between money, medication, and manners, 172; discretionary money and, 143–49; as life domain supported by situated practice, 15; limitations of strengths case management and, 204; monitoring of, 49, 50(table); as social support model, 34; see also Daily living skills Margolin, Leslie, 4 Marmor, Theodore, 22 Maslow, Abraham, 80, 81

I N DEX

Mass transit, 28, 89, 98–99 Med boxes, 162–67 Med drop, 163–67, 169, 232n1 Medicaid, 44, 52, 67; home visits and, 116 Medications, 15, 34, 150–79, 154–56(tables), 175–76; baseline behavior, 51; categories of, 152(table), 153, 155–60; combinations of, 156–60; complex relationship between money, medication, and manners, 172; compliance monitoring and, 49–51, 50(table), 102–3, 160–67; consumers’ failure to connect drug compliance with improvement, 172, 178–79; crises and, 162; desired effects of, 157–59, 165–79; disciplinary knowledge/power and, 175–76, 179; division of labor, 160–67; effect interpretation, 151, 157, 165–76, 204; frequency of use, 153–56; goal planning and, 121–22, 164, 169, 178; high users, 151, 156–59; injectable, 162, 175–76; levels of service, 55; low users, 151, 156–59; med room, 160–67; number used per consumer, 157; overmedication, 160; perception of effects on the body, 176–79; prescription frequency, 153, 154–56(tables); Robert and (case study), 113–17, 119–21; side effects, 232n3; situated knowledge/power and, 151, 157, 167–79; transportation and, 99; unpredictable effects of, 151, 153, 155, 157–60, 165, 178 Med room, 160–67 Mellaril, 154(table), 155, 166 “Member,” as term for service recipient, 58–59

I N DEX

Memory and concentration, poor, 152(table), 153, 178–79; case managers as auxiliary memory for consumers, 176, 178–79 Mental health policies: lack of literature on social work practice, 20; Marmor and Gill’s fragmented polity thesis, 22, 24; measurements of success focused on reduction of hospital utilization, 27; naming of service recipient as “client” or “consumer” and, 56–60; politics of categories focused on “illness identities,” 24–26; politics of location, 24, 26–28; review of studies on deinstitutionalization, 20–24; Weiss’s study, 21; see also Deinstitutionalization Mental illness: chronic nature of, 33–34, 56, 118, 121; cyclical nature of, 26, 124, 168; labeling and, 71–72; language and (see “Doing for/doing with” expression; “Gets it” expression; “Low/high need,” “low/high functioning” expression; Natural consequences); oral narratives and language about need, dependency, and illness, 109–10, 118–24; suppression of language of illness in written narratives, 117–18; see also Medications; Target symptoms Mobility, 21; case managers and, 42; continuum of care and, 38; mental hospital compared to community support services, 9(table); monitoring mobility as the core of community support services, 48, 49–56; see also Transportation Money, 15, 125–49; case managers as representative payees, 129–37; com-

259

plex relationship between money, medication, and manners, 172; consumer management of, 127, 137–41; consumers’ need for, 127; crises, 133–36, 141–42, 145; debate over separation or integration of social service with cash assistance, 148–49; discretionary, 141–49; engagement ring crisis, 133–36; goal planning and, 132–37, 139–40, 143–46; historical use of money in social work, 148; household maintenance, 55; as incentive for “investment” in CSS, 143–44, 147; language for self-monitoring capability, 204–5; life skills and rehabilitation model, 34; limitations of strengths case management and, 132–37, 148–49; linking and, 125–26; manners and, 143–49; median incomes in High County, 101(table), 102; medications and, 162; mental hospitals as socialized economy, 126–27; monitoring and, 103, 104, 125; moral economy of case management and, 126, 128–49; need to adapt low incomes to high-income landscape, 102; Robert’s ﬁnances (case study), 111–12; sex and, 139; spending sprees, 136–37; strengths case management and, 127–49; substance abuse and, 103, 112; symbolic component of desires, 139–40, 148–49; transportation and, 99; weighing desires and needs, 139–41; welfare debates of the 1950s and 1960s, 148 Monitoring, 42, 104; consumer drop-in center and, 90–91; employment and, 104; ﬂuid boundary between social workers’ and recipients’ space, 96;

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Monitoring, (Continued ) and Foucault’s pessimism about progress in liberal social projects, 24; intrusiveness of, 105–6, 206; living situation and, 49, 50(table), 51, 96, 104; medications and, 49, 50(table), 51, 102–3, 160–76; money and, 103, 104, 125; monitoring changes in life domains, 51; monitoring mobility as the core of community support services, 48, 49–56; power relations and self-monitoring, 203–4; reading clues during home visits, 77–78, 103–5, 206; relationship between linking, monitoring, and driving, 102–7; site for self-monitoring, 204–5; social skills and, 49, 50(table); strengths case management and, 105–6 Moral economy of case management, 126, 128–49, 204, 205; discretionary money and, 141–49; engagement ring crisis, 133–36; housing and, 145–46; weighing desires and needs, 139–41 Motivations of consumers: hidden motivations off-limits in strengths case management, 135, 168–69; money and, 135; see also Desires of consumers Narrative, 108–24; empirical site of situated vs. disciplinary knowledge, 109; importance of using both oral and written narratives in research, 108–11, 116–17; work performed by both spoken and written narrative, 109; see also Disciplinary knowledge/power; Situated knowledge/ power

I N DEX

Narrative, oral, 6, 15, 109–10; expressions signifying situated knowledge (see “Doing for/doing with” expression; “Gets it” expression; “Low/high need,” “low/high functioning” expression; Natural consequences); language about need, dependency, and illness, 118–24; medications and, 164–66, 168–74, 177–79; money and, 133–34, 143–48; ofﬁce talk, 119–20; structured interviews, 217, 223–225; team meetings, 118–20, 133–34, 165–66, 168–74, 177–79; unique work performed by, 109 Narrative, written, 15, 109, 113–18; focus on goal-attainment in, 113–17; incomplete nature of, 116–17; as records of disciplinary knowledge only, 209–210; repetitive nature of strengths-based text when confronted by failure to achieve goals, 116–18; suppression of language of illness, 117–18; textual, self-directed consumers, 112–14, 116–17; workshop training, 63–82; written texts as copies of disciplinary knowledge, 116 National Institutes of Mental Health (NIMH), 13; Community Support Systems Strategy Development and Implementation, 34; conferences on early deinstitutionalization policy, 28–31; on CSS and case management, 32–34; proposals for reform of community support services, 31–34; strengths case management and, 64; Weiss’ study on, 21 Natural consequences, 110, 191–95; dependency and, 192–93; examples of use, 118–20; failed goals and, 123;

I N DEX

“gets it” and, 122–23, 193–94; housing and, 123–24; money and, 134–35, 137, 141; situated knowledge and, 118–20, 122–23, 191–95 The Natural History of Discourse (Silverstein & Urban), 107 Navane, 154(table), 155 Nelson, Barbara, 20 NIMH-CSP conferences, 29–31 Normalization, principle of, 33, 36–37, 69–70, 204; naming of service recipient as “client” or “consumer” and, 57; structuring community time and, 49; written text and, 114 Oaklawn, KS, 39–40, 52, 87–88, 101(table) Ochberg, Frank, 31 Ofﬁce spaces, 86–97 Outcomes, 24–25; limitations of strengths case management, 117–18, 121–23, 202–9; measurements of success focused on reduction of hospital utilization, 27; research on case management and, 65, 66, 207, 214 Outreach Place, 58–59 PACT model, 65–66 Pamelor, 154(table) Parent/child dispositions, 16, 198–200 Parnate, 154(table) Parry, John, 126 Partial hospital programs (PHP), 44–45, 53; disciplinary knowledge inappropriate for real-life intervention, 66; focus on group and sitespeciﬁc surrogate activities, 45–46, 48–49; PHP sector of CSS, 53–54; spatial enclosure of social relation-

261

ships of helping and, 87; statistics on client activity, 46–47(tables) Partnership Agreement for Continuity of Treatment, 39 PASS program, 145 Patients: economy of the hospital and, 127; as service recipient in mental hospital social ﬁeld, 9(table), 56; see also Consumers (former hospital patients) Paxil, 154(table) Personal Plan, 79–81 “A Person and a Patient” (poem), 71 Pertofrane, 154(table) PHP, see Partial hospital programs (PHP) Piven, Frances Fox, 2 Policies, see Mental health policies Policy environments, 84–86 Politics: classiﬁcation as syntax of political rhetoric, 20; politics of categories focused on “illness identities,” 24–26; politics of location, 24, 26–28 Pondimin, 154(table) Poverty, perception of welfare as a bigger problem than, 27 Power relations: ﬂuid boundary between social workers’ and recipients’ space, 96; medications and effect interpretation, 165–66; pervasive power vs. power-over, 127; power relations of work sites, 87; see also Relations between helper and service recipient Practical wisdom, see Situated knowledge/power Practitioners, see Case managers Prevocational training, see Vocational and prevocational training

262

Principle of normalization, see Normalization, principle of Prior, Lindsay, 25 Prisons, 23 Privacy: managers’ need for, 89, 96; ofﬁce space and, 89, 94–97 The Professional Altruist (Lubove), 195 Prolixin, 154(table), 155, 171, 175–76 Prozac, 154(table) The Psychiatric Persuasion (Lunbeck), 209 Psychiatrists, 166–67, 174–75 Psychodynamic theory, 149, 206 Psychotherapy, and “clinical” vs. “case management” terms, 32 Qualitative research methods, 215–220 Rapp, Charles, 13, 61–63, 201 Recovery model, 230n5 Recreational activities, 47(table), 48 Rehabilitation models, 22, 64–65, 228n1 “Rehabilitation” (term use), 65 Relations between helper and service recipient, 21; behavioral change and, 67–68; broker model and, 66–67; carspeciﬁc interactions, 97–98, 105; case managers as auxiliary memory for consumers, 176, 178–79; consumers as drivers of their desires and of the helping relationship, 73; framed by categories (“chronically mentally ill,” “disabled,” etc.), 25; medications and effect interpretation, 165–66; money and, 131–49; naming of service recipient as “client” or “consumer” and, 56–60, 72–73; negotiation between case managers and consumers, 95; psychodynamic theory needed for

I N DEX

understanding impact of money on helping relationships, 149; relationship between linking, monitoring, and driving, 102–7; spatial enclosure of social relationships of helping, 86–87, 96, 107; strengths case management and, 73–74, 78–79, 81, 200–1; strengths management conﬁned to surface level of helping relationships, 206, 208; teacher/student and parent/child dispositions, 16, 198–200; translating wants into concrete tasks and, 200–1; see also Monitoring Research: on broker model, 66; KU work on developing strengths case management, 61–63; neglect of reallife applications of models, 207, 211, 214; on PACT model, 65; review of studies on deinstitutionalization, 20–24 Research methodologies, 11–15, 209–214, 215–220; structured interviews, 217, 223–225; see also Ethnography; Narrative, oral; Narrative, written Residential House, 53–54, 123–24 Residential institutions, 20; see also Categorical institutions; State mental hospitals Resources: internal and external, 69; securing and maintaining, as goal of strengths case management, 68–73; segregated, 85, 89, 91, 99–100 Restaurants, as private spaces, 89, 96 Richmond, Mary, 180 Risperdol, 154(table), 155, 175 Ritalin, 154(table) Salaries of case managers, 11, 196 Sayer, Andrew, 216

I N DEX

Schorr, Alvin, 148–49 Scull, Andrew, 22–24 Secrecy, 85 Segal, Steven, 30 Segregated resources, 85, 89, 91, 99–100 Self-actualization, 80, 81 Self-improvement schemes in Western culture, 195–96, 198, 201 Service recipient, see Consumers (former hospital patients) Serzone, 155(table) Sex, 139 Sharfstein, Steven, 30 Silverstein, Michael, 107, 114 Sinequan, 155(table) Situated knowledge/power, 180, 219(ﬁgure); consumer drop-in center and, 91; discretionary money and, 141–49; distinguished from disciplinary knowledge/power, 5–6; in early years of CSS, 44; funding and, 44; helper habitus and, 180–201; language about need, dependency, and illness, 109–10; levels of service and, 55; medications and, 151, 157, 167–79; money management and, 135; monitoring and, 105–6; nature and study of, 209–214; oral narrative as empirical site of, 7, 109–10; oral narratives and language about need, dependency, and illness, 118–24; partial hospital programs and, 44; relations to disciplinary knowledge/power, 6, 123–24, 175, 179, 206–7, 209–214; unique work performed by, 109, 118–24, 210–214 Situated language, 16, 110, 206; see also “Do him” expression; “Doing for/doing with” expression; “Gets it” expression; “Low/high need,”

263

“low/high functioning” expression; Natural consequences Situated practice, 6; life domains supported (meds, money, manners), 15; relation to disciplinary practice illuminated by crisis and social drama, 14–15; role of spatial arrangements in deﬁning the nature of practice, 14; sources of, 15–16; transition from situated case management into disciplinary knowledge, 52–56, 63 Smith, Dorothy, 233n3 Social ﬁelds: Bourdieu’s concept deﬁned, 7–8; community support services as, 7–8, 12, 19, 20–28, 37, 40; elements of mental hospitals and community support services compared, 9(table), 24; naming of service recipient as “client” or “consumer” and, 56–60; NIMH reform proposals and, 31–34; principle of normalization and, 36–37; research methodology and, 219–220; rise of case managers, 42–60 Social skills, see Manners Social work: community support services as a new social ﬁeld, 19; competing paradigms of, 19; historical perspective on deinstitutionalization and growth of social work as a profession, 17–19, 42; inﬂuence of policies on, 2; modalities of (diagnosis, inference, treatment), 18–19; role of spatial arrangements in deﬁning the nature of practice, 85–86 (see also Landscape for case management); schools of therapy, 19; spatial enclosure of social relationships of helping, 86–87

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Social workers: “coercive” and “acquiescent” views of, 2; division of labor, 53, 93, 160–67; education and training of, 43, 73–82, 198–99; learning by doing, 42–45; statistics on staff activity, 47(table); subjective conditions of work and, 42, 49–56, 97–98; theoretical and methodological considerations in study of, 2–7; see also Case managers Socioeconomic status of case managers, 196–98 Soja, Edward, 85 Space, 21, 86–97; boundaries, 96, 106–7; clinical treatment and, 9, 14, 32, 85; de facto living spaces in CSS buildings, 89–91; ﬂuid boundary between social workers’ and recipients’ space, 96; geopolitical space, 85, 100–2, 107; irony and, 92–93; landscape of state mental hospitals, 90; least restrictive environment, 33, 36, 49, 51; limited public spaces in suburbs, 91; location and spatial arrangement of CSS ofﬁces, 87–93; med room, 160–67; mental hospital compared to community support services, 9(table); ofﬁce spaces, 86–97; politics of location, 24, 26–28; privacy, 89, 94–97; role of spatial arrangements in deﬁning the nature of practice, 14, 85–86 (see also Landscape for case management); social production of social space, 85; spatial enclosure of social relationships of helping, 86–87, 96, 107; suburban public space, 99; see also Homelessness; Landscape for case management; Mobility; Transportation

I N DEX

“Speciﬁc” intellectual, Foucault’s concept of, 5 State mental hospitals, 8–9; boundaries and, 106; clinical environment described, 8–9, 14; coercive nature of, 8–9; compared to community support services, 9(table), 24; landscape of, 90; naming of service recipient as “patient” and, 56; redeﬁned as spaces for short-term use and stabilization, 40; as socialized economy, 126–27; spatial enclosure of social relationships of helping and, 87; spatial signiﬁcance and, 85; see also Partial hospital programs (PHP) Stein, Leonard, 30 Stelazine, 155(table) Stimulants, 158(table) Stone, Deborah, 25, 28 Stone, G. Bart, 31 Street, Allen, 34–35 Strengths case management, 1, 13, 61–82, 206; assessment in, 64–65, 69, 73–82, 76(table); assumptions of, 62, 73, 116–17, 195–96, 198; background and development of, 61–63; behavioral and motivational clues, 77–78, 103–5, 206; change as a product of identifying agreed-upon competencies in communities, 18; choice and, 79, 120–21; clinical skills and, 207–9; de facto living spaces in CSS buildings and, 89, 91; deﬁned/described, 63–68, 230–231n1; as disciplinary knowledge/power, 5; employment and, 103; “gets it” expression and, 194; “getting underneath,” 75–77; helping people achieve their desires

I N DEX

as purpose of, 68–73; interdependency and, 69; “in vivo” methods and, 77; lack of guidance for work in a suburban landscape, 106; “low/high need,” “low/high functioning” categories and, 188–89; mandated by state, 67, 109–10, 210; medications and, 175, 178; money and, 127–49; monitoring and, 105–6; naming of service recipient as “consumer,” 57, 70–72; naturally occurring vs. segregated resources, 89, 99–100, 204; normality and, 69–70; Personal Plan, 79–81; production of goal-oriented, self-directed subject and, 116–17; property to produce helping effects, 5; relation between helper and service recipient, 73–74, 78–79; self-monitoring as goal of, 79, 121, 204–5; suppression of language of illness and need, 117–18, 121–22; wants distinguished from needs, 80–81, 200–1; writing strengths cases, 73–82; see also Goal planning; Limitations of strengths case management; Money; Narratives, oral; Narratives, written; Relation between helper and service recipient Subjective conditions of work (Abbott’s concept), 42, 97–98; mobility and, 49–56 Substance abuse, 103; money management and, 134–35; Robert and (case study), 110, 112 Suicide, 152(table), 163 Symmetrel, 155(table) Symptoms, see Effect interpretation; Target symptoms

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Talbot, John, 30 Target symptoms, 152(table), 153–60, 165; listed, 152(table), 153; medication and, 165, 168–79; see also Effect interpretation Taylor, Betsy, 63–72 Teacher/student dispositions, 16, 198–200 Teasley, Sarah, 43–57, 87 Tegretol, 155(table) TenHoor, William, 29, 30, 31, 32, 33, 34 Test, Mary Ann, 30 Therapy: schools of, 19; transition from group to individual, 45–48 Thirdspace (Soja), 85 Thorazine, 150, 155, 155(table) Thoreau, Henry David, 81 Thresholds (organization), 21, 229n3 Time: clinical treatment and (ﬁftyminute hour), 32; community time, 21, 48–49; institutional vs. personal and private time, 9; medications and, 161; mental hospital compared to community support services, 9(table); recognition of need for ongoing support (“inﬁnite duration” of mental illness), 33–34; time management needed for case management, 183–85, 188–90; time necessary to complete daily living tasks, 55 Tofranil, 155(table) Topeka State Hospital, 10, 40, 93 Transitional housing programs, 21, 22, 26, 39–40, 53–54, 123–24, 145–46 Transportation: carless mentally ill, 89, 97–107; driving time, 97–98, 100, 106; landscape for case managers and, 83–107; as a major issue of deinstitutionalization, 11, 28; relationship

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between linking, monitoring, and driving, 102–7; statistics on providing transportation to service recipients, 47(table), 49; suburban landscape and, 14, 97–107; suburban public space and, 99; time management and, 183–85; see also Mobility Treatment: as a modality of social work, 18–19, 42; relation to diagnosis and inference, 18; treatment distinguished from helping people to get what they desire, 68; see also Strengths case management Trilafon, 155, 155(table) Turner, Judith, 29, 30, 31, 32, 33, 34 Turner, Victor, 14–15 University of Kansas Ofﬁce of Social Policy Analysis, 27 University of Kansas School of Social Welfare, 13, 19, 52, 61–73, 230–231n1 “Unspeciﬁed worker behavior,” 207 Urban environments, homelessness and, 100 Urban, Greg, 107, 114 Valium, 155(table) Vega, George, 62

I N DEX

Vocational and prevocational training, 51, 53; statistics on time spent on, 47(table), 49; vocational sector of CSS, 53–55 Voluntary participation in programs, 59 Wakeﬁeld, Jerome, 4 Walsh, Joseph, 208 Weiss, Janet, 20–22 Welfare: perception of welfare as a bigger problem than poverty, 27; welfare debates of the 1950s and 1960s, 148 Welfare state, 2; economics of deinstitutionalization and, 22–23 Wellbutrin, 155(table) Wickenden, Elizabeth, 148 Wolfensberger, Wolf, 30, 37 “Worried well,” 11, 12, 32, 87 Writing strengths cases, 73–82 Wyatt v. Stickey, 36 Xanax, 155(table) Zoloft, 155(table) Zyprexa, 153, 154(table), 155, 166