Meds, Money, and Manners: The Case Management of Severe Mental Illness
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Appendix A for a description of the
research methods.
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References for a list of
citations.
See news article describing the book: "
A Case for
Intuition."
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Book Reviews
Synopsis
Policy analysts, historians, legal scholars, sociologists, and academic social workers often
represent human service practitioners as omnipotent or self-interested state functionaries, as
naïve minions, regulating, policing, and controlling behavior. Some argue that no unprompted action
is possible, while others look for agency, resistance, discretion, autonomy, and empowerment.
Post-modern theorists represent social work as the product of pervasive and dispersed systems of
policy, organization, and discursive production. And the steady expansion of "totalizing" systems
raises significant theoretical and practical questions about the sites where practitioners take the
products of policy, organization, and discursive formations and with them make or do something
strategic, personal, and new.
In this ethnographic and historical-sociological study of case managers, I explore the terrain
between these opposing representations of helping professionals, between Joel Handler's coercive
social worker and Richard Cloward's and Frances Fox Piven's acquiescent one. Specifically, this
study is about case managers who mobilize resources in a mental health organization to produce the
effect of keeping the mentally ill living in communities. The policy is deinstitutionalization and
the disciplinary practice is strengths case management.
My study of case managers' everyday work-what I have called disciplinary and situated
practices-explores not only how the policy of deinstitutionalization, community support service,
and strengths case management determines practice. It also examines how practitioners produce
effects that are of their own making. My work challenges studies of social workers by not
presupposing total autonomy or determination. With the concepts 'disciplinary' and 'situated'
knowledge\power I place the argument between binary or dichotomous representations. Most important,
I argue that without the concept situated practice, indigenous or local knowledge, there is only a
history or sociology of structures: policies, organizations, state formations, or particular
knowledge paradigms. In short, a history without social workers cannot produce a history of social
workers.
I examine a suburban, Midwestern, community mental health center to identify the disciplinary
and situated practice of thirty-five case managers and explore how they use knowledge\power to
produce the effect of deinstitutionalization. I am not, however, testing any particular hypothesis
about the effectiveness of the helping profession or case management; this is not an outcome
evaluation study. Nor am I studying the labor process of managers or the organization of work, as a
sociologist might study work and organizational behavior. Moreover, it is not my aim to make a
judgment about the relative merits of community living over hospitalization.
I provide a corrective to accounts of social workers that rely solely on the analysis of
disciplinary knowledge. A holistic understanding of practice must show how two knowledge\power
systems-the disciplinary and situated-produce effects. Here, I address epistemological and
methodological questions related to the study of situated practice. How does one know, for example,
when a practice is situated or disciplinary? And, are situated practices inscribed into
practitioner texts? If the situated is unwritten, how might the study of social workers benefit
from ethnographic and related qualitative methods? I analyze the limits of reading the written
texts of practitioners. By concatenating written and oral narratives, I produce a new narrative of
case management. I show how case managers' oral narratives, or situated knowledge, performs
different work with a language different from strengths case management. In addition, I demonstrate
the limitations of using written texts to understand social work practice.
My use of the concepts social field, habitus, and social space lead to an understanding of how a
study of situated practice requires specific units of analysis: the social field, the field's
unique power relations, the field's corollary use of space, and the field's sense and use of time;
these are elements of helping social fields that make social work a lived experience, an experience
with strategic, contextual, and helper habitus practices. Although managers are constrained by the
conditions of practice, they also find in the interstices the possibility and material for situated
understandings and response.
Community support service and mental illness serve up to practitioners the quotidian problems of
meds (medication), money, and manners. Managers negotiate these through recursive exchange; they
hope, for example, to exchange medication for consumer target symptoms: confusion, lethargy,
paranoia, hostility, agitation, and depression. I show how the exchange of practitioner medical
knowledge (medicine) for consumer psychiatric symptoms entails worker interpretation. When medicine
fails to produce the desired effect, my data shows that managers use "effect interpretations" to
give meaning to the use of medications. Likewise, when clients "irrationally" spend money, they are
confronted not with strengths but with a situated and moral economy of case management.
In sum, in substituting the subject position "patient" for "consumer," service recipients of
strengths case management transpose dependent and institutionalized forms of hospital-based
behavior for the normalized and commodity-based social services of meds, money, and manners. I
argue that strengths case management erases the self and ironically abandons the client to a
sociological island of community resources. I discover situated practice by first studying how
managers use strengths to negotiate (structured by the CSS social field) everyday exchanges.
Second, I investigate cases of unsatisfactory outcomes. And third, I look for the conditions of
situated knowledge in the manager's effort to resolve problematic cases. Finally, I argue that the
epistemology of situated knowledge is found in the practice space between the unresolved effects of
applied disciplinary scheme(s) and the practitioner's language\action that strives to achieve the
social field's hoped-for and desired effect (e.g., apartment-dwelling consumers of mental health
services).
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