ESSAY REGARDING CASE MANAGEMENT
JAMS
clinical_case_management_2010.pdf
Published in ―Theory and Practice of Clinical Social Work (2 nd
Edition), J. Brandell,
Ed., Columbia University Press, 2010.
2200
CLINICAL CASE MANAGEMENT
Joel Kanter
Over the past 30 years, case management has become a ubiquitous intervention
approach throughout the mental health and health care fields. Often poorly defined, case
management, perhaps a linguistic repackaging of ―social work‖ or ―social casework,‖
encompasses a wide range of environmental interventions with persons in need,
including persons suffering from severe mental illness, substance abuse, and chronic
medical conditions such as HIV, tuberculosis, and diabetes. In health care, the term case
management can refer to cost-conscious telephone interventions to monitor medical
services or to discharge planning from an inpatient facility. In mental health, case
management may refer to helping a client obtain disability benefits or apply for housing
assistance. Or it may refer to a friendly paraprofessional visitor who assists with
homemaking and transportation.
Addressing these disparate needs, an array of case management models have
been identified and articulated: brokerage, rehabilitation, strengths based, and clinical.
Other adjectives have been frequently used to characterize less specific case
management interventions: ―intensive,‖ ―assertive,‖ and ―standard.‖ Understanding the
case management literature often requires readers to carefully examine details of the
actual interventions and human resource issues to determine what the term case
management means in each situation.
Were the interventions short-term or long-term?
Were the relationships between case managers and clients personal or
administrative?
Was ―case management‖ the main activity of the worker or one of an array
of interventions?
What were the duration and frequency of case management contacts?
Were the scope of case management interventions focused on clients
holistically or were they narrowly focused on a single illness or life domain?
How large were case managers‘ caseloads?
Did case managers address the interplay between psychological and
environmental concerns?
What was the professional training and experience of the case managers?
In this chapter, the focus will be on a specific case management model—clinical
case management—that addresses the above questions with more clarity than other
approaches. In a clinical case management approach, relationships with clients are
valued, interventions are holistically focused, and case managers recognize the interplay
between psychological and environmental domains. Clinical case management can be
defined as a modality of social work practice that, acknowledging the importance of
biological and psychological factors, addresses the overall function and maintenance of
the person‘s physical and social environment toward the goals of facilitating physical
survival, health and mental health, personal growth, and community functioning
(Kanter, 1989).
This definition has several distinctive components. First, it identifies clinical
case management as a modality of social work and mental health practice, implying that
it involves special training and skills comparable with those required in psychotherapy,
psychopharmacology, or psychosocial rehabilitation. Clinical case management is a
specialized professional field practiced by social workers and other mental health
clinicians; it is not merely an administrative system for coordinating services.
Second, while focusing on the patient‘s physical and social environment, this
definition recognizes the importance of integrating case management into a
comprehensive biopsychosocial treatment plan. Although some case management
models advocate segregating case management from other clinical interventions (Rapp
& Chamberlain, 1985), clinical case management can be one of several intervention
strategies used by a social worker, or it can be the primary role of the worker,
implemented as part of a team of mental health or health care professionals.
Finally, this definition of case management focuses on all aspects of the physical
and social environment. These involve formal resources, which offer housing, financial
support, and medical care, as well as informal resources, such as families, roommates,
neighbors, and churches. From this perspective, a mere referral to a housing program is
an inadequate response to a person without a social network or fulfilling daily activities.
In clinical case management, five principles are emphasized:
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)
5. Facilitating client resourcefulness or strengths
Clinical case management involves an array of intervention strategies. Although
the early case management models outlined five core components—assessment,
planning, linking, monitoring, and advocacy—an examination of the actual practice of
case management identified 13 components that encompass the delicate process of
engaging clients in a collaborative relationship, a variety of interventions with both the
client and the environment, and the recurring need for crisis intervention in the context
of a long-term relationship.
Components of Clinical Case Management
Initial phase
1. Engagement
2. Assessment
3. Planning
Environmental focus
4. Linking with community resources
5. Consulting with families and caregivers
6. Maintaining and expanding social networks
7. Collaborating with physicians, social agencies, mental health, and health care facilities
8. Advocacy
Client focus
9. Intermittent individual psychotherapy
10. Teaching independent living skills
11. Psychoeducation about psychiatric and medical disorders
Client-environmental focus
12. Crisis intervention
13. Monitoring
The scope of clinical case management can be best appreciated through how this
approach would be used in assisting a homeless person. In a generic case management
approach, the problem is simple: to help the homeless person find housing. The case
manager‘s role might even begin and end with a simple referral to a homeless shelter or
to a low-income housing program. Or perhaps, viewing the problem as simply a matter
of inadequate resources, the case manager might refer the homeless person to an
employment program or to a Social Security office.
In contrast, the clinical case manager would understand that homelessness often
results from multiple factors: untreated mental illness, substance abuse, domestic
violence, natural disasters, unemployment, family disintegration, family conflict, poor
social skills, and so on. And even these factors rarely occur in isolation. The survivor of
domestic violence may have a severe psychiatric disorder, which makes her susceptible
to exploitation. Or a young man ejected from a family home may have severe problems
with substance abuse.
Of course, the economic factors that enable residential stability are inevitably
affected by these other domains. Employment difficulties are frequently exacerbated by
psychiatric disorders, substance abuse, or chronic medical illness. Even obtaining
disability benefits for psychiatric disorders can be impaired by the very disorder that
entitles a person to such benefits.
Finding and maintaining a stable home involves addressing these relevant
factors; otherwise, a simplistic residential ―placement‖ is likely to deteriorate quickly
and result in new episodes of homelessness. The clinical case manager does not address
all these problems single-handedly. Invariably, other resources are involved: concerned
relatives and friends, other mental health professionals, health care services, social
agencies, community programs, government agencies, and the client himself or herself.
The clinical case manager‘s job is to mobilize these disparate resources, sometimes
through a simple referral, sometimes through ongoing consultation and collaboration,
and sometimes through direct interventions.
Clinical Case Management: A Historical Perspective
Although environmental interventions have been conducted for many years, the term
case management did not enter our professional vocabulary until 1976, when it was
articulated as a key element of the Principles for Accreditation of Community Mental
Health Service Programs, issued by the Joint Commission on Accreditation of
Hospitals (JCAH; 1976). This report, authored by Ronald Gerhard and Richard Dorgan,
policy analysts for the New York State Department of Mental Hygiene, presented the
basic principles of the Balanced Service System model (Gerhard, Dorgan, & Miles,
1981), a comprehensive approach to community mental health programming that
provided the conceptual foundation for the National Institute of Mental Health‘s
community support system model (Turner & TenHoor, 1978).
The JCAH‘s (1976) guidelines defined case management as ―activities aimed at
linking the service system to a consumer and at coordinating the various system
components in order to achieve a successful outcome. The objective of case
management is continuity of service‖ (p. 20). The report went on to enumerate five
basic functions of case management: (1) assessment, (2) planning, (3) linking, (4)
monitoring, and (5) advocacy.
Reflecting a widespread dissatisfaction with the psychotherapeutic orientation of
many community mental health professionals, this concept of case management
promoted a service brokerage approach that was conceptually and administratively
segregated from other treatment interventions. For example, the JCAH (1976) report
states that ―case management is essentially a problem-solving function designed to
ensure continuity of service and to overcome system rigidity, fragmented service,
misutilization of certain facilities, and inaccessibility‖ (p. 21).
Although acknowledging that ―case managers maintain continuous relationships
with consumers, assisting, whenever required, in the alleviation of crisis-provoking
situations‖ (p. 21), the thrust of the JCAH (1976) report and the Balanced Service
System model promoted a separation between clinical and environmental interventions.
Case management was viewed as an activity that linked clients to an array of services
with the following goals: identification, crisis stabilization, growth, sustenance,
prevention, and general health. Although the authors of the JCAH report acknowledged
that the case manager may be the client‘s ―primary therapist,‖ elsewhere they explicitly
advocated segregating case management from clinical services (Platman, Dorgan, &
Gerhard, 1982). This conceptual confusion continues through the present day.
Similarly, British social workers had also been conducting such interventions
with mentally ill persons for many years (Timms, 1964). Many of these British efforts
were inspired by the work of D. W. Winnicott, a pediatrician and psychoanalyst, and his
wife Clare, a social worker, both of whom were influential within the British social
work profession (Kanter, 2000b, 2004, 2005). D. W. Winnicott, most noted for his
concepts of the ―transitional object‖ and the ―holding environment,‖ used the term
management synonymously with social work to describe direct interventions with the
environment that facilitate the healing and maturation of very troubled individuals, a
usage clearly compatible with contemporary case management practice (Kanter, 1990).
While the contemporary usage of the term case management emerged from the
mental health field, the concept of integrating environmental and psychological
interventions when assisting individuals and families with a wide array of difficulties is
nearly a century old. In 1922, Mary Richmond defined social casework as ―those
processes which develop personality through adjustments consciously effected,
individual by individual, between men and their social environment‖ (pp. 98–99). This
tradition continued through the 1960s, elaborated by social work leaders such as
Gordon Hamilton (1951), Helen Harris Perlman (1957), and Florence Hollis (1967).
But by 1970, the social work profession had become increasingly bifurcated
between the psychological and environmental approaches. Social workers interested in
psychological domains identified themselves as ―clinical social workers‖ and
increasingly pursued careers as psychotherapists. On the other end of the spectrum,
social workers interested in environmental concerns became interested in community
organizing. The term social casework, reflecting an integrative perspective, became
increasingly anachronistic and was largely abandoned by the social work profession.
Even the esteemed journal Social Casework, founded in 1920 by Mary Richmond,
changed its name to Families in Society.
Yet the work of ―social casework,‖ largely orphaned by the social work
profession, had to be rediscovered by others under the rubric of ―case management.‖
And the same tensions between the psychological and environmental domains
continued in the case management field. Within five years of the publication of the
1976 JCAH report, which introduced the term case management, these tensions
surfaced in the literature in evocatively titled articles such as ―Therapist-Case
Managers: More Than Brokers of Services‖ (Lamb, 1980) and ―How Many Case
Managers Does It Take to Screw in a Lightbulb? (Deitchman, 1980).
On the one hand, academics and policy makers envisioned a case management
model centered on resource acquisition and brokerage. The case manager would quickly
assess what resources a client lacked and would formulate a plan to obtain these. This
would involve coordinating referrals to appropriate agencies, obtaining entitlements,
and perhaps arranging for appropriate treatment. Reflecting this perspective, one author
defined case management as follows:
The process of planning for individuals or families who require the
organization of services to effect desired outcomes by assuring that all
aspects of that outcome are controlled by reducing harmful effects. . . .
case management is carried out by case managers, who in turn maintain
a complete record of interactions by timely notations in the case record.
(Sullivan, 1981, p. 120)
On the other hand, case managers, supervisors, and program directors
acknowledged that the practice of case management was rarely that simple or
straightforward. Developing a relationship with clients unfamiliar with respectful
collaborative relationships was rarely easy, and clinical instability required varying
degrees of support and structure. While the ideal of each client having both a
psychotherapist and a case manager seemed appealing, this was difficult to
operationalize in actual practice as ongoing psychotherapy was often unavailable. For
better or worse, the case manager became a central therapeutic figure in the lives of
clients, symbolizing the parental function of supportive care and implementing ego
functioning that was frequently impaired by psychiatric disorders.
By the late 1980s, there was a need to delineate a specific model of case
management that recognized that both psychological and environmental perspectives
were equally important, and a literature emerged that reflected this approach (Harris &
Bergman, 1987; Kanter, 1985a, 1987). I first heard the term clinical case management
used in 1986 by William Knoedler, the medical director of the original PACT (Program
of Assertive Community Treatment) Program in Madison, Wisconsin. This program of
―assertive community treatment,‖ pioneered by Stein and Test (1978), has been
replicated many times and is a model of assertive outreach to high-risk clients with
severe psychiatric disorders. In 1988, Harris and Bachrach edited the first monograph
titled ―Clinical Case Management,‖ which included an assortment of papers by various
authors, including the first article elaborating clinical issues in the case management
relationship (Kanter, 1988). Over the next few years, a more substantive literature on
clinical case management emerged, including the first paper on clinical case
management in a psychiatric journal (Kanter, 1989) and a series of relevant books
(Harris & Bergman, 1993; Kanter, 1995; Manoleas, 1996; Surber, 1994; Walsh, 2000;
Wong, 2006).
Meanwhile, the clinical case management model was adapted to other
populations, including HIV patients (Johnson, n.d.), substance abusers (Siegal, 1998),
emergency room recidivists (Okin et al., 2000), and a geriatric clientele (Morrow-Hall,
1992).
Clinical Case Management Research
Various research efforts also addressed clinical case management issues.
Hemming and Yellowlees (1997), Australian researchers, explored the issue of
construct validity, surveying both clients and case managers about their identification of
the 13 case management components outlined in Table 20.1. They found that both
groups identified and valued similar activities in the case management process.
More recently, Ziguras and Stuart (2000) published a meta-analysis of mental
health case management research. They identified 13 empirical studies that compared
what they characterized as clinical case management with the ―usual treatment.‖ They
found that ―clinical case management is generally effective in improving outcomes from
mental health services, as measured by clients‘ level of social functioning, symptoms,
client and family satisfaction, and family burden of care‖ (p. 1417). In a related meta-
analysis, Burns and associates (2007) examined 29 relevant studies and found that
―intensive case management‖ significantly reduced hospital utilization for persons with
severe mental illness who were high users of inpatient services.
Similarly, other research has shown that clinical case management reduced
emergency room utilization (Okin et al., 2000) and improved outcomes for persons with
co-occurring disorders (i.e., substance abuse and psychiatric disorders) (Essock et al.,
2006).
Furthermore, empirically validated treatment approaches for borderline
personality disorder and schizophrenia have recognized that clinical case management
is often a fundamental support for these treatment interventions. In her seminal volume
on dialectical behavior therapy (DBT), Linehan (1993) discusses clinical case
management as the recommended case management approach to augment DBT
interventions. Similarly, Hogarty (2002) discusses clinical case management as an
effective support for his ―personal therapy‖ approach to schizophrenia.
Knowledge Base of Clinical Case Management
Responding to the concrete demands of day-to-day practice and the atheoretical
ethos in the public mental health and many social services, most literature on case
management has avoided discussion of theoretical issues. Perhaps more than any other
practice modality in social work, clinical case management requires a comprehensive
biopsychosocial perspective (Engel, 1980) that draws on knowledge from many
different fields, including biological psychiatry, medicine, learning theory,
psychoanalytic theory (including ego psychology, self psychology, and object relations
perspectives), role theory (Estroff, 1981; Kanter, 1985a), social network and support
theories (Walsh, 1994, 2000), and general and family systems theory.
While there are certain areas of knowledge that are generic to all clinical case
management interventions, practice expertise requires familiarity with information
specific to the client population and the community served. Whether clinical case
managers are serving persons with severe psychiatric disorders, substance abuse, or
medical illness, they should be familiar with each condition‘s symptoms, course, and
treatments.
For example, when treating a male client with a learning disability, a depressive
disorder, and poorly controlled diabetes, I had to thoroughly educate myself on diabetes
and its management and consider how difficulties in self-management were affected by
cognitive and emotional issues (Kanter, 1996a). Because of the cognitive limitations,
conventional diabetes education had little impact. And defensive denial often quickly
led to diabetic crises. Finally, passive, dependent personality traits were often reinforced
by the tendency of nurses to take control of diabetes management rather than promote
self-management skills.
Similarly, specific knowledge of environmental resources is essential.
Understanding issues regarding Social Security disability programs and other pensions
is often critical. When the case manager assists clients in considering a return to work,
knowledge of the complex incentives and disincentives regarding employment is
important.
While this sort of information is objectively based, knowledge of other resources
requires a more experiential and subjective perspective. For example, treatment
resources and social programs (i.e., housing, employment, and social support) often
have quite broad admissions criteria. However, understanding the informal criteria can
be even more critical.
For instance, with the aforementioned diabetic client, I understood that the
mental health residential programs would be uncomfortable becoming involved with
diabetic management, while residences that served persons with medical illnesses
would have a largely geriatric population, ill suited for a 35-year-old man. Or when
seeking housing for a 22-year-old man with schizophrenia, I understood that his
occasional marijuana usage would inevitably lead to his expulsion. A durable residential
placement required a more tolerant environment while the marijuana use was addressed
over several years.
While some case management approaches envision an ideal process where a
client freely chooses between an array of resource options and opportunities, more often
environmental and social resources are severely circumscribed. I often characterize the
case manager‘s activity as helping find a square hole that can accommodate a square
peg. The case manager often can assist both client and social resource in
accommodating one another to some degree, but inevitably there are limitations. For
example, a mental health housing program was willing to quickly accept a homeless
woman with schizophrenia and a forensic history when she agreed to begin injectible
long-acting antipsychotic medications (Kanter, 1990). The case manager managed
negotiations with both parties, asking the residential program if initiating injections
would encourage them to consider admitting this client and asking the client if she
would be willing to try this medication.
The importance of a sound knowledge base around client difficulties and social
resources differentiates the clinical case management approach from the ―strengths
model‖ of case management (Rapp & Goscha, 2006). In the strengths model, case
managers can be trained to work with persons with severe mental disorders in a matter
of days with minimal knowledge of psychiatric illness and its treatment. Proponents of
the strengths model pose an explicit dichotomy between focusing on client strengths
and acknowledging and addressing client deficits (Floersch, 2002). Strengths model
case managers are trained to view any focus on deficits as antithetical to case
management progress. However, as Floersch‘s naturalistic study of this approach
revealed, strengths case managers are ill equipped to deal with problematic behavior or
psychiatric relapse.
Besides factual knowledge about relevant issues such as diagnostic criteria,
medications, and eligibility criteria for social programs, clinical case managers use an
array of theoretical perspectives to provide guidance in addressing the complex
situations and crises faced in everyday practice. The value of a thoughtful eclecticism
can be easily illustrated by considering how a clinical case manager addresses a client at
risk for homelessness because of a deteriorating living situation. The case manager may
consider whether the crisis could be addressed by a referral for a medication
consultation (biological psychiatry), teaching social skills (learning theory), helping the
client control his or her anger (ego psychology), clarifying the client‘s distorted
perception of his or her living companion (object relations theory), empathizing with
narcissistic rage (self psychology), discussing the role transition involved in moving
into a supervised living situation (role theory), or consulting with a landlord or family
member (social network and systems theories).
In turn, each of these interventions may also involve multiple theoretical
perspectives. For example, in consulting with a family member, a case manager may
explain the therapeutic action of psychotropic medications, empathize with the
relative‘s anger, identify ineffectual relational patterns, and teach limit-setting skills.
Although the pressing demands of this work often minimize opportunities for
theoretical reflection, case managers can intervene more effectively in such situations
when they can identify the theoretical strands underlying these clinical problems,
formulate clinical hypotheses, and test these formulations in the context of an ongoing
relationship. Without this comprehensive perspective, case managers are likely to
address client difficulties in a stereotypical fashion, attributing most problems to a
favored nostrum, such as medication noncompliance, substance abuse, or
―manipulation.‖
All these theories can be applied within the context of a generic stress-
vulnerability model of psychopathology (Anderson, Reiss, & Hogarty, 1986) that
addresses the environmental factors that trigger relapse; they can also be applied in
understanding the impact of case management in facilitating longitudinal processes of
recovery and development (Harding, Brooks, Takamaru, Strauss, & Breier, 1987;
Hogarty, 2002; Hogarty, Greenwald et al., 1997; Hogarty, Kornblith et al., 1997;
Kanter, 1985b; Strauss et al., 1985).
However, as Harris and Bergman (1987) have discussed, object relations theory
is uniquely valuable in helping us understand how clients learn to cope more effectively
with their environment through internalizing the problem-solving capacities of their
case managers. Unlike earlier ego psychology theories, which focus on intrapsychic
processes, object relations theories (and its more contemporary ―cousin,‖ relational
theory) focus on the interplay between the internal and external worlds.
The application of these theories to social work practice was pioneered by D. W.
Winnicott and Clare Winnicott, who began their collaboration working with evacuated
children with special needs during World War II (Kanter, 1990, 2000a, 2004). In this
work, they explored the therapeutic impact of various residential environments on the
developing child.
D. W. Winnicott (1953/1975c) specifically conceptualized the process of
―management‖ as the ―provision of that environmental adaptation, in the clinical
situation and outside it, which the patient had lacked in his developmental process‖ (pp.
xxvi–xxvii). He viewed the initial paradigm for ―management‖ emerging from the
mother‘s caretaking of an infant, noting as follows:
It is helpful to postulate the existence for the immature child of two
mothers . . . [an] ―object-mother‖ and [an] ‗environment-mother.‖
[These terms] describe the vast difference . . . for the infant between the
two aspects of infant-care, the mother as object . . . that may satisfy the
infant‘s urgent needs, and the mother as the person who wards off the
unpredictable and who actively provides care in handling and in
general management. (Winnicott, 1965c, p. 75)
Winnicott suggests that the ―individual introjects the ego-supportive mother‖
(1958/1965a, p. 32) as ―de-adaptation‖ occurs in graduated doses as a ―gradual
development . . . of the complex mental mechanisms that make possible, eventually, a
move from dependence to independence‖ (1965b, p. 146).
Winnicott‘s differentiation of the ―environment‖ or ―ego-supportive mother‖
from the ―object mother‖ is an important theoretical distinction. Psychoanalytic theory
has often emphasized the psychosexual dimensions of parenting (i.e., the oral, anal, and
genital stages), which reflect the child‘s passionate experience of the ―object mother,‖
and even the oedipal stage, which reflects the ―object father.‖
What is frequently overlooked are the more banal aspects of parenting reflected
in the ―environment mother‖ concept: bedtimes, selecting appropriate day care and
schooling, getting ready for school each morning, engaging the child in household
chores, facilitating involvement in hobbies, dispersing spending money, and so on.
Much of what is involved here is often referred to as ―parental judgment,‖ a complex
cognitive process that involves an objective analysis of the child‘s needs, strengths, and
deficits; an empathic understanding of the child‘s subjective world; and an informed
knowledge of the environmental resources.
Winnicott suggests that these parenting functions are internalized by the child in
the course of development and become what some call ego capacities and what others
call independent living skills. For example, many adult clients in case management have
difficulty with money management, budgeting limited funds appropriately to ensure that
basic needs for housing, food, and other essentials are appropriately addressed.
In many instances, these problems can be traced back to childhood. One client
may have been continually indulged, given funds for every need or desire; another may
have never have been permitted any autonomy around financial matters. If this tight
control is abruptly relaxed in adult life, the lack of internalized money management
skills may be catastrophic.
When confronted with an adult client with severe money management problems,
the clinical case manager supports neither total financial autonomy nor total financial
control (Brotman & Muller, 1990). With the developmental objective of promoting
skills in this area, the case manager might help establish a plan, with the client‘s active
consent, where important bills are paid directly with a disability check or other funds
and small sums are disbursed at predetermined intervals, which the client can spend at
will. Over time, this structure, openly discussed with the client, can become
internalized, and the case manager‘s role in this activity can diminish.
The Clinical Case Manager as Transitional Participant
Another dimension of clinical case management is the case manager‘s role as a
―transitional participant.‖ This term comes from the work of Clare Winnicott (Kanter,
2000b, 2004), who extended her husband‘s concept of the ―transitional object‖ into
social work practice. While D. W. Winnicott (1953/1975d) addressed the use of
inanimate objects—such as a child‘s stuffed animal or blanket—to maintain ties
between past and present, between fantasy and reality, Clare, explored how social
workers and other caregivers play a similar role.
In a jointly authored paper, the Winnicotts described Clare‘s role as the social
worker in a program for evacuated children, who works with the separate threads of the
child‘s life and gives the child the opportunity of preserving something important to
him or her from each stage of his or her experience:
The function of the psychiatric social worker as far as the children are
concerned is to give them a sense of continuity throughout the changes
to which they are subjected. She is the only person who knows each
child at every stage. It is she who first comes to his rescue in the billet
in which he is causing a disturbance. She sees him in his school and
billet, and then in the hostel, and possibly in more than one hostel. If
there is a change in hostel wardens, it is the psychiatric social worker
who gives some feeling of stability during the period of change. It is
the psychiatric social worker who re-billets the child if and when the
time comes. She is also in contact with the child‘s home, visiting the
parents whenever possible. She is thus able in some degree to gather
together the separate threads of the child‘s life and to give him the
opportunity of preserving something important to him from each stage
of his experience. (Kanter, 2004, p. 157)
In her later writings, Clare Winnicott elaborated on the difference between
psychotherapy and social work. This is a lengthy passage reflecting child welfare
practice, but its implications for clinical case management should be apparent:
The social worker . . . starts off as a real person concerned with the
external events and people in the child‘s life. In the course of her work
with him, she will attempt to bridge the gap between the external world
and his feelings about it and in doing so will enter his inner world too.
As a person who can move from one world to another, the
social worker can have a special value all her own for the child, and a
special kind of relationship to him which is quite different in kind from
the value and relationship that a psychotherapist has. [The social
worker] can never become entirely the subjective object which the
psychotherapist becomes; she is bound to external reality because she is
part and parcel of the child‘s real world, and often is responsible for
maintaining that world. The social worker . . . is therefore in a strategic
position in their lives because she is in touch with a total situation
representing a totality of experience . . .
Undoubtedly, a very valuable part of our relationship with
children lies in their knowledge that we are also in direct touch with
their parents and others who are important to them. Of a time, perhaps,
our relationship is the only integrating factor in their world, and we
take on a significance which is beyond what we do or say. We make
links between places and events and bridge gaps between people which
they are unable to bridge for themselves. As we talk about real people
and real happenings, feelings about them soon become evident and
before we know where we are we have entered the inner world of the
individual, and so we bridge another gap, that between fact and fantasy.
(Kanter, 2004, pp. 171–172)
Besides focusing on how the social worker can be used by children to keep alive
positive internal representations of significant others, Clare also described how the
worker‘s ongoing presence in the child‘s life helps facilitate psychic integration across
time and space:
[We would] go over the same ground again and again. It might begin
with ―Do you remember the day you brought me here in your car?‖
And we would retrace our steps, going over the events and explanations
once more. This was no mere reminiscing, but a desperate effort to add
life up, to overcome fears and anxieties, and to achieve a personal
integration. In my experience, feelings about home and other important
places cluster round the caseworker, so that when the children see her
they are not only reminded of home but can be in touch with that part
of themselves which has roots in the past and the [outside] world.
(Kanter, 2004, p. 171)
Any parent will immediately recall the ―remember when‖ game that is such a
significant component of parent-child interactions. Beyond our universal fascination
with photo albums or home videos—especially when shared by significant others—we
all take great satisfaction in the mutual recollection of memorable shared experiences;
these might include vacations, the death of a first pet, birthday parties, or even a burnt
dinner.
Unlike her husband‘s concept of the transitional object, Clare Winnicott‘s
transitional participant is not a passive recipient of the child‘s projections; the social
worker actively positions himself or herself in the child‘s life, making direct contact
with an array of significant others and informing all parties of this array of contacts.
With the knowledge of this participation, the child is then able to internalize the social
worker as an embodiment of this life experience.
This role as a transitional participant is perhaps the defining characteristic of
clinical case management practice. Clinical case managers position themselves in the
middle of a network of caregivers and concerned parties that may involve dozens of
individuals over the years: doctors, nurses, attorneys, home care aides, relatives,
acquaintances, pharmacists, social workers, probation officers, rehabilitation workers,
and so on.
While our professional literature addresses building therapeutic relationships
with our patients, it has largely neglected the professional skills involved in engaging
these significant others (Kanter, 1996b). These involve knowledge of the relevant
medical, psychiatric, legal, and social welfare systems as well as some facility with the
unique language employed in each. As our community has become increasingly
internationalized, skills in collaborating with caregivers from other cultures are also
important. This involves understanding an array of medical, psychiatric, and legal issues
and being able to communicate this knowledge to a wide range of concerned parties
without resorting to diagnostic and technical jargon.
The clinical case manager‘s function as a transitional participant is highlighted
when there is a psychic deficit, which Werner Mendel (1976) identified as a ―failure of
historicity,‖ a characteristic that is common to many clients unable to construct coherent
personal narratives. Mendel wrote as follows:
Historicity is that quality in human existence that makes our lived
personal history available to us to draw on for the conduct of our lives.
. . . This lived, available history makes it possible for each of us to risk
new situations, new relationships and new experiences . . . In the
schizophrenic existence, this lived history seems not to be available. . . .
It is as though prior relationships and experiences have gone right
through the person. They have not stuck to his ribs. Each new
relationship has to be entered into anew. Each new activity is taking
place for the first time. Thus the day becomes long and strenuous. The
schizophrenic human being enters into situations and relationships like
a new-born infant, having no experience, no way of predicting, no way
of using shared assumptions with others in the transaction. (pp. 43–44)
To address this deficit, Mendel recommended
arranging concrete experiences with the patient in the therapeutic
transaction that allow him to establish the flow of time from past
through present to future . . . the ongoingness of the relationship, not as
an abstraction, but as a concrete series of events, helps to counteract the
failure of historicity. The patient comes for his therapy appointment. If
he does not appear, the therapist goes out and gets him . . . During the
therapy appointment, the patient is concretely reminded of the prior
appointment and he is told some of the things that were discussed and
planned at that time. He is asked to tell what has happened since his last
appointment and how the plans that were formulated have worked out.
Then he is told of the next appointment. (p. 46)
Mendel is addressing the same issues as Clare Winnicott; whether a child in
need or an adult with schizophrenia, a sense of personal integration—of people, places,
and events—develops as the flow of time is experienced through the actual involvement
of a ―transitional participant‖ in the flow of life. This integration occurs first in the mind
of the clinical case manager, whose capacity for historicity is unimpaired; certainly, a
process of internalization plays a major role in this process.
Practice Issues in Clinical Case Management
As indicated in Table 20.1, clinical case management has at least 13 distinct
components. These include the engagement, assessment, and planning of the initial
phase as well as interventions focused on the environment, interventions focused on the
client, and interventions that encompass both client and environment. Some have
suggested that case management interventions must focus on the environment and be
administratively separated from more psychological interventions (Johnson & Rubin,
1983).
While this may be an attractive ideal, such a separation is rarely workable on an
ongoing basis. Although the aforementioned components may be implemented by
various members of a treatment team, including case managers, nurses, psychiatrists,
and staff from rehabilitation and residential programs, the clinical case manager is
ultimately responsible for the provision of these services, gathering together, as Clare
Winnicott noted, the ―separate threads‖ of the client‘s life. For example, staff from a
residential program may be responsible for teaching independent living skills when
clients reside in their program; however, when clients leave the program, the case
manager again assumes this responsibility.
The clinical case manager recognizes that even environmental interventions
require psychological sensitivity. Clients may be afraid to enter a new residential or
vocational program. Merely referring them with the program may result in failure
unless there is ample preparation and an ongoing dialogue is maintained about these
new experiences. In some situations, this dialogue can help clients overcome their fears
and successfully adapt to new experiences; in others, these discussions can help clients
and case managers learn from unsuitable placements without exacerbating feelings of
failure.
The very process of linking clients with resources has important psychological
implications. Clinical case managers may choose whether to have clients contact
resources on their own, to only make an initial phone contact, or to accompany clients
through some or all phases of an application processes. Each of these strategies conveys
a different message to clients and presents them with different levels of challenge. In
some instances, minimal intervention may convey the strongest message of support. In
others, the case manager‘s activities may provide clients with ―a model for operating in
the world as a capable individual, secure in the ability to influence external events‖
(Harris & Bergman, 1987, p. 298).
Finally, clinical case managers play a central role in facilitating communication
between all caregivers, relatives, and members of the treatment team. Although these
collateral consultations are essential components of effective case management, social
workers and other professionals receive little training in conducting these interventions
(Kanter, 1996b).
As Perlman (1979) has eloquently outlined, case managers must listen as
attentively to the concerns of these significant others as they do to their clients:
Take care not to lose sight of the signs of (the collateral‘s) dubiousness
or halfheartedness. They need to be acknowledged openly and
understandingly received. Perhaps his participation can be tentative, a
tryout. He must not feel, when you have gone, that he has been had,
because his cooperation then is likely to be short-lived. If he is openly
resistive, we need to take care to act in full awareness that being our
client‘s advocate does not mean we are thereby the other‘s adversary.
Rather, our task is to try to draw him into a shared, partway advocate
position. (p. 194)
This empathic, even seductive, approach to client advocacy is often far more
effective than approaches that rely on assertive persuasion, negotiation, and
bureaucratic and legal ―clout.‖
However, the successful implementation of this approach also requires that
clinical case managers have a clear understanding of the client‘s strengths and deficits,
including any psychiatric or medical disorders, as well as knowledge of available
resources. In many instances, this requires an ongoing learning process as the case
manager may need to learn more about a psychiatric illness, a medical condition,
community resources, or cultural issues that are relevant to a specific client. This may
involve consulting the professional literature or asking informed sources for further
information.
Titrating Support and Structure
While some approaches to case management have emphasized the importance of
assertive outreach with reluctant and resource-poor clients (Stein & Test, 1978), clinical
case managers must vary the intensity and nature of their involvement to reflect their
clients‘ individualized and ever-changing needs, personalities, and psychiatric
disorders. Like psychiatrists who adjust medication dosages to reflect the client‘s
fluctuating competence in coping with an ever-changing world, case managers
collaborate with clients and social networks in titrating the levels of environmental
support and structure needed to facilitate recovery and community functioning and
avoid deleterious effects.
Recognizing their clients‘ changing needs, clinical case managers often begin
interventions with high levels of support, including assistance with housing,
transportation, and entitlements, especially following a psychiatric hospitalization or
other crisis. As clients stabilize and crises are resolved, support can be reduced, and
clients should be expected to manage more of their own affairs (Bjorkman & Hannson,
2000). In other situations, especially when clients are wary of any sort of social support
or interpersonal contact, case management interventions may begin with less intensive
contacts as trust and rapport are developed. Similarly, case managers vary their
activities in response to the availability of other community resources (Fiorentine &
Grusky, 1990).
The expertise of case managers in titrating their support in response to both the
changing needs of clients and the available community resources has important
economic implications; effective timing of interventions can enable case managers to
greatly maximize their efficiency and serve larger caseloads. Too often, case managers
spend many hours in futile pursuit of reluctant clients and then withdraw when crises
ensue, sometimes requiring hospitalization, that offer opportunities for learning and
growth (Kanter, 1991).
These issues are especially relevant when considering the assertive community
treatment (ACT) model of intervention with persons with severe psychiatric disorders
(Dixon, 2000; Stein & Test, 1978). In this model, caseloads are low (8–10:1), service
intensity is high, duration of services is unlimited, and there are often specific
guidelines for frequency of staff contact. These resource-rich case management
programs have demonstrated great effectiveness and cost savings with clients who are
frequent hospital recidivists. However, there is increasing evidence that the benefits of
ACT relative to less intensive approaches diminish when clients are not high users of
hospital treatment or when clients stabilize over time (Burns et al., 2007; McRae,
Higgins, Sherman, & Lycan, 1990; Ziguras & Stuart, 2000).
In fact, McRae and associates (1990) demonstrated in a naturalistic study that it
was possible to quadruple the caseloads of ACT case managers without deleterious
effects after several years of stabilization. This suggests that over the long term,
continuity of case management relationships may be more important than the level of
intensity.
Understanding the Case Management Relationship
The case management relationship, with clients, families, and other caregivers,
is the cornerstone of clinical case management. The case management relationship
manifests all the interpersonal dynamics encountered in psychotherapy. As case
management encompasses a wide range of activities—including sharing a hamburger at
a fast-food restaurant, counseling in a clinic office, obtaining a commitment order, and
driving a client to a doctor‘s appointment—the case management relationship can
exhibit an almost overwhelming complexity of interactions. Unconstrained by the
parameters of conventional psychotherapy, case managers strive to establish
collaborative relationships that address both the psychic and the environmental needs of
clients; yet they encounter a variety of transference and countertransference reactions
evoked by a wide range of reality situations (Angell & Mahoney, 2007; Kanter, 1988).
This relationship contains both opportunities and hazards. A supportive
collaboration can help clients accept social support and psychiatric treatment. Over
time, the relationship is often internalized, enabling clients both to accept needed
support and to function more independently (Harris & Bergman, 1987). And, as
discussed previously, the case manager‘s role as ―transitional participant‖ can help
clients construct an ongoing personal narrative that can become a cornerstone for
recovery and personal integration.
Alternatively, difficulties in the case management relationship can precipitate
client relapse, recidivism, and even homelessness or case manager helplessness, anger,
and burnout.
Although most case managers attempt to interact with clients and their social
networks on a conscious and concrete level, transference and countertransference
reactions abound. These reactions crystallize around the complex reality of the case
management relationship, including the following seven factors:
1. When clients require case management, they have at least a partial impairment, either
temporary or ongoing, in their capacity to fulfill their environmental needs. These needs
involve both concrete and social dimensions: for housing, employment, or entitlements
on the one hand and for friendship and personal support on the other. This impairment
is not directly related to the extent of psychopathology; even some persons suffering
from schizophrenia are able to manage their lives with minimal assistance.
2. Clinical case managers address these impairments by functioning as intermediaries
between clients and their environments. They assist clients in fulfilling concrete and
psychic needs while facilitating the development of their clients‘ capacities to fulfill
their own needs. For better or worse, a relational hierarchy is defined by the case
manager‘s greater expertise in obtaining environmental resources.
3. While serving as ―travel guides‖ for clients with impairments in community
functioning, case managers simultaneously function as ―travel companions,‖ offering
empathic support and understanding. In so doing, case managers often attempt to
obscure the hierarchical dimension in the case management relationship (Estroff, 1981),
ameliorating the narcissistic injury implicit in the acceptance of the client role.
4. Having little faith in human relationships in general and professional relationships in
specific, many clients are reluctant participants in the case management process. Often,
case managers have more investment in the relationship than their clients. In some
situations, clients may be indifferent to contact with their case managers; in others,
clients may desire a personal, even erotic, involvement with their case managers while
avoiding a working collaboration. These divergent agendas are a major source of
tension in the case management relationship.
5. When successfully engaged in a case management relationship, clients will inevitably
be dependent, to a greater or lesser extent, on their case managers. This dependency has
both a psychological and a physical dimension, as case managers provide both
emotional and environmental support. Although societal and professional value systems
focus on pathological forms of dependency, case managers ―must teach clients that
there is a form of dependency that is necessary, normal, and constructive‖ (Deitchman,
1980, p. 789).
6. Unlike other mental health interventions based on privacy and confidentiality, most
case management relationships have a significant public dimension, as case managers
interact directly with clients‘ families, social networks, and formal caregivers. Such
environmental interventions require quite different understandings about
confidentiality; in many cases, clients come to trust their case managers‘ judgment and
tact about how these external contacts are handled. Case managers also surrender
privacy in their professional activities; in contrast with psychotherapy, their work is
often scrutinized by a network of concerned parties.
7. Finally, while client self-determination is a cornerstone of mental health practice,
case managers are inevitably subjected to social pressure, conveyed through their
agency or other funding sources, to place social needs before client wishes. These
societal interests include an economic goal of reducing recidivism and hospital tenure
and a social control goal of reducing deviant social behavior. These conflicting agendas
frequently affect the managerial relationship as staff are torn between loyalties to clients
and agency mandates.
Transference Reactions in Case Management
Against this background of complex reality, transference reactions—the human
tendency to perceive and interpret interpersonal situations as a repetition of prior
experience—permeate the case management relationship. These transference reactions
always crystallize around the actual characteristics and behaviors of significant others;
they are not merely fantasy creations arising from the unconscious. While
psychotherapists occupy a symbolic parental role, case managers activate transference
reactions when they actually fulfill parental functions, providing both physical and
psychic support.
Negative transference reactions often ensue as a defensive reaction to the
dependency and friendship inherent in the case management relationship. Clients may
become embroiled in a ―need-fear dilemma,‖ where they fantasize that the love and care
they crave will be accompanied by disappointment, rejection, domination, and abuse
(Burnham, Gladstone, & Gibson, 1969). To avoid provoking such responses to the
emerging positive feelings, case managers may consider suppressing their friendly
inclinations, approaching their clients with more interest than warmth.
Although not unrelated to dependency issues, case managers commonly
encounter transference reactions around issues of control (Angell, Mahoney, &
Martinez, 2006). Attempts to provide clients with stability and structure are often
perceived as attempts to control them. Such responses are commonly evoked by
involuntary commitment proceedings, medication issues (Angell et al., 2006), money
management (Brotman & Muller, 1990), or expectations to participate in daily
activities. Regardless of their therapeutic motives or even the client‘s expressed wishes,
case managers may be viewed as controlling tyrants who aggrandize their egos at their
clients‘ expense.
Countertransference Reactions in Case Management
While burnout and compassion fatigue are frequently discussed in the case
management literature, countertransference reactions are rarely acknowledged (Kanter,
2007). While burnout is often conceptualized as a staff response to unsupportive work
environments and inadequate resources, countertransference involves reactions to the
interpersonal relationship between staff and clients.
In case management practice, countertransference problems occur when case
managers struggle with their helplessness, anxiety, and anger. While these emotions can
be overwhelming to professionals working in inpatient settings or private practice with
middle-class clients with less challenging disorders, they are even more problematic in
case management practice. Besides coping with the objective challenges of severe
mental illness, homelessness, substance abuse, or chronic disease, case managers also
struggle with the confounding variables of poverty, racism, conflicting legal and
administrative mandates, bureaucratic inertia, limited access to social resources,
inadequate professional support, large caseloads, voluminous paperwork, and low
salaries.
Thus, it is hardly surprising that case managers are often overwhelmed by their
countertransference responses to clients who may be attention seeking, help rejecting,
or even suicidal. Unprepared to treat such difficult situations, case managers may
simultaneously feel pressured to keep the client alive, avoid rehospitalization, gratify
narcissistic needs, and document ongoing progress in meeting service plan goals.
Often lacking the experience or training to establish realistic expectations for
their own performance, clinical case managers cope with their anxiety and helplessness
through a variety of strategies, including the following:
1. Undertaking quixotic efforts to resolve characterological deficits and
childhood trauma
2. Withholding attention from ―unmotivated‖ clients
3. Neglecting clients unable to access a given resource (e.g., ―There‘s
nothing I can do unless he or she is admitted to a residential drug
treatment program‖)
4. Establishing written treatment contracts likely to fail
5. Substituting compliance with bureaucratic mandates for creative
clinical interventions
6. Leaving case management for another line of work
Sadly, none of these coping strategies is likely to facilitate client recovery or the case
manager‘s professional development.
How, then, can case managers cope more adaptively with their feelings of
helplessness, anxiety, and despair? First, they can come to accept these emotions as an
implicit part of the challenge of the work itself; much as a stage actor accepts ―stage
fright‖ as part of the challenge of live performance. Familiarity with the professional
literature on countertransference can reassure the neophyte case manager that even
highly skilled, experienced professionals struggle with these emotions (Kanter, 2007;
Searles, 1979).
D. W. Winnicott‘s classic paper ―Hate in the Countertransference‖ (1947/1975a)
specifically addresses the emotions evoked in the management of psychotic patients,
reminding professionals that intense hostility is commonplace even when ―normal‖
mothers care for their beloved infants. He emphasizes that these responses only become
problematic when they are repressed and thus are not subject to conscious control.
To become aware of and understand these responses, case managers need an
agency and supervisory climate that is accepting of their personal responses, enabling
them to share feelings of affection and disgust, satisfaction, and disappointment. Case
managers should be able to complain freely about case assignments or discuss sexually
charged situations. They should also be able to reject cases that elicit particularly
uncomfortable reactions, such as clients who too closely resemble a relative or who
make persistent sexual advances.
Second, they can acquaint themselves with the emerging scientific data on the
longitudinal course of severe mental illnesses (Harding et al., 1987) or the issues
involved in any given client population. This research suggests that these disorders are
treatable; however, it also indicates that recovery may take many years and is rarely a
linear, predictable process (Björkman & Hansson, 2007; Hogarty, 2002; Hogarty,
Greenwald et al., 1997; Hogarty, Kornblith et al., 1997). When case managers are
familiar with this research, they can view their efforts as analogous to running a
marathon in which they struggle—with their clients—to learn, through trial and error,
better ways of preventing relapse, ameliorating despair, and enhancing community
functioning.
Finally, they can learn to avoid case management ―technologies‖ that
seductively promise simple and painless methods for achieving successful outcomes.
Even for skilled, experienced practitioners, clinical case management is stressful and
challenging work, requiring patience, resiliency, creativity, and courage.
The following case will offer an illustration of this process.
[BEGIN CASE STUDY]
Case Illustration
Craig was a 22-year-old single male who became homeless in a large city far
away from his family of origin. An intelligent man who had dropped out of several
colleges, he had lived at home for several years working at a challenging job.
During this period, Craig‘s social and recreational life was minimal, and though his
parents encouraged him to seek psychiatric treatment, he did not follow through
with either medications or psychotherapy.
Various grandiose fantasies of professional success had caused Craig to move to
a new city that he viewed as more glamorous than his hometown. His move was
precipitous, and for several months his parents had no knowledge of his
whereabouts. Without any substantial resources, he was homeless, and his
inappropriate behavior soon led to his arrest on a minor charge. The police
recognized a psychiatric disorder, and he was psychiatrically evaluated before going
to court. His mother learned of this court proceeding and flew in to attend his trial.
He was released for ―time served‖ and rushed out of the courtroom without
speaking to his mother.
Over the next several months, a young professional couple, Mr. and Mrs. A, met
Craig wandering around their neighborhood. Young and relatively unscathed by
homeless life, he seemed different from other homeless persons. The As took a
personal interest in him, offering him the opportunity to earn some money doing
odd jobs around their home and yard. Craig performed well in these tasks, and the
couple offered him a place to stay while he did more work for them and earned
enough to find his own place.
Mrs. A understood that Craig had some sort of psychiatric illness but was unable
to learn much about his background, family, or current situation because he was
very guarded in his communications. While the living arrangement worked out
adequately for a month, Mr. and Mrs. A became dissatisfied because Craig
essentially stopped doing any work around the house and showed no interest in
obtaining competitive employment. Nor would he seek treatment or other housing.
Over time, he became more hostile, paranoid, and entitled.
Eventually, Mrs. A learned about the whereabouts of Craig‘s family and
contacted them without his knowledge. They were relieved to learn about his
whereabouts and to learn that he was safe for the time being. However, over the
next month, Craig‘s behavior became intolerable for the As and, because he would
not collaborate with any mental health program or social service agency, they
regretfully came to the conclusion that he would have to leave.
At this point, Craig‘s mother contacted me for assistance. She desperately
wanted to help her son and did not want him becoming homeless again. Meanwhile,
the As wanted Craig out of their home in the next few days. I spoke at length on the
phone with Craig‘s parents and with Mrs. A, learning as much as I could about
Craig‘s history and current functioning.
Given the impending crisis, there were several problematic options. One
possibility involved the As simply going forward with their plan to insist that Craig
leave their home. There was some chance that he would stay in the As‘
neighborhood and that he could be engaged in some sort of helping process through
persistent outreach efforts. But it also seemed likely that even if he stayed in the As‘
neighborhood, Craig would be difficult to locate and that outreach efforts would be
highly time-consuming and likely to fail.
Another possibility involved me going to the As‘ home to meet Craig before he
left and offering assistance at that time. But it seemed most likely that he would
reject this assistance as he had rejected all prior efforts at professional intervention.
After extensive discussion, Craig‘s parents, Mrs. A, and I decided to pursue a
third alternative. Craig‘s parents would fly in over a weekend, and we would have a
collective meeting at the As‘ home. We debated whether to inform Craig of this
meeting in advance, but it seemed inevitable that he would leave the As to avoid
such an encounter and the visit would be futile. So we planned to go to the As‘
home at a time when Craig could be expected to be there.
About an hour before this meeting, I met with Craig‘s parents at a nearby coffee
shop. They seemed, as in our phone calls, genuinely concerned with their son‘s
welfare. I prepared them for the meeting at the As‘. I thought it was quite likely that
Craig would become quite distraught at this unexpected gathering and certainly
paranoid fantasies would be activated. I encouraged them to simply express their
concern about Craig and follow my lead. But we soon received a call from Mrs. A
that Craig had not returned home at his usual time. I waited another half hour, and
we planned a meeting at the As‘ home early the next morning, when we knew Craig
would be there.
The next morning, Craig‘s parents and I arrived at the As‘ home and were
greeted at the door by Mrs. A. We were escorted into Craig‘s room, and he awoke
with a start, seeing his parents for the first time in months. I introduced myself and
explained that we were concerned about his impending homelessness and wanted to
assist him. Craig did not respond verbally. He hopped out of bed, got dressed
quickly, grabbed a small backpack, and dashed out the door, walking at full speed
down the street. Craig‘s father, and I followed.
I walked alongside Craig, and Craig‘s father followed about 100 feet behind. I
explained that I was a social worker who was intervening in a difficult situation and
empathized with his shock at seeing his parents. Craig never responded verbally and
continued walking at a very fast pace. Sometimes he would glance at me, and
occasionally he would offer some sort of mischievous gesture. He seemed aware
that his father was tailing behind but never made direct eye contact with him.
After about 15 minutes, it seemed clear to me that Craig was not taking any
evasive action to ―escape‖ from us and seemed to be enjoying challenging our
stamina. He led us across the city for over an hour, and we eventually entered a
shopping mall that had a movie theater. As it was Sunday morning, a community
church was holding services in one of the theaters. The church featured a young,
blue-jeaned minister and a rock band. Most of the participants were casually dressed
young adults. It seemed apparent that Craig was familiar with this church and had
this destination in mind when he left the As‘ home.
Craig took a seat at one end of a crowded row, and Craig‘s father, and I
remained in the back until the service ended an hour later. In the interim, I called
Craig‘s mother and Mrs. A on a cell phone and asked them to join us at this mall.
When Craig emerged from the service, he walked more slowly back out to the
mall‘s food court and remained stationary several feet away from his father and me
for several minutes. Then, he took off again in another direction leading out of the
mall.
As we went up an escalator, his mother appeared on the next floor. Suddenly,
Craig stopped and silently embraced her. He then signaled for all of us to follow
him. As I had spent more than three hours that morning attempting to make contact
with Craig, I used that opportunity to excuse myself. Later that day, I learned that he
had lunch at a restaurant with his parents and Mrs. A. He spoke minimally, and his
parents, as we had planned, made no overt attempt to bring him home or help him
get treatment. Before returning home later that day, their objective was simple: to
merely express, ―We care about you and we are here for you when you are ready.‖
The next day, Mrs. A told Craig that he could not live in their home unless he
was working with me, and we had a three-way meeting to develop a new plan. Craig
agreed to a meeting with me at a bookstore. To my surprise, he seemed willing to
converse with me. He told me about a talk he had just heard at the bookstore and
took me inside to show me the speaker‘s book. He also thanked me for telling him
about a special exhibit at an art museum we had passed on our ―walk‖ a few days
earlier. (I had been trying to make conversation during that walk and spoke about
various buildings and sights that we had passed by.) He said that he had gone to the
exhibit earlier that day and had enjoyed it.
I suggested that I drive him back to the As and we discuss his continued
residence there with Mrs. A. He refused to ride with me and suggested that I take
the bus with him. I told him that I was unable to do this as I did not have time to
take a bus to and from the As and then return to my office in my car.
I told him that Mrs. A would not take him back that night unless there was a
three-way meeting between us. Craig said that he didn‘t know why our conversation
outside the bookstore wouldn‘t be sufficient. I told him that Mrs. A had concerns
about him that she wanted to discuss. Ultimately, Craig headed back toward Mrs.
A‘s neighborhood carrying a sleeping bag in an egg crate. He wanted to pick up a
jacket at Mrs. A‘s but seemed resigned to sleeping outside.
The next three weeks were stressful on all involved. Craig remained largely on
the streets; fortunately, the weather was mild. One night, he was found sleeping on
the porch of a nearby suburban house where a high school acquaintance resided
with four young professional girlfriends. Needless to say, all were concerned about
the uninvited appearance of this homeless man. The acquaintance later called
Craig‘s mother and offered to help, but Craig did not return to her home.
Talking to Mrs. A, I learned that there was evidence that Craig lurked around
their home at night. I suggested that she leave out a package with food on the porch
with a friendly note. The package was gone the next morning, and we began to use
this as a method to communicate with Craig. I left some notes offering to assist with
housing and other needs, and I encouraged his mother to send a parcel with some
shoes and clothing that he valued. These too were removed overnight.
After several weeks, Craig knocked on Mrs. A‘s door around 10 p.m. and asked
if he could come in and shower. She agreed and gave him a meal. Craig puttered
around the As‘ home until 2 a.m. before departing. Finally, he agreed to a three-way
meeting with Mrs. A and myself. This was held at the As‘ home, but Craig was
evasive and uncooperative, and we were unable to arrive at any consensus.
About a week later, one month after the initial visit, Craig returned to the As‘
home, frankly acknowledged his difficulties, and asked Mrs. A for help. This was in
sharp contrast to earlier dialogues where he had approached her with a sense of
haughty entitlement, as if he were doing her a favor by gracing her home with his
presence. He expressed an interest in working with me, and Mrs. A called me
immediately to set up another three-way meeting.
When the meeting was held the next day at the As‘ home, it was apparent that
there was a dramatic change in Craig‘s mental state. He was communicative,
personable, and collaborative. Mrs. A decided to allow Craig to return while he
worked on getting a job and alternative housing. Also, Craig expressed an interest in
communicating with his parents and was pleased that I was in touch with them.
I discussed these changes with Craig‘s parents, who were delighted about the
change in events. I asked for their cooperation in several ways: to send some
clothes, to fund an inexpensive prepaid cell phone so we could all be in contact with
Craig, and to send him weekly gift cards from a nearby grocery.
Also, I asked his parents to pay for an optical exam and an inexpensive pair of
eyeglasses. This was an important issue as Craig was severely nearsighted and had
been for months without glasses. Previously, he had refused eye care, preferring to
see the world as a blur. Now, he was amenable to getting eyewear, a sign that he had
a strong desire to ―return to reality.‖ I made a plan to meet Craig the next day and
take him to an optician for an exam and a purchase of eyewear.
Craig was waiting for me at the appointed location, and we went to the optician.
He cooperated, seemed pleased with the exam, and sought my advice in selecting
glasses. I gave him the prepaid cell phone, and he seemed pleased with this
possession. I programmed my number in the phone so he could reach me. Then, we
had a brief lunch and scheduled an appointment for the next day at my office.
Craig arrived for his appointment in a timely manner, and we discussed various
options for getting employment. He had changed into neat casual dress clothes,
which his parents had sent and looked presentable for job hunting.
For the next several weeks, we met twice weekly in my office. While Craig
initially seemed to be enthusiastic about looking for work, it became apparent that
he was doing more thinking about applying for jobs than actually applying. While
he had had previous success in his hometown in food service jobs, he was not
interested in these positions but rather preferred a well-paying position as an
administrative assistant. He seemed unable to understand that he would likely not be
competitive for these positions because of his erratic work record and recent
criminal record.
Meanwhile, it became apparent to Mrs. A that Craig was not complying with her
expectation that he look for work on a daily basis. He had become increasingly rude
and entitled in her home. In one of our sessions, he told me that he would not accept
any job that paid less than $100,000.
Clearly, Craig‘s mental state was deteriorating. While medication might have
helped, it was apparent that he would not see a psychiatrist or take medications.
Craig no longer acknowledged his difficulties but rather blamed a community that
would not recognize his superior talents. Finally, Mrs. A, quite reluctantly, told
Craig that he had to leave her home as he had not been willing to cooperate with the
plan that they had made. Craig ignored her request, pursuing his activities in her
home as if she was not there. Finally, she told Craig that she would call the police if
he would not leave. He ignored her, and Mrs. A did call the police. They came an
hour later and asked Craig to leave the premises. He quietly gathered his
possessions and left. Mrs. A felt extremely guilty about taking this stance.
Nearly eight weeks after his parents‘ visit, Craig was back out on the streets, to
the dismay of all involved. He also had ended his contact with me and was not
answering his cell phone. Again, we arranged for small parcels and notes to be left
on Mrs. A‘s porch. These included more gift cards for the grocery from his parents;
it was important for Craig to understand that his parents cared about his material
welfare.
For much of the next week, Mrs. A, his parents, and I heard nothing from Craig,
and anxiety mounted about his whereabouts. Then, he returned one morning to the
As‘ home and had a reflective conversation with Mrs. A about his prospects. He
acknowledged his difficulties in finding work and wondered if his prospects would
be better in his hometown, where he had an established employment record. Mrs. A
encouraged him to consider this course of action and invited Craig to return for
dinner the next evening.
Later that day, Craig called his mother and expressed his wish to return home in
an extended phone call. His mother was pleased about this initiative but was anxious
about the actual possibility of his return after a year‘s absence. She contacted me for
advice, and I suggested that she and her husband discuss what they would require
from Craig if he did return. This involved working with a mental health professional
and seeking a job where he had realistic employment prospects.
Over the next several days, there was a flurry of contacts, both by phone and by
e-mail, between all involved: Craig, Mrs. A, Craig‘s parents, and myself. Craig and
his mother had another lengthy phone call where they discussed the details of a
possible return to the family. His mother told Craig that it was important that he
respect the needs of others in the home, keeping regular hours, joining the family for
dinner, and performing household chores. (All these areas had been problematic
before Craig left his hometown.)
She also told him that it was important that he meet with Dr. Z, the psychiatrist
whom Craig had seen before leaving. Dr. Z was an experienced psychotherapist
who used medications sparingly and understood the challenges of forming an
alliance with patients such as Craig. This led to an extended conversation on
whether psychotherapy would be helpful. Craig feared an excessive focus on the
past. His mother said that unless one understood the past, one was doomed to repeat
it. Craig agreed with this and thought it would be helpful if his mother came to some
sessions to understand his history.
Craig‘s mother contacted Dr. Z and asked if he would be willing to treat Craig if
he returned. Dr. Z said Craig would have to understand that he would likely
prescribe medications and suggested raising this issue before his return.
To further evaluate Craig‘s readiness to return to his family, his mother
recommended that he contact me for an appointment. Craig called me, and we met a
day or two later. His appearance and demeanor were much improved, and he
seemed comfortable collaborating with his parents‘ expectations.
Craig also had various contacts with Mrs. A during this period, and these
contacts were pleasant and respectful. We also arranged for his parents to pay for
him to live in a youth hostel instead of a homeless shelter. Craig seemed
appreciative of these improved accommodations and family support.
I discussed with Craig‘s parents the possibility of their flying to our city to
further evaluate his return, but this seemed impractical. With a holiday approaching
in a few days, we collectively agreed to facilitate Craig‘s speedy return, and an
airplane ticket was purchased. A plan was made for Craig to visit me at my office
for a termination session before heading off to the airport.
Craig appeared on time at my office, backpack in tow. We chatted about his
experience and plans for returning home. His schizoid demeanor had disappeared.
He seemed to enjoy our conversation while expressing excitement about leaving. I
printed out a boarding pass and called for an airport shuttle to pick him up at my
office.
Later that day, I received an e-mail from Craig‘s mother discussing his first day
at home. Some relatives were leaving their city just after Craig arrived at the airport
and greeted him at the gate. Then, he enjoyed a family dinner with his parents and
siblings and conversed for hours. He began playing his beloved piano and then
enjoyed guitar duets with his father.
Over the next year, Craig‘s recovery continued in his hometown. He quickly
obtained employment—two part-time jobs in retail and food service, was awarded
―employee of the month,‖ and became a shift supervisor in one position. Working
nearly 50 hours weekly, much of his earnings went to pay off the substantial debts
he had incurred some years previously when living in another locale. Family life
was calm, and social life was minimal. Craig saw Dr. Z for a few sessions but did
not continue. He still considered Mrs. A a confidante and e-mailed and called her
occasionally. He wanted to return to college as a full-time student, but because of
his previous academic difficulties, his parents insisted on only funding a single class
initially. Craig would not accept this compromise and saved his earnings for a full-
time enrollment.
It is apparent that there are residual difficulties, but both Craig and his
supportive family are working on these. Everyone agrees that returning home was
the right decision.
[END STUDY]
Discussion
Although my intervention with Craig was uncharacteristically short-term, lasting
barely two months, it illustrates many of the components of clinical case management,
most notably the balance between engaging the client in a working alliance and ongoing
consultation with the social network. My initial extensive contacts with Mrs. A and his
parents were critical, enabling me to construct a portrait of Craig in my own mind that
allowed me to create a workable plan for intervention. It seemed quite evident that
Craig was suffering from some sort of psychotic state with both paranoid and schizoid
features. Similarly, narcissistic issues, including a sense of entitlement, alienated Mrs.
A, the life-saving social support who had generously volunteered her involvement with
Craig. These issues made any sort of collaboration in a helping relationship
problematic.
At the same time, I quickly appreciated that Mrs. A and Craig‘s parents were
empathic and caring supports. If we were to prevent Craig becoming homeless in a
large, chaotic city, we needed to act quickly; there was no time for an extended period
of outreach engagement. Thus, his parents‘ visit was a way to buy another week of the
As‘ support. Although Craig was sorely trying the As‘ patience, they were amenable to
allowing him to stay until his parents arrived.
How did I come up with the plan for the parents‘ impromptu visit? This involves
a process of what Fonagy and associates (2002) described as mentalization, a form of
imaginative mental activity that allows us to perceive and interpret the behavior of
others in terms of intentional mental states. This capacity clearly evolves in one‘s
professional development as one gains experience with a wide range of clinical
situations.
The history I had gleaned from his parents and Mrs. A informed me that Craig
had powerful attachment needs, which he struggled with internally. At times, he had
sought the support and protection of the As and his parents, and at others, he had pushed
them away and created a pseudo-independent existence where he coped marginally. I
thought it worth the gamble to have his parents appear in person to remind Craig that
their love and support truly existed. And combining this with my initial appearance in
his life, Craig might see me as an extension of this caring family.
When discussing this plan with Craig‘s parents, I was explicit that I did not
know if this plan would be successful; nor did I have any clear idea about how events
would unfold. But given that the As were at the end of their rope and Craig faced a
return to the streets, I saw little downside to trying something that might seem ―out of
the box.‖
As the visit approached and as his parents arrived in town, I continuously
addressed the anxieties of all involved, sharing my own worries about what might
transpire. I prepared everyone to expect Craig to be shocked when we greeted him at
home and advised all to give Craig ―space.‖ When he quickly bolted out the door, none
of us were surprised. Following him across the city in this torrid ―walk,‖ I carefully
monitored Craig‘s nonverbal communications, which clearly signaled that he did not
wish to escape his father and me. I was also impressed with his father‘s empathic
sensitivity in following us at a modest distance. He was clearly in Craig‘s field of vision
but also allowed Craig and me to share some personal space. As the morning transpired,
Craig increasingly signaled a desire to connect with us, and I felt comfortable having
his mother and Mrs. A join us at the mall. When he embraced his mother, I knew that
this intervention might bear fruit.
Also, I had prepared his parents to simply share their love and concern for him,
not to threaten his fragile sense of autonomy by recommending a return home or any
other course of action. This template continued through the weeks ahead. I worked with
his parents to carefully titrate their gestures of support, a grocery gift card and some
clothes initially and, later, eyeglasses, a prepaid cell phone, and so on.
In guiding these gestures, I used a metaphor from feeding programs that help
persons suffering from starvation; in such situations, one understands that the digestive
system cannot tolerate large quantities of food and that overfeeding can lead to distress
and even death. We began with ―small meals‖ and gradually increased the quantity of
support. Even so, there were times when Craig‘s schizoid defenses could not tolerate
this support and he withdrew from contact.
Winnicott‘s (1954/1975b) concept of ―regression to dependence‖ is very
relevant here. To move ahead in their development, many case management clients,
particularly those with paranoid and schizoid characteristics, first need to begin to come
to terms with their own dependency needs and allow others to care for them. This
process often runs counter to the ethos in many mental health and social service
programs that promote ―independence‖ as a valued goal. But ―independence‖ is
invariably an illusory state for the human species; we all are interdependent in various
respects, and ―dependency‖ predominates at various points in the lifecycle: childhood,
illness, old age, and even a college student‘s return on vacation. At the same time, it is
important that these needs are expressed in an appropriate way that does not alienate
social supports.
Conclusion
This case report offers an illustration of the distinctive practice model of clinical case
management. Conventional office-based psychotherapy clearly could never have helped
Craig at this stage in his life. Nor could a brokerage model of case management have
assisted him in this crisis. Actually, Craig had some interaction with case managers at a
program for the homeless. This intervention was able to help Craig obtain some
minimal resources, such as bus tokens, which made his homeless state more tolerable,
but was unable, lacking any relational matrix, to address the basic facts of his
homelessness and psychiatric illness.
The strengths model of case management may have ultimately been helpful,
working as part of a homeless outreach team, and in many respects, this is how Mrs. A
functioned in the first weeks of her contacts with Craig, when she invited him into her
home. She astutely recognized the strengths underlying his eccentric presentation and
attempted to support these while housing him. But she, like the strengths case managers
that Floersch (2002) observed, was unable to muster a useful conceptual framework to
address Craig‘s problematic behavior in her home. Nor could she appreciate Craig‘s
intense intrapsychic conflict regarding his dependency needs, which, quite possibly,
was activated by the very support she was providing.
Finally, the strengths case management approach does not encompass the
clinical skills involved in what Winnicott (1971) called therapeutic consultations with
the network of caregivers. Both he and his wife, Clare, saw this consultative work with
the persons directly involved on a daily basis as a cornerstone of effective social work
practice (Kanter, 1990, 2000b, 2004, 2005). Applying the clinical understanding of
experienced psychotherapists, these consultative interventions require the same skills
used in clinical supervision: containing countertransference responses, conceptualizing
clinical hypotheses, and exploring possible intervention strategies (Kanter, 1996a).
Undoubtedly, effective clinical case management requires a professional level of
competence (Kanter, 1987). Some case managers without a professional background
can obtain this in on-the-job experience, ongoing study, and clinical supervision.
However, for most, professional training is of considerable benefit, offering an initial
introduction to psychiatric diagnosis, psychodynamic issues, interviewing skills, and the
―person-in-environment‖ paradigm. Even so, achieving competence as a clinical case
manager often involves at least three years of postgraduate supervised work experience.
Sadly, the belief that case management is a paraprofessional activity has led to
poor salaries and, in turn, high turnover. Many new social workers begin this work
enthusiastically, but many agencies do not fund career tracks, which would encourage
case managers to remain in their positions long enough to attain substantive
competence.
Often, a false sense of economy is involved here. Consider, for example, the
cost of my involvement with Craig and his network. Although relatively intense for
several months, about 40 hours spread over nine weeks, the costs were considerably less
than long-term homeless services, incarceration, hospitalization, or even a year‘s
prescription of a single psychiatric medication. Even within a managed care context,
clinical case management can lead to major cost savings in medical and psychiatric care
(Kanter, 1996b; Okin et al., 2000).
And since clinical case management titrates intervention levels according to
need, it provides a conceptual model for increasing support in crises and minimizing
involvement during phases when engagement is problematic or when crises have
stabilized. Similarly, clinical case management, embracing a network consultation
approach, economizes by empowering the family and social network to function more
effectively (Kanter, 1995). In Craig‘s situation, more than two thirds of my time was
spent in consulting with his parents and Mrs. A. The follow-up in this case suggested
that his parents learned skills during this intervention that proved extremely useful to
them in subsequent months, helping them support Craig‘s functioning with minimal
professional intervention.
Furthermore, while clinical case management merely stabilizes some situations
by providing appropriate environmental support, this approach can have a definitive
therapeutic impact, contributing to recovery from psychiatric disorder and facilitating
personal maturation.
As Bachrach (1992) has suggested, a false dichotomy has developed between
the professional knowledge and skills implicit in clinical case management and the
personal qualities of enthusiasm, commitment, warmth, and respect emphasized in other
case management approaches. Effective clinical case managers do not wear ―white
coats‖ or engage in psychiatric reductionism. They acknowledge both strengths and
deficits in both the client and the network and use their clinical skills to mobilize these
same strengths to address an array of difficulties.
Finally, acknowledging the importance of theory, rather than just simplistic
techniques, clinical case management provides a framework for addressing complex
problems and unpredictable events. As Clare Winnicott sagely observed of social
workers,
[They] have to be able to tolerate sometimes feeling awful and or
confused or ignorant and at other times feeling good or clever or lucky .
. . in almost every case there is a difficult middle period to be gone
through while things are sorting themselves out and we cannot see the
end, or even if anything is happening at all. . . . Something goes on is
us all the time and the experiences with clients are being unconsciously
assimilated, and every now and then we become aware that this is
happening. . . .
As we make the effort to consciously assimilate our experiences
. . . there comes a point at which we can very usefully turn to the theory
of dynamic psychology which can throw further light on our work. . . .
The theory can not only enable us to understand ourselves and our
clients better, but, most important of all, it can provide a frame of
reference which gives us a feeling of confidence . . . [that] we need not
be entirely at sea when we face the unknown. Moreover, theory can
save us time by helping us to see more quickly what is significant. . . .
.theory . . . does not have to be complete or final, and it does not
necessarily have to be right, but does have to exist and to be there as a
starting point, or as something to catch hold of so that we can meet
what comes without panic. (Kanter, 2004, 233–234)
Arguably, clinical case management is the most challenging approach in clinical
social work practice. It not only requires all the knowledge and skills of the
psychotherapist but also requires us to apply these in the dynamic social environment
without the comforting certainties of our enclosed consulting rooms and the 50-minute
hour. But over time, the clinical case manager participates in unfolding dramas that are
both personally and professional rewarding.
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