Jerry Floersch, Meds, Money and Manners: The Case Management of Severe Mental Illness

Journal of Sociology and Social Welfare, March, 2004 by Rafael Herrera

New York: Columbia University Press, 2002. $22.50 papercover, $49.50 hardcover.

The type of intervention most likely provided by social workers and other mental health professionals to individuals suffering from severe mental illness is "case management." The literature on case management practice has grown and matured over the years and has spawned a wide variety of theories and models. The same literature, Floersch points out in Meds, Money, and Matters, for the most part, argues for the effectiveness and utility of case management in improving the quality of life of individuals suffering from serious mental illness, by linking them to social, medical, and mental health services. Utilization of these services, it is argued, yields many desirable outcomes. Independent living and a decrease in hospital utilization are seen as highly indicative of successful case management. Floersch asks and provides answers to the questions: What does a case manager face on a daily basis while going about the multiple tasks involved in providing case management services? What guides the case manager's practice? What happens when case management fails?

After an introductory chapter describing the theoretical and methodological consideration that historically have been utilized in the field, Floersch introduces the concepts of disciplinary knowledge/power and situated knowledge/power. The former refers to the theories and models utilized in case management practice, while the latter refers to practitioner produced case management practice that is local, specific, and contextual. While acknowledging he has not operationalized these concepts, and that he borrows from Michael Foucault's ideas and from the literature on situated learning, he argues that while case managers are guided and influenced by theories of social work practice, managed care, and the politics and economics of the welfare state, case managers also practice and produce effects that are of their own making, unique and personal.

Utilizing what he describes as a multimethod, interdisciplinary, and critical-realistic perspective, and after describing the setting for his study and the historical antecedents that gave rise to the social policy of the deinstitutionalization of the mentally ill, the remaining nine chapters present his ethnographic study of case managers. One of the chapters provides a very useful review of social work's historical role in the formation of community support services in general, and specifically in High County, Kansas, the setting for the study. Another chapter is devoted to the rise of the case manager practitioner who, it is argued, required something other that the disciplinary knowledge of the clinic or hospital social workers. Case managers, when assigned the goal of keeping individuals out of the hospital, had to learn to monitor meds, money and manners. Floersch makes this point by recounting the history on one social worker assigned to work within a case management paradigm shortly after earning her MSW.

One of the most interesting chapters describes the development of the strengths case management model at the University of Kansas School of Social Welfare and how this model found what Floersch would call scientific legitimization. In a chapter on the oral and written narratives of case management, Floersch analyzes the work of case managers using a strengths perspective. He analyzes text and oral narratives and presents a case study that makes the point that the language of the strengths philosophy found in the written narrative is not necessarily found in the oral narrative. The consequences of actions taken, or not taken, to maintain fidelity with the strengths model is explored, as are the creative ways in which case managers navigate around the limitations of case management practice models to achieve desired outcomes utilizing situated knowledge. Money and the impact on the studied case manager's work, is explored by Floersch in what he refers to as the moral economy of case management. He examines social work's historical use of money in helping relationships and reviews some of the questions and difficulties encountered by case managers in his study involved in managing and/or assisting clients manage their money.

Psychiatric medications and their role in the deinstitutionalization of individuals suffering from severe mental illness are briefly reviewed in a chapter dedicated to psychotropic medications. Here, Floersch examines the everyday interaction among case managers with psychiatrists, nurses, and consumers when medications are prescribed, and explores the different categories of the drugs used and their expected impact on targeted behaviors and emotions. Once again, Floersch compares the written and oral narratives of case managers, as well as the notes taken from case manager's team meetings. He suggests that the disciplinary/knowledge of medications utilized in institutions, is not sufficient for those needing medications and require the situated/knowledge of the case manager as the key figure in medication monitoring. This, Floersch suggests, compromises some of psychiatry's authority over medical matters. In his concluding chapter, while not asking for the return of the fifty-minute hour, Floersch, seems to call for the return of ego psychology or of "clinical" case management as a means of bringing "a theory of the self back into management work." He does not, however, articulate how a case manager's psychodynamic understanding will translate into well medicated, and well mannered, consumers, who spend their money wisely. His work does collect a formidable amount of actual experiences obtained during the provision of strengths case management services. Funneled through the strainer of the ethnographer, that experience results in a clear, well documented and researched book that adds significantly to our understanding of the daily realities faced by those who provide services to the mentally ill. It raises many points worthy of further inquiry.