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Case Management: Time for step four!

November 01, 2009

We're worried about case management. Over the years, stacks and stacks of regulations and rules have been developed and applied to case management in an attempt to regulate its function and standardize its practice. For the most part, the end result of all this regulation and standardization is a significant reduction in the effectiveness of the case management function. A conservative estimate of the amount of time spent on paperwork that is unrelated to recovery is approximately 70 percent. This is not good!

Basically, the practice of case management hasn't changed much over the years, despite the fact that it was conceived during a time when recovery from mental illness was not thought possible. So, we have two problems that need to be addressed and the sooner the better. The first problem is that it is based on an outdated premise. The second is that it has been over-regulated to the point that time is mostly spent doing paperwork-yet the paperwork has almost nothing to do with promoting recovery.

How did we get to this point? Well, let's take a look at how case management was created in the first place. There were three historical steps, which I will summarize below.

Step One (1950-60). The deinstitutionalization movement began. This movement was prompted by the development and use of pharmacological interventions and the false belief that people could be treated less expensively in the community.

Step Two (1963). The Community Mental Health Center (CMHC) Construction Act was passed, which funded the mental health outpatient centers that sprang up across the country. The purpose of the centers was to provide treatment to people who had been deinstitutionalized and returned to the community.

Step Three (1977). The National Institute of Mental Health (NIMH) established the Community Support Program (CSP) in response to the fragmented community mental health system and the unmet needs of people with severe mental illness, most of whom had been former patients in state hospitals. “Casework” was reconceptualized and renamed “case management,” and it takes center stage in the CSP vision.

Here we are, over 30 years later, with a service that doesn't work nearly as well as we think it should. Folks, it's time for step four!

Step four should identify and eliminate irrelevant requirements and paperwork that distract case managers from real, essential work. We aren't the first people with this idea. People have been calling for changes for decades, yet nothing ever seems to happen-except more regulations and paperwork. OK, to be fair, there may be a program here and there that has managed to reduce paperwork requirements, but they've never gone far enough and, most important, the service has never been deliberately aligned with recovery principles and practices. This is tragic.

Think about it: Case management as currently being practiced hasn't changed much from the year it was born in 1977, the CSP era. Yet, significant knowledge has surfaced since then that should have changed everything: We now know that people can recover from mental illnesses.

Before we knew that people could recover, most of what we did in the name of treatment had to do with managing people-hence the designation, “Case Management.” The focus was and, for the most part, continues to be on controlling people's behaviors and taking care of them. But we now know that these approaches get in the way of promoting recovery. People rightly say, “We are not cases and we don't want to be managed.”

It's one thing to point out the problems with something and quite another to come up with some good solutions. So let's get back to step four-how the heck can we fix case management? Maybe a good place to start is to pretend that it has disappeared overnight. What will happen? What problems will emerge? How could we address those problems in ways that would promote recovery?

Our friend Mike Boyle, a recovery pioneer in both addictions and mental health, has a great way of framing an event like this. Mike says, “Never waste a crisis.” So how could we respond to this crisis in ways that would allow for a giant transformation toward recovery-oriented programming?

A guiding question we could ask ourselves as we think through the issues is this: “What kind of services would support people as they begin and continue their journey of recovery?” Answering this question will help us develop a service that is truly relevant to the issues people face today as they try to recover from mental illnesses. In this article, we can only outline what we think are the most important aspects of change. We are working on a new curriculum and organizational plan that will address these issues in detail, and we'll share that information with you as it's developed. In the meantime, here are the key elements that need to be included in a “step four” case management function:

First, a new name. We don't want to keep calling this service “case management” if we don't plan to manage cases.

Second, we need to learn from our well-intended mistakes so we can avoid repeating them. Primarily, we need to shift the power back to the person instead of using it to control and manage them. We need a service that promotes empowerment, builds on people's strengths and interests, and focuses on self-determination.

Third, we need to understand that caring about people does not result in taking care of them. Truly caring about them should result in us helping them care for themselves so they can own a sense of mastery over life issues.

Fourth, we need to provide advanced training that teaches staff how to inspire and empower people, rather than manage and control them.

Fifth, let's reconsider where and how we deliver this service. Why would we provide this service in a clinic if our main job is to inspire and empower people to recover? Maybe it would make more sense to carry out this function in a wellness center where many other recovery resources are available to people.

Sixth, we need to remember that the most fundamental ingredient of case management is the positive interpersonal relationship that develops between people.

Seventh, because effective case management depends on practitioners' skills, let's include an integrated workforce. This must include well-trained peer employees who are great at inspiring others through their own stories of recovery.

To learn more about the evolution of case management, we have a few recommendations: First, take a look at work that's been done through Boston University (also known as Bill's Place). Consult the second edition of BU's book, Psychiatric Rehabilitation, for a very informative section about case management by William Anthony, Mikal Cohen, Marianne Farkas, and Cheryl Gagne.

An older, but still relevant, resource is Models of Community Care for Severe Mental Illness: A Review of Research on Case Management (1998). It was written by four of the most prominent behavioral health researchers-Kim Mueser, Gary Bond, Robert Drake, and Sandra Resnick-and was published in the Schizophrenia Bulletin in 1998.

Another good resource are case management guidelines written by Martha Hodge, et. al. You can find this resource at

For more information, e-mail

Behavioral Healthcare 2009 November-December;29(10):8

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