Read the following case study and consider your approach when treating this client.

© 2008 Springer Publishing Company 106 Care Management Journals Volume 9, Number 3 2008 DOI: 10.1891/1521-0987.9.3.106 This article proposes a reorganized model of case management for persons with a serious psychiatric illness, including a sub- stance abuse disorder. The model was designed as a response to the changing demands of federal law, public funding sources, and social work licensure requirements in some states. It partners case management with social role theory and uses the person- in- situation paradigm and social functioning as organizing concepts.

This model may be helpful for those adult mental health agen- cies serving this population who are faced with making adjust- ments to changing demands of federal law, public funding sources, and the requirements of social work licensure in some states, all of which place restrictions on service delivery. An important feature of the model is partnering case management with social role theory in a way that enhances the delivery of case management services. It is being implemented at Touch- stone innovaré , a mental health agency serving adults who have a serious psychiatric condition or a co-occurring disorder .

Keywords: case management; partnering; social role theory Case Management and Social Role Theory as Partners in Service Delivery Thomas J. Blakely, PhD Gregory M. Dziadosz, PhD T ouchstone innovare ’ is located in Kent County, Michigan.

Its program has been described in detail in Care Manage- ment Journals (Blakely & Dziadosz, 2003). It also has a co-occurring disorders program (Blakely & Dziadosz, 2007b), an electronic record system (Blakely, Smith, & Swenson, 2004 ), and a valid and reliable outcome measure (Blakely & Dziadosz, 2007a). LITERATURE REVIEW Studies by Taylor and Dear (1980) and Brockington, Hall, and Levings (1993) about respondents’ stigmatizing attitudes toward persons with a mental illness centered on the factors of authoritari- anism, benevolence, and fear and exclusion. These attitudes were that these persons cannot make their own decisions, that they need to be cared for like children, and that they should be feared and therefore segregated. Institutionalization was perceived as the most appropriate response.

Deinstitutionalization, beginning in the 1950s and continu- ing for the next two decades, changed the focus of treatment from the institution to the community (Talbott, 1987), with mixed results for many (Grainick, 1985; Hornbeck, 1997; Torrey, 1997).

Associated with this change was the development of a new ser- vice function, case management, and a new mental health profes- sional, a case manager (Mueser, Bond, Drake, & Resnick, 1998).

However, the negative attitudes previously described established case management as a maintenance service. These attitudes con- tinue to affect the delivery of mental health services, especially as they have in uenced public decision makers about the de nition of case management.

Case management has a long history in social work practice.

Weil and Karls (1985) in their book about case management wrote that “the roots of case management in the United States can be traced as far back as 1863” (p. 4). They also expressed the view that case coordination as observed in the Charity Organiza- tion Society movement and the settlement house movement was “an early conceptualization of case management” (p. 133). From this it would appear that case management in some form has a long history in human services. However, this history is associ- ated with a widely viewed goal of social work as helping people to help themselves by connecting them to community resources and service systems. Social work knowledge has advanced consider- ably beyond connecting clients with services, and this professional knowledge base should be applied more broadly.

Anthony, Cohen, Farkas, and Cohen (2000) have observed that services to persons with a mental illness have been described as “fragmented and uncoordinated” but that “case management is a needed function” (p. 97). De ned by the Case Management Society of America (2007), “Case management is a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost- effective outcomes.” How well the preceding de nition ts the contemporary needs of persons with a serious psychiatric condition is questionable.

It appears that this and other de nitions of case management are driven by the notion of transferring the care program of the institution directly into the community. The institutional ideol- ogy of caring for patients because they can’t care for themselves has to be changed. Partnering case management with social role theory (SRT) considerably solidi es it as a way of organizing services to these clients that empowers and engages them in the self-management of their chronic illness in a way that leads to recovery. Partnering Case Management and Social Role Theory 107 One model of case management was labeled the broker model, and the functions were assessment, planning, linking to services, monitoring, and advocacy (Intagliata, 1982). This model ts the Medicaid de nition as written in the De cit Reduction Act of 2005. Others are the clinical model, Assertive Community Treat- ment (ACT), intensive case management (ICM), the strengths model, and the rehabilitation model (Mueser et al., 1998).

Rapp (1993) described the strengths model as being focused on strengths rather than pathology, the essential nature of the client– case manager relationship, client self-determination, community ing, and monitoring of the plan. Case managers use community resources to assist clients in meeting goals. There is an emphasis on hope for recovery. PCP ts with the rehabilitation model and is an adjunct to the reorganized model.

The literature search also produced articles about how case management has been joined with brief treatment and the task- centered system (Naleppa & Reid, 2000) and a solution-focused approach for case management (Greene et al., 2006 ). No reference was located that described partnering case management with SRT and social functioning taken from that theory. The authors have written previously about social functioning, a concept in SRT, as a sociological base for social work practice (Blakely & Dziadosz, 2007c). ISSUES LEADING TO DEVELOPING A REORGANIZED CASE MANAGEMENT MODEL The Medicaid de nition of case management services for which it will pay is the broker model, of which linking, or referral, is a major component. This may be problematic because case managers may perform their brokering tasks very well, but in most areas of the country resources to which referrals must be made do not exist in suf cient numbers for effective referrals to occur. An alternative is partnering case management with SRT. This provides a theory base that enables case managers, through the professional relationship, to empower the client to engage in a self-management process that leads to recovery.

Another issue is that most public mental health programs have employed bachelor-level social workers as service providers. In several states the licensure level for these personnel does not per- mit them to provide treatment services. However, partnering case management with SRT enables bachelor-level staff to work with clients around planning and decision making that also promotes self-management and positive outcomes.

Another, and probably larger, issue is a broadly held attitude that serious psychiatric conditions are not viewed in the same way as any chronic physical health condition. Instead, serious psychiat- ric conditions are viewed as disabling, requiring systems to provide for such persons and from which recovery is not believed to be a possibility. This attitude persists in spite of the experience of men- tal health providers (Anthony, 1993; Gagne, White, & Anthony, 2007; Mulligan, 2003). THE PROPOSED REORGANIZED MODEL The proposed reorganized model partnering case management with SRT includes elements of the strengths and rehabilitation models.

The person-in-situation paradigm (Hollis, 1972) and social func- tioning (Bartlett, 1970) are organizing concepts for this partner- ing. Included in the case managers’ assessment of a client’s needs is an assessment of social functioning in the social position of client and other client-preferred social positions. The element of social The institutional ideolog y of caring for patients because they can’t care for themselves has to be changed. resources, community contacts, and an attitude that clients can change and improve. He has authored a de nitive book on the strengths model (Rapp, 1998). The strengths approach has been viewed as a framework that provides better outcomes than the broker model (Sal & Joshi, 2003) and that is more successful in reducing hospital days of care and having more satis ed clients than standard care (Bjorkman, Hansson, & Sandlund, 2002 ).

Elements of the strengths model are signi cant in the reorga- nized model that is proposed here. The client’s adaptive strengths and positive role behaviors in preferred social positions are used to encourage behavioral change. Clients are continuously reminded to think of themselves as having a psychiatric condition rather than believing they are de ned by that condition . The signi cance of the client–case manager relationship is emphasized. Promoting cli- ent self-management of the psychiatric condition with the goal of recovery is a major objective.

The rehabilitation model (Mueser, Bond, Drake, & Resnick, 1998 ) is like the strengths model in that services follow the client’s goals and skills. This model is concerned with the consequences of the illness and not just the illness itself. The reorganized model incorporates it through a focus on a client’s behavior change, rather than the psychiatric condition, in a way that increases adaptation and social functioning. Adaptation is de ned as successful manage- ment of the symptoms of the psychiatric condition and appropri- ate response to the expectations of others. Social functioning is de ned as normative behavior in a social situation.

Touchstone innovaré staff use Person Centered Planning (PCP) in writing the case management plan. This process requires the cli- ent to be involved in every aspect of the assessment, planning, link- Blakely and Dziadosz 108 functioning in the various social positions in which clients interact on a daily basis is a focal point of this part of assessment and the subsequent development of the case management plan. PERSON-IN-SITUATION PARADIGM The person-in-situation paradigm is one organizing concept for the reorganized model. It has been a core concept in social work practice since the writings of Mary Richmond (1917), the rst to formally conceptualize social work as having a focus on both the person and the environment. Although psychoanalytic theory greatly in uenced social work, Hamilton (1951) highlighted social work’s historical concern with the environment, using the words “person” and “situa- tion” as necessary to assessment and intervention. For a time, clinical treatment became a major focus of practice, resulting in diminishing the environment as a contributing variable to psychosocial problems, but in the 1990s the “person-in-environment” view gained attention once again due in part to the de nition of clinical social work by the National Association of Social Workers (Northen, 1995).

Over time, views of the thrust of social work practice has var- ied, but the person-in-situation paradigm has occupied an in u- ential position. It ts nicely with the social functioning concept in SRT and with classical sociological theory as proposed by Mead (1934). SOCIAL FUNCTIONING AND SOCIAL ROLE THEORY Social functioning, taken from SRT, has been described as a socio- logical base for social work practice (Blakely & Dziadosz, 2007c).

SRT also appears in the social work literature (Turner, 1996). It is related to the person-in-situation paradigm, as both are concerned with social positions, a concept that is at the core of a person’s interaction with his environment. For our purposes, social func- tioning is de ned as normative behavior in social situations. Nor- mative behavior is that to which observers generally would not object. Adaptation leads to positive social functioning. It is de ned as appropriate responses to the symptoms of the psychiatric condi- tion and successful management of the demands of others in the person’s social environment.

The reorganized model includes, in addition to assessment, plan- ning, linking, and monitoring, an analysis of a client’s adaptive and social functioning role behaviors in ascribed or achieved social posi- tions. This follows the person-in-situation paradigm and is essential as it indicates the capacity of the client who has a serious psychiatric condition to participate in the case management process. THE FACTOR OF RELATIONSHIP The case manager’s relationship with the client is a major factor in case management. It is the basis for how well they can work together to develop and implement a case management plan. Buck and Alexander (2005) found that the clients in their study desired connections with others through their relationship with their case manager. It is important for clients to understand the social position of the case manager, and the case manager must become aware of the signi cant social positions of the client to make this connection.

A mutual understanding of these social positions also is in accord with the person-in-situation paradigm because it contributes to a clearer assessment of the client’s psychosocial situation and a plan developed mutually by the client and the case manager to resolve the immediate problem and increase social functioning. It also helps to establish a professional working relationship, because the social role behaviors of both the case manager and the client are mutually understood. It is not a direct treatment strategy but rather a process of empowering the client to take a major role in resolving psychoso- cial problems associated with a psychiatric condition. It is important for clients to understand the social position of the case manager, and the case manager must become aware of the signi cant social positions of the client to make this connection. The relationship between the case manager and the client begins with the rst contact. Transference is a major factor in how it begins.

Transference is a factor in all relationships. It is de ned as a tendency to project onto others the attitudes, feelings, and values that charac- terized parents, who are the rst people with whom a person inter- acts. If the client’s transference reaction is negative, the best way to manage this is to be professional and follow the structured process described in this article. If negative transference is not resolved in a couple of sessions, the case manager needs to make a decision about the potential bene t of continuing the relationship to resolve the client’s issues that contribute to the transference or transferring the client to another staff member. The client may make a request for change rst, and if so this should be considered.

Counter transference is the reaction of the case manager to the client. Negative counter transference may generate as much strain in the relationship as transference. If a case manager has a negative reaction to a client or a client’s behavior, this should be discussed with a clinical supervisor immediately for the sake of the case man- ager’s professional growth. There may be circumstances when the client should be transferred to another case manager. Partnering Case Management and Social Role Theory 109 A relationship is de ned as a formal agreement between the cli- ent and the case manager to work together to carry out the case management process within appropriate boundaries. It begins with a thorough explanation to the client about the agency and its services and the social behaviors of the case manager social posi- tion. The more the client understands about what he can expect from involvement with the agency, and from the case manager, the greater the likelihood his social role behaviors will be characteristic of full participation in the case management process. RECOVERY, A DESIRED OUTCOME Since the beginning of the 1990s, there have been a number of journal articles about recovery from mental illness (see, for exam- ple, Anthony, 1993; Bradshaw, Armour, & Rosenborough, 2007; Deegan, 1988 ; Drake et al., 2006; Farkas, 2007).

There are different ways of de ning recovery that have appeared in the literature. The Touchstone innovare ’ president, the program consultant, and selected clinical staff worked together to de ne recovery for our purposes. It was conceptualized as a state of psy- chiatric well-being that was achieved when all a client needed from the mental health system was a place to obtain psychotropic medi- cations, a place to go when symptoms or emotional upset occurred, and a place to go for short-term counseling. An outcome measure- ment, the Psychiatric Well Being (PWB) scale, was developed to determine clients’ level of recovery. (See Appendix for examples of items on the PWB scale.) The achievement of normative social functioning is essential to a state of psychiatric well-being and to recovery. Normative social functioning and a state of psychiatric well-being are evidenced by behavioral change. Total absence of symptoms or periodic emo- tional upsets are not required, and most clients continue taking psychotropic medications. THE CLIENT ’ S SOCIAL POSITIONS AND SOCIAL ROLE BEHAVIORS The client’s social position, as de ned by many in our culture, is that of a mental patient. It is not necessary to use this term with a client. The term psychiatric condition is more appropriate. This social position is acquired, meaning that others de ne it. It is essen- tial to communicate to the client that the psychiatric condition is something they have, from which recovery is possible, and is not who they are. This de nes a new desired social position, “person in recovery,” as opposed to the socially imposed position of “mental patient.” This labeling by the culture is a good example of the person-in- situation paradigm. A person with a serious psychiatric condition faces the challenge of adapting to the condition plus adapting to the attitudes of others, especially those that support stigma. Adap- tive failures in this context are the fault of the system. The case manager is charged with the responsibility of assisting the client to successfully meet this challenge so that his/her social functioning is normative.

Explaining to the client that the purpose of involvement with the agency is to focus on positive client social positions and social role behaviors is essential. Assessing the client’s social role behaviors in the negative social position of mental patient yields information The client’s social position, as de ned by many in our culture, is that of a mental patient. It is not necessary to use this term with a client. about his strengths and weaknesses in adaptation and social func- tioning in that position. Using the strengths of adaptation and social functioning in positive positions and roles, the case manager encourages the client to use them to consider behavioral change in the negative position toward a normative mode.

The weaknesses in role behaviors of adaptation and social func- tioning become goals and objectives for behavioral change that increase the likelihood of achieving the goals of the case manage- ment plan. Planned interventions help reduce the negative social role behaviors of the psychiatric condition until they are dimin- ished to the point at which they are not signi cant factors in the client’s life.

Assessing the strengths and weaknesses in social functioning means determining the level of normative responses the client exhib- its in the various social settings and circumstances of his social envi- ronment. This means gathering information about signi cant social positions, acquired or achieved, that the client holds, and the norma- tive nature of the client’s social role behaviors in these positions. This information also is part of the assessment of a client’s daily living, social service, medical, and mental health needs for the case manage- ment plan. It also is useful in enabling the client to achieve the goals and objectives of the case management plan. Each goal may have behavioral change objectives that relate to achievement.

THE CASE MANAGER’S SOCIAL POSITION AND SOCIAL ROLE BEHAVIORS Applying the reorganized model means that both the client and the case manager must mutually understand each other’s social posi- tions and social role behaviors.

The initial social role behavior in the social position of case manager is an assessment of the client’s daily living, social service, Blakely and Dziadosz 110 medical, and mental health needs. Some of the information gath- ered for the assessment is appropriate for completing a PCP if this is part of the agency’s protocol. Completing the content of a PCP should take into account the process of using SRT as an organizing principle for service delivery when the person-in-situation para- digm also is applied.

The content of a PCP often focuses on the client’s dreams, goals, and outcomes. After the client has an opportunity to express these, the case manager and the client together assess their reality and trans- form them into workable goals and objectives, considering the SRT analysis of a client’s social functioning. This cooperative effort con- tributes to the developing relationship and is signi cant in empower- ing the client to participate fully in the case management process.

Other social role behaviors of the case manager’s social position are planning and referral. The data that was gathered about the cli- ent’s needs in the assessment are stated as goals and are rank-ordered.

A case management plan is developed with the client to achieve these goals. The action steps of the case management plan are created with the full involvement of the client. The goals, objectives, and inter- ventions and the person responsible for each need are speci ed. The plan must be detailed. The client must understand it and the change in social role behaviors that will be required for its implementation.

Implementing the case management plan is an additional social role behavior. Both the client and the case manager, and whoever else is designated as a participant in the plan, have speci c tasks to complete. How well these tasks are completed will depend on the level of the client’s social functioning and his ability to work with the case manager regarding behavior change. A mutual understand- ing of case manager-client social positions and social role behaviors is a signi cant factor in outcomes.

The case manager is responsible for monitoring activities of the plan. In some instances a referral to another person or agency for treatment or other services may be necessary. Referring a client to another agency or resource is a complicated matter. Depending on circumstances it may have been very dif cult for some clients to go through the process of accessing mental health services. Dealing with the onset of a chronic illness, especially a chronic psychiatric condition, is very dif cult for some people. Referring a client to another agency may be very anxiety provoking, especially for those clients who deny they have a chronic illness. The quality and suf- ciency of the client–case manager relationship will be important in the client’s acceptance of a referral.

Simply telling a client where to go is not enough. A full discus- sion of the daily living, social service, medical, and mental health needs is required; this should be accompanied by an explanation of the alternative agency’s capacity to meet a particular client need.

The level of the client’s social functioning will affect whether a client accepts a referral. It may be necessary to make an appoint- ment at the alternative agency and follow through by making sure the client keeps the initial appointment. Thereafter, regular contact with that agency’s professional personnel is required to monitor how well that aspect of the case management plan is being car-ried out. These activities, carried out within the relationship with a focus on the person-in-situation paradigm as an organizing con- cept, promote adaptation and social functioning.

Other social role behaviors are advocating for the client in whatever ways are required to obtain or establish resources to meet needs. Depending on the capacity of the client these service activi- ties may require frequent client contacts. THE REORGANIZED MODEL AS A RESPONSE TO THE ISSUES Medicaid-de ned activities of case management are assessment, planning, linking, and monitoring, elements typically found in the broker model. The reorganized model includes these but organizes delivery around the paradigm of person-in-situation and the con- cept of social functioning taken from SRT. It also incorporates some elements of other case management models. This combination of ideas does not violate the legal de nition while it promotes a pro- cess with an underpinning theory. This theory base is holistic as it focuses on behavior change toward normative social functioning.

The proper use of the model is directed toward positive social func- tioning and recovery, so it is a direct response to the unwarranted negative views about persons who have a psychiatric condition.

The use of SRT as a clarifying mechanism regarding adaptation and social functioning that empowers and supports clients toward normative behavior ts the scope of practice for licensed bachelor social workers. This is helpful to many public mental health agen- cies, as many case managers there are degreed at this level.

The reorganized model is structured to focus on behavioral assessment and interventions leading to improving adaptation and social functioning to this chronic condition in the same way that a person would adapt to any chronic health problem. CONCLUSION This article has proposed a reorganized model for case manage- ment services to persons with serious psychiatric conditions. The reorganized model has a theory base, organizing concepts of the person-in-situation paradigm and social functioning, and a de ned process. The strengths of a client’s social role behaviors in positive social positions are a basis for encouraging behavior change. Weak- nesses in social role behaviors become targets for behavior change toward normative social functioning.

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Weil, M., & Karls, J. M. (1985). Case management in human service prac- tice. San Francisco: Jossey-Bass. Thomas J. Blakely, PhD, is a consultant at Touchstone innovaré . He is a professor emeritus from the School of Social Work at Western Michigan University in Kalamazoo. Gregory M. Dziadosz, PhD, is the president and chief executive of cer of Touchstone innovaré .

He holds a doctorate in psychology and neurophysiology from the University of Wisconsin–Madison.

Correspondence regarding this article should be directed to Thomas J. Blakely, PhD, Consultant, Touchstone innovaré , 5250 Blakely Dr., Belmont, MI 49306. E-mail: thomas.blakely@ wmich.edu Blakely and Dziadosz 112 APPENDIX The following are examples of the scale items in the Psychiatric Well Being scale.

2. The frequency and duration of periods of symptom exacerba- tion are at a level that do not affect social functioning.

Relapse and remission are typical of a serious, chronic illness and are to be expected with a mental illness as well. Symptom exacerba- tion may occur for a variety of reasons, some of which may become known and anticipated, and some of which may remain unknown.

Symptom exacerbation may sometimes be cyclical, and so may be predictable even if the cause remains unknown. The objective is to minimize the occurrence of relapses that interfere with functioning that is related to a desired social position.

1. Symptoms return regularly and frequently and seriously limit social functioning.

2. Symptoms return regularly, possibly frequently, and always at least moderately affect social functioning when they do recur. Symptoms have a debilitating impact less than half the time.

3. Symptoms return periodically, they may be frequent, but they usually have only a small impact on functioning. Debil- itating symptoms are infrequent.

4. Symptoms return sometimes. They are not regular or fre- quent, and when they occur they almost always have only a minimal impact on social functioning. Debilitating symp- toms are rare.

5. Symptoms return sometimes, but when they do, they almost always have little or no impact on social functioning. Occa- sionally they will have a moderate impact.

6. Symptoms may reoccur, but they never have more than a minimal impact on social functioning 7. Symptom exacerbation has no impact on social functioning. 3. The side effects of psychotropic medications are at a level that does not affect social functioning.

The impact of side effects of psychotropic medications are related to a client’s physical response and drug metabolism, but impact is also related to the client’s subjective response to the side effect. As with symptoms, one can expect great variability in a per- son’s response to side effects. Interventions intended to increase tolerance of side effects may be as effective as those intended to directly reduce them. This scale is meant to assess the impact of the side effects on social functioning, not the side effects themselves.

1. The client’s response to side effects interferes to the extent it is the dominant feature and determinant in the client’s life.

2. The client’s response to side effects frequently interferes with desired social functioning; this may be ongoing and signi - cantly troublesome but not debilitating.

3. The client’s response to side effects interferes with desired social functioning; interference may be episodic and serious or ongoing and moderate, requiring intervention at the time in either case.

4. The client’s response to side effects sometimes interferes with desired social functioning. Interference is episodic and mod- erate or ongoing and tolerable but unpleasant. Additional intervention may be indicated with episodic occurrence.

5. The client’s response to side effects occasionally interferes with desired social functioning and the interference is either episodic at widely spaced intervals, or ongoing but well tol- erated.

6. The client’s response to side effects rarely interferes with desired social functioning and other aspects of life. Interfer- ence is an exceptional event of short duration not requiring additional intervention.

7. The client’s response to side effects never interferes with desired social functioning or other aspects of life.