Social Service Review (2002) 76(4):701-703
Book Review
Meds, Money, and Manners: The Case Management of Severe Mental Illness. By Jerry Floersch. New York: Columbia University Press, 2002. Pp. 286. $49.50 (cloth); $22.50 (paper).
After deinstitutionalization, community support services were created to respond to the changes in service delivery requirements. Community-based practice methods emerged with new configurations of the helping relationship and a new language to characterize those relationships. "Patients" became "clients" or "consumers"; the practice setting was now the whole community rather than an institution. Using ethnographic methods, Jerry Floersch analyzes community support services (CSS) and specifically the practice philosophy of strengths case management. This text is a compelling example of the strength of ethnographic research and what can be revealed through observation, interviews, and written documentation. His observations offer powerful insights on the process of community-based practice. While some may find the language of this type of critical analysis to be a bit strenuous, the book is a rich critique and analysis of case management.
What I enjoyed most were two sets of tensions illustrated throughout Floersch's study. One is a public-private dialectic implicated in issues of personal space, architecture, and awareness. For example, community living would seem to imply a level of privacy for managing one's life in contrast to the imposition of an institutional routine. Life outside the hospital suggests greater personal space than would have been possible within an institution. However, as Floersch demonstrates, personal details of a consumer's life, such as hygiene, laundry, housekeeping, and finances, are potential topics for attention between the case manager and the consumer. These private aspects of life also may be rendered quite public through discussion in staff meeting. The apparent potential for a more private life in a community setting rather than an institution is countered by the realities of case management and CSS.
Another aspect of this tension is illustrated in the use of physical space. The architecture of the buildings designed for service delivery of CSS include primarily social spacesactivity areas, shared desks, open doorsrendering the entire service delivery system public and accessible. Practice space is reorganized to create a "public practitioner." As a result, staff sacrifice the privacy necessary for conversations, case notes, and storage. A staff person's car becomes a site for refuge, storage, and dialogue; a restaurant table offers space for paperwork and, ironically, for privacy.
At another level, this public-private tension highlights an important distinction between what is said in contrast to the unstated. In this sense, "public" references what is announced or rendered public verbally; "private" acknowledges the unspoken dimension. By focusing on the self-defined goals of the consumer, strengths case management works best with what consumers can make public, in terms of simple awareness and ability to articulate. Conversely, private goals are those unstatedperhaps unconsciousmotives, wants, and desires. Decisions about money provide an illustration of the moral deliberations that are not acknowledged by strengths case management. Case managers describe the constant demand by consumers for spending money which, given their limited income, is a luxury. Case managers, then, constantly find themselves evaluating the merits of a claimed expense or "need." The concept of "spending goals" does not entirely capture the more complicated desires for funds. Strengths case management, by not including a language for those more complicated wants, sacrifices the "private" and renders those wants invisible. Thus, there is no method for awareness of the self in this practice philosophy.
Since strengths case management emphasizes self-identified goals, a second tension is a voluntary-unconscious dialectic. A case management philosophy that focuses on goal-directed action not only assumes an ability to identify relevant goals but also a willfulness to pursue them. Expectations for rational, purposive behavior are juxtaposed against a disease that can rob people of the ability to self-direct. For example, with medication, inconsistent follow-through is interpreted as an absence of rational understanding, according to Floersch. Consequently, case managers struggle with genuine self-determination versus professional oversight. This struggle makes visible the practice and moral quagmire created with a posture of "facilitation" when noncompliance can be self-destructive. In their interviews, case managers distinguish between "doing for" and "doing with," shorthand phrases illustrative of the ethical dilemma of self-determination versus paternalism. These deliberations of "with" and "for" are powerful representations of a dilemma sometimes only superficially acknowledged by advocates of strengths-based approaches.
Ultimately, Floersch leads us to a paradox: While a goal of strengths case management is to create self-monitoring individuals, any sense of [private] self is obscured. Decisions about changing medications or allowing consequences to occur as a natural response to consumers' actions are expected to enhance self-awareness yet are determined by the case managers, not by the consumer. The effort to induce awareness is controlled externally, through medication and the experience of consequences for behavior. Without the language or place for self-awareness, the potential for developing self-monitoring behavior through strengths case management is constrained, at best.
Throughout the book, Floersch identifies and builds on a distinction between disciplinary knowledge and situated knowledge along with the power inherent in each type of knowledge base. Strengths case management is presented as the disciplinary knowledge/power, a practice philosophy and method designed in response to the need for community support services and case management. Situated knowledge/power is contextual and subjective, part of the practice experience. Disciplinary knowledge/power is legitimated through science; situated knowledge/power is validated through experience. This study demonstrates how the gaps created by disciplinary knowledge are of necessity addressed by situated knowledge. Revealing the relationship and interaction between these two bases for knowledge (and power) is a major contribution of the book. The thoroughness of this research allows the reader to be privy to the enactment of strengths case management, to understand the daily challenges of the case manager role (e.g., general time management, time spent in a car), and further, to appreciate the critical contribution of the subjective experiences of practitioners. As scholars, we may specialize in disciplinary knowledge; Floersch shows us why we also need to be conversant with contextual knowledge.
Deborah L. Padgett, Ph.D. University of WisconsinMilwaukee
Book Review
Meds, Money, and Manners: The Case Management of Severe Mental Illness. By Jerry Floersch. New York: Columbia University Press, 2002. Pp. 286. $49.50 (cloth); $22.50 (paper).
After deinstitutionalization, community support services were created to respond to the changes in service delivery requirements. Community-based practice methods emerged with new configurations of the helping relationship and a new language to characterize those relationships. "Patients" became "clients" or "consumers"; the practice setting was now the whole community rather than an institution. Using ethnographic methods, Jerry Floersch analyzes community support services (CSS) and specifically the practice philosophy of strengths case management. This text is a compelling example of the strength of ethnographic research and what can be revealed through observation, interviews, and written documentation. His observations offer powerful insights on the process of community-based practice. While some may find the language of this type of critical analysis to be a bit strenuous, the book is a rich critique and analysis of case management.
What I enjoyed most were two sets of tensions illustrated throughout Floersch's study. One is a public-private dialectic implicated in issues of personal space, architecture, and awareness. For example, community living would seem to imply a level of privacy for managing one's life in contrast to the imposition of an institutional routine. Life outside the hospital suggests greater personal space than would have been possible within an institution. However, as Floersch demonstrates, personal details of a consumer's life, such as hygiene, laundry, housekeeping, and finances, are potential topics for attention between the case manager and the consumer. These private aspects of life also may be rendered quite public through discussion in staff meeting. The apparent potential for a more private life in a community setting rather than an institution is countered by the realities of case management and CSS.
Another aspect of this tension is illustrated in the use of physical space. The architecture of the buildings designed for service delivery of CSS include primarily social spacesactivity areas, shared desks, open doorsrendering the entire service delivery system public and accessible. Practice space is reorganized to create a "public practitioner." As a result, staff sacrifice the privacy necessary for conversations, case notes, and storage. A staff person's car becomes a site for refuge, storage, and dialogue; a restaurant table offers space for paperwork and, ironically, for privacy.
At another level, this public-private tension highlights an important distinction between what is said in contrast to the unstated. In this sense, "public" references what is announced or rendered public verbally; "private" acknowledges the unspoken dimension. By focusing on the self-defined goals of the consumer, strengths case management works best with what consumers can make public, in terms of simple awareness and ability to articulate. Conversely, private goals are those unstatedperhaps unconsciousmotives, wants, and desires. Decisions about money provide an illustration of the moral deliberations that are not acknowledged by strengths case management. Case managers describe the constant demand by consumers for spending money which, given their limited income, is a luxury. Case managers, then, constantly find themselves evaluating the merits of a claimed expense or "need." The concept of "spending goals" does not entirely capture the more complicated desires for funds. Strengths case management, by not including a language for those more complicated wants, sacrifices the "private" and renders those wants invisible. Thus, there is no method for awareness of the self in this practice philosophy.
Since strengths case management emphasizes self-identified goals, a second tension is a voluntary-unconscious dialectic. A case management philosophy that focuses on goal-directed action not only assumes an ability to identify relevant goals but also a willfulness to pursue them. Expectations for rational, purposive behavior are juxtaposed against a disease that can rob people of the ability to self-direct. For example, with medication, inconsistent follow-through is interpreted as an absence of rational understanding, according to Floersch. Consequently, case managers struggle with genuine self-determination versus professional oversight. This struggle makes visible the practice and moral quagmire created with a posture of "facilitation" when noncompliance can be self-destructive. In their interviews, case managers distinguish between "doing for" and "doing with," shorthand phrases illustrative of the ethical dilemma of self-determination versus paternalism. These deliberations of "with" and "for" are powerful representations of a dilemma sometimes only superficially acknowledged by advocates of strengths-based approaches.
Ultimately, Floersch leads us to a paradox: While a goal of strengths case management is to create self-monitoring individuals, any sense of [private] self is obscured. Decisions about changing medications or allowing consequences to occur as a natural response to consumers' actions are expected to enhance self-awareness yet are determined by the case managers, not by the consumer. The effort to induce awareness is controlled externally, through medication and the experience of consequences for behavior. Without the language or place for self-awareness, the potential for developing self-monitoring behavior through strengths case management is constrained, at best.
Throughout the book, Floersch identifies and builds on a distinction between disciplinary knowledge and situated knowledge along with the power inherent in each type of knowledge base. Strengths case management is presented as the disciplinary knowledge/power, a practice philosophy and method designed in response to the need for community support services and case management. Situated knowledge/power is contextual and subjective, part of the practice experience. Disciplinary knowledge/power is legitimated through science; situated knowledge/power is validated through experience. This study demonstrates how the gaps created by disciplinary knowledge are of necessity addressed by situated knowledge. Revealing the relationship and interaction between these two bases for knowledge (and power) is a major contribution of the book. The thoroughness of this research allows the reader to be privy to the enactment of strengths case management, to understand the daily challenges of the case manager role (e.g., general time management, time spent in a car), and further, to appreciate the critical contribution of the subjective experiences of practitioners. As scholars, we may specialize in disciplinary knowledge; Floersch shows us why we also need to be conversant with contextual knowledge.
Deborah L. Padgett, Ph.D. University of WisconsinMilwaukee