Funder by the Department of Human Services Auspiced by Our Community

A CONSUMER'S GUIDE TO CASE MANAGERS

The role of case manager emerged in the 1990s as the emphasis in the public mental health system spun around to pay greater attention to people diagnosed with psychotic illnesses.

In a mental health setting, your case manager might be a mental health nurses, psychologist or social worker. If you want to know what sort of training someone has had it is fine to ask them.

Case managers can do a 'mental state examination', which is like a clinical assessment - see here for more on this: http://en.wikipedia.org/wiki/Mental_status_examination.

Case managers are there to 'manage' our day-to-day living, which may include: our emotional and mental wellbeing; how we deal with stress and illness; our safety and the safety of others; our friendships and relationships; our work, leisure and education; our daily living skills; our physical health; our income and housing; and our rights and advocacy.


Treatment plans

Treatment plans are known in some states as 'management plans' and that's what they tend to be. Treatment plans are supposed to be drawn up collaboratively with our case managers, though in reality very rarely does that happen. It's much more common for a case manager to create a treatment plan and then elicit our signature.

Often people who are 'assertively case managed' within the public mental health system are people who are deemed to be 'seriously ill'. Many will have huge files or histories and in these documents will possibly be, either known to the 'patient' or not, many cruel labels and assumptions. These may well include words like 'attention seeking', 'acting out', 'refusing care', 'non compliant', 'unstable' and many more.

Although the system officially wants co-writing of treatment plans, the structure and conditions under which psychiatry itself, and the public system in particular, works mitigates against this dual decision making taking place.

In the private sector there is more time and money to make dual decision-making possible but there are still many structural problems, including greater power to individual psychiatrists who might not want power shared in this way, even when the case manager is enthusiastic.

These are some of the reasons the process of writing a treatment or management plan morphs back to the same process of one-sided decision making that many consumers are used to:

It's important to know that we don't have to sign if we don't agree with the plan or the language in it. However, the consequences of not signing can mean we become 'labelled' within the system attracting such words as 'trouble-maker', 'uncooperative', 'difficult', 'uncompliant' or 'treatment resistant'. [See Judi Chamberlain's Confessions of a non compliant patient.]


The trouble with being 'managed'

Many people who have been diagnosed with 'mental illness' have been 'case managed' for much of their lives. They are 'case managed' by Centrelink, they are 'case managed' by Area Mental Health Services (the community arm of public mental health services), they are 'case managed' by services providing support in finding work and finding accommodation.

There are many of us who hate the language of 'case management', finding it controlling and inherently disrespectful of our capacity to run our own lives, make decisions for ourselves, and operate without rules and regulations demanded from bureaucrats.

Some of us are sceptical about the case manager concept and the way it is practised - whether we have been diagnosed with a 'mental illness' or not, most people do not want our lives managed. Many of us would feel more comfortable with the term (and practice) of an individual's 'service manager'. It's a common consumer refrain: "I'm not a case and I don't want to be managed!"

The paradox of case management

'Case managers' believe that a significant part of their job is to encourage, cajole, document and even 'empower' us to manage our lives more effectively. Many consumers argue that 'empowering' is not something any clinician can do to us. As soon as another person tries to empower us this is evidence that they have considerable power over us - empowerment can only ever be bestowed by someone who has institutional power over the bestowed-upon. The best a case manager can do is look at their own behaviour and stop disempowering us.

It is, of course, impossible for us to self-manage at the same time that we are 'being managed'.


Good case management

Many consumers report three things that they believe make for a good 'case manager':

  1. Personal qualities. Personal qualities of empathy and humility, a person who loves his/her work, does not have 'compassion fatigue', is committed and reflective, moves through the world confidently and has good-quality supervision from experienced staff. Fortunately, there are many 'case managers' that fit this bill and continue to operate under difficult circumstances in what can be a thankless task. We admire you. We thank you!
  2. Someone who is here to stay. Distressed consumers working with distressed 'case managers' is a recipe for something to snap. Often it is the 'case manager'. The turnover rate in some of the most stressful areas of case work is high. Rapid turnover of staff is unsettling and particularly unfortunate for many of us who battle with issues of trusting and reliable interpersonal relationships.
  3. Good management. Consumers need managers to be accessible, able to relate to the consumer experience and realistic about what does and should happen under their watch. In terms of the merry-go-round of 'case managers' they need to be proactive in recruiting, supporting and recognising emotionally fatigued staff.

There's information elsewhere in this series of help sheets designed to help us write a letter of appreciation for those case managers who have been faithfully at our side as we have made wise decisions. It's good to write to them. They need our support.


The relationship

'Case management' can be a fraught role. In some ways, it's a bit no win. Some of us are lonely, sad, housebound, estranged from our families. Our regular interaction with our 'case manager' might provide vital interaction with the world.

However, we are only one and the 'case manager' could have 20+ people to keep a clinical eye on. This is fraught - difficult for the 'case manager' but even more difficult for us. Our needs must be bent and bruised around a reality that this person, perhaps the person we talk to most often in the world, is nothing but a worker.

As flagged above, many consumers argue that the very term 'case management' can damage client/clinician relationships and set up barriers to communication. They would prefer the term 'service manager', believing this more accurately describes the job these clinicians do.


Making a complaint

It is the case manager's job to ease the navigation channel for us to move through and to the services and resources we are entitled to and need. They are not there to make judgement upon us, to make us feel inadequate, to hand out ultimatums, or to liaise with us in any other way than the way they would want to be negotiated with themselves.

Being 'mentally ill' and broke are difficulty enough; being judged, contracted into subservience, treated as not having a 'real mental illness' or dismissed because we are on a Community Treatment Order can do great damage to our souls. We may have made mistakes in our lives, we may have illnesses that test our energy levels, we may take therapeutic drugs that make us unattractive or fat or drooling or zombie-like - but these are no reasons to accept 'case managers' who are rude, bossy, write nasty things about us or pretend they have consulted us when they have not.

None of these behaviours should be part of any case manager's modus operandi.

If you do come across such poor treatment, you may wish to complain. Every time someone complains it opens up an opportunity for someone else to feel strong enough to do likewise. Plus there's a chance that you might contribute to a change in the system!

Of course, not all of us will want to complain. Many of us have very real fears about the awful consequences of disagreeing with 'our' case manager. Despite the ideal which is loftily promoted, few of us are going to be self-determining in the short term if this means losing the kids to the state or being thrown back on a Community Treatment Order. This is obviously very unhelpful for us when we want to build autonomy and develop independence from the service system.

Real fears notwithstanding, there are groups that can help us move into this place of social and cultural interdependence from which safer options to move away from case management can emerge. These include community legal centres, and the Victorian Mental Illness Awareness Group (VMIAC). There are also some wonderful wells of inspiration coming out of the Psychiatric Disability Support Sector (PDSS).