My social work experience with deinstitutionalization, case management, severe mental illness, and medication management began at the Topeka State Hospital in 1974. I was an undergraduate social work intern among the first to work in adult community reintegration. Little did I know where this monumental shift in public policy would lead. And after completion of the master's degree in 1977, I worked in a substance abuse outpatient setting where I saw firsthand the challenge posed by psychotropic treatment for those with substance abuse (later called dual diagnosis) and mental illness. Later, in conducting emergency psychiatric evaluations in an urban hospital, I experienced the unfolding of deinstitutionalization (1981-1994). In 1994, when I left to pursue doctoral education, I was responsible for the diversion of patients to community mental health centers for medication evaluation and treatment. Between 1981 and 1994, I implemented and managed temporary, emergency, group home, and permanent community housing programs in a suburban environments.
In Meds, Money, and Manners: The Case Management of Severe Mental Illness (Columbia University Press, 2002), for example, my first book, I explored manager use of the strengths model in everyday work and problem-solving. I looked at how practitioners used situated knowledge to recover clinical work suppressed by the model. I showed how managers invented a practical language (i.e., situated knowledge) to explain why and how clients failed to rationally budget and use money. Throughout this work I have argued that situated knowledge is a form of practice resistance. In turn, I have shown how these active forms of resistance challenge the myth of social workers,—a dominant theme in the literature and in much of contemporary critical historiography of social work practice,— as coercive and unwitting agents of the state or as subjugated by discursive, knowledge/power systems. My study of managers in a community mental health center and subsequent analysis of agency and state documents showed how managers require clinical training to do the work of successful management. In particular, I demonstrated how workers used practical wisdom or situated knowledge to address problems that urban and suburban environments served up to practice. I have practiced, researched, and published on strengths case management and although I am critical, I make clear the important contributions the model makes to effective practice; in the conclusion of the book, I advocated for the combination of clinical skills with strengths management. As a result of this work (2004), I was invited to contribute a book chapter that deepens this understanding, "Psychodynamic Case Management."
The central aim of my current research on psychopharmacology is to construct a psychosocial model for clinical practice related to youth psychotropic treatment. There are many and difficult questions about the increasing use of off-label and other medications among youth. What, for example, do families and providers need to know about the psychosocial consequences of psychiatric medication? How should providers approach medication for those at differing developmental levels: pre-school, middle school, high school, and college? I am the first to look systematically at the developmental and psychosocial implications. Just as blood circulates medication to neurotransmitters for biologic action, so do meanings of medication circulate among multiple relationships and contexts for psychosocial action. Thus, in medicating youth we must see from more than biomedical and pharmaceutical perspectives. In short, the role of social work is not to privilege the person-in-psychopharmacologic environment. In using the expression, person-in-psychopharmacological environment, an obvious play on social work’s signature concept, person-in-environment, I argue that when we silence the meaning making aspects of medication, we will reduced psychosocial interventions to bio(logic) ones.
My work on case management practice has implications beyond work with the severely mentally ill. The case manager is often the entry-level position for social workers across fields of practice: substance abuse, child welfare, social welfare, and health care. And irrespective of the specific limitation in client self-monitoring, it is often the case manager, with case management theory, who is charged with coordination of resources and calibration of their distribution according to client need and desire. Without adequate training, managers often find themselves in systems policing, monitoring, or managing medication, money, and social manners. I have shown how case managers, the central actors in all forms of deinstitutionalization, require more than management models. In the era post-deinstitutionalization, I have argued that we must reassess our approach to case management and clinical social work.