(N a
I
)
VI EWPOI NT
DISABILITY POLICY AND SOCIAL WORK PRACTICE Three articles in this issue discuss disability policy in the United States and its implications for social work practice. Patricia Fishley's "I Am John" reflects the evolution of society's care, treatment, and support of people with developmental disabilities. John's history, told from his point of view, is a dramatic history of hope. Despite periods of cruelty, neglect, and abuse, this brief sketch of society's response to people with developmental disabilities reflects some positive policy and programmatic outcomes, albeit on an incremental basis and for a specific target population, produced by a tireless social movement. Susan Meyers Chandler's "Brown versus New York: The Rashomon of Delivering Mental Health Services in the 1990s" highlights social workers' provision of dignified and respectful support to people experiencing psychiatric problems. It challenges social workers to reflect on whether their practice ensures self-determination for the people they work with in spite of society's inability or unwillingness to ensure that all people obtain the basic resources of life: housing, training, income, employment, and health care. Whereas the story of John reflects a history of hope, the story of Joyce Brown comments on misdirected professional action. Allen Rubin's "Is Case Management Effective for People with Mental Illness? A Research Review" is sobering and humbling. It concludes that social workers may be using an interven-
tion—case management—whose effectiveness still has not been demonstrated with certainty. In reality, social workers do not know much about the impact of case management on the quality of life of people with severe and persistent psychiatric disabilities. Joyce Brown may not benefit from case management in a society that cannot provide all its citizens with adequate and acceptable life-sustaining resources, including decent housing and a reliable income. "1 AM JOHN"
The field of mental retardation, and later that of developmental disabilities, has evolved considerably since the 18th century and most dramatically since it became a social movement in the United States during the early to mid-1960s. "I Am John" captures three policy epochs of this field: custodialism, normalization, and social integration. Custodialism is well documented by such authors as Rothman (1971, 1980) and Scheerenberger (1983). The policy aim of custodialism was clear: control the person, whether control was to protect society from the person with mental retardation or to protect the person from society. The asylum (later to become the state institution) was seen as an innovation and as a reform movement sparked in part by the mistreatment and neglect of people with mental disabilities by local citizens and by poor houses.
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People with mental retardation were once auctioned off to the lowest bidder by local governments seeking to rid themselves of long-term responsibility for dependent people. In some communities, gangsters drove these individuals out of town during early morning raids. "Passing on," in which officials passed people with mental disabilities from one town to the next, was widely practiced. The asylum, based on moral treatment principles, was seen as a specialized environment for the management of people who could be restored to some normality or rationality. The demise of this rehabilitation ideal resulted in the conversion of the asylum into a holding tank. Institutions as "snake pits" were not uncommon, and the many exposes, especially the dramatic photographic essay Christmas in PurgaWry (Blatt & Kaplan, 1974), illustrated inhumanity to dependent, fellow human beings even through the late part of the 20th century (Rothman & Rothman, 1984). Abuse, neglect, and the absence of habilitation were several forces leading to the demise of the institution. Citizen advocacy, professional involvement, and judicial activism led to this demise and to innovations in legislation such as the mental retardation, developmental disabilities, and rehabilitation acts of the 1960s and 1970s (Braddock, 1987). Yet society's inability to promote the well-being of people with mental retardation and developmental disabilities was reflected in the many problems created by deinstitutionalization. The demise of the institution and the subsequent deinstitutionalization of people with developmental disabilities produced the normalization movement. Based on ideas imported from Scandinavian countries and introduced into the United States by Wolfensberger (1972) and others, development began of comprehensive community-based programs to meet the broad community living needs of people with developmental disabilities (Castellani, 1987; Gardner & Chapman, 1990). Based on the ideology of normalization, these programs, especially residential programs, sought to help people with developmental disabilitiesachieve a physicalpresence in the community, increase their participation 100
in mainstream social activities,and develop skills that would help them become participants in communities. Whether this actually occurred is an empirical question (Baker, Seltzer, & Seltzer, 1977; Bercovici, 1983), yet without such a physical presence, any subsequent Integration would have been unlikely. The 1980s was a turning point for the developmental disabilities movement. This decade witnessed the emergence of integration, the movement away from merely helping people with developmental disabilities achieve a presence in their communities to assisting people in becoming active participants. Specialized programs began to fall into disfavor as the movement embraced programmatic strategies based on supporting people in mainstream environments. Innovations such as supported employment, supported housing, family support programs, and inclusiveeducation emerged to assist people with developmental disabilities in becoming employees, home owners, regular (and not special) students, and family members. "I Am John" portrays the complex evolution of social policy. The implications of this article for social work practice are threefold. First, social workers must direct their energies to helping people with developmental disabilities become members of communities of their own choosing. Social workers must promote the selfdetermination of people with developmental disabilities and listen closelyto clients or to their representatives about what they want to achieve for themselves (Turnbull, Turnbull, Bronicki, Summers, & Roeder-Gordon, 1989). Second, more programmatic and support alternatives are now available to people with developmental disabilities than at any time in U.S. history. Sheltered environments are yielding to mainstream work settings, segregated leisure programs are yielding to inclusive recreational settings, and group homes are yielding to individual homes and apartment settings. Social workers must help people with developmental disabilities form and sustain support systems based on inclusion and community involvement, if this is what their clients want. Third, developmental disabilities policy is still evolving and social work practice must catch up
HEALTH AND SOCIAL WORK/VOLUME 17, NUMBER 2/ MAY 1992
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with its idealism. Certainly, audiences can view the character Benny of "LA. Law" achieving status as a citizen by successfully defending his right to vote, by achieving self-worth as a contributing member of a legal team, and by even adopting a homeless young person. Yet, social workers must question why people with developmental disabilities are not participating in such cherished institutions as the Olympics and why they require their own program of athletic competition. More threatening, however, is that institutions are being revived in some states, and in some cases these institutions are being located adjacent to prison facilities. Retrenchment in state budgets is leaving many people with developmental disabilities and their families with diminished resources, a situation that is resulting in increased rates of institutionalization in some states. Social workers who are committed to this field of practice must undertake partnerships with families and clients that will result in improved quality of life for people, who like John, want to be valued and active members of society. "BROWN VERSUS NEW YORK: THE RASHOMON OF DELIVERING MENTAL HEALTH SERVICES IN THE 1990s"
Chandler discusses the attempts of New York City to involuntarily hospitalize a homeless person, Joyce Brown, and illustrates two of society's inadequate responses to caring about and for people with severe and persistent psychiatric problems: psychiatric hospitalization and homelessness. Brown's situation reflects the numerous perspectives operating within U.S. mental health systems about what constitutes mental illness and how communities should respond to this social problem. Her situation reflects Matza's (1966) notion of the "Columbus complex," in which society periodically reawakens to discover that people coping with psychiatric problems are once again being mistreated, abused, or neglected. However, as noted by Matza in relationship to poor people, society soon forgets again about their plight. Brown's visibility on the streets and her challenge to "middle-class" values as articulated by
Mayor Ed Koch served as a rallying point for her "protection." From the standpoint of the medical model, this protection meant forced incarceration. From the standpoint of civil libertarian and perhaps antipsychiatric perspectives, this meant not invading Brown's privacy. From a consumer standpoint, this meant offering her alternatives that were acceptable to her and that respected her values, desires, and wishes. Policies in this case study reflect different definitions of mental illness, desirable response, and the role of the professional in "serving" people with mental illness. The article highlights the misinterpretation by mental health professionals of Brown's opposition to the alternative she was offered and to the way she was being treated as resistance to treatment by a "hostile" person. "Brown versus New York" highlights the poverty of many of our responses to people with psychiatric problems, especially to those who are also homeless. A society that cannot provide adequate housing and income to all of its members will have to tolerate homelessness, institutionalization, and premature death as "normar outcomes. Allowing people to squat on heating vents or coercing people into institutional settings are direct consequences of the inadequacy of the social services system and of the inability of society to provide a decent income. Given the functional difficulties that can be created by psychiatric problems, it is not surprising to find that people coping with psychiatric problems are the most sensitive to even the smallest decreases in social benefits. This article offers an alternative to the polarities of homelessness and institutionalization. Social workers must design services and supports that are acceptable to clients. According to Chandler and others, social workers must seek extensive client input in the identification of needs and desires, make certain input is acted on by the client and the professional, work with the client as a partner throughout the service delivery process, and provide services and supports that are flexible and that respect the preferences of the client. This article also underscores the importance of social workers as leaders in shaping policies
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and practices that are geared to the promotion of client-driven support systems. These support systems must emphasize increased attention to economic supports, disability entitlements, and consumer involvement, a view articulated by the National Mental Health Consumers Association; must eliminate coercion into mental health treatment, a view articulated by the National Alliance of Mental Patients; and must emphasize success in environments and in roles chosèn by consumers themselves, a vision articulated by the psychiatric rehabilitation movement (Farkas & Anthony, 1989). "IS CASE MANAGEMENT EFFECTIVE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS? A RESEARCH REVIEW"
Case management as a programmatic innovation hos emerged in mental health systems as a popular approach to working with people with psychiatric problems. Especially in community support systems, case management is seen as a means of integrating and coordinating benefits and services that cut across the boundaries of service delivery systems (for example, vocational rehabilitation, income maintenance). Rubin's review highlights the problems that have arisen in ascertaining empirically whether case management indeed helps people cope with psychiatric disabilities to increase their quality of life. Issues raised include a lack of consensus on the ultimate aims of case management, a plurality of models of case management, and a limited number of outcome studies that have clearly delineated the case management model serving as the independent variable and that have used systematic designs to evaluate the model's effects. Perhaps "case management" may not be the best term to apply to the diversity of models that have been identified as case management. Rather, case management may be used as a label for a form of social work practice that is interpersonally oriented but that involves community-based service delivery, linkage of clients to resources, direct involvement with consumers based on the development of a strong relationship and partnership, and advocacy to help consumers access needed resources. It may be more 102
productive to view case management more narrowly as the coordination of multiple service providers who are delivering services and supports to the same person (Linz, McAnally, & Wieck, 1989). In John's situation, case management may be productive because a range of locally based and administered services and supports for people with developmental disabilities are available through federal and state mandates in many communities. Within such a network of services and agencies, a need may exist for someone to work with clients and providers in the overall coordination of service delivery. However, in the case of Joyce Brown, case management may not be relevant, because many local communities lack the support systems to serve people with psychiatric disabilities. Compounding this problem are bureaucratic barriers and social factors that impede the access of people with psychiatric problems to income benefits, training programs, public housing resources, and other entitlements. Whereas case management may be effective in other fields of practice, what may be needed in the field of psychiatric disability are dedicated advocates who represent the preferences, desires, and wishes of people with psychiatric problems as if they were their own. This conception of advocacy is consistent with Rose's (1992) model of case management, a strengthsoriented approach to case management (Rapp & Wintersteen, 1989), and the conception of interpersonal advocacy tested by Freddolino, Moxley, and Fleishman (1989). People coping with severe and persistent psychiatric problems are likely to face formidable barriers in achieving a decent living in their communities of choice. The availability of dedicated, committed, and flexible allies who will assist them in achieving what they want for themselves is imperative. Perhaps attaching the label of case management to such proactive, advocacy-oriented practice is counterproductive. IMPLICATIONS FOR PRACTICE
These articles have important implications for social work practice. People with disabilities face monumental barriers in obtaining employ-
HEALTH AND SOCIAL WORK /VOLUME 17, NUMBER 2 / MAY 1992
Downloaded from https://academic.oup.com/hsw/article-abstract/17/2/99/710348 by Rutgers University Libraries/Technical Services user on 12 January 2018
ment, education, housing, and income. Given this reality, they form a large minority group that experiences perhaps the highest level of discrimination in society (DeJong & Batavia, 1990). Despite the enactment of the Americans with Disabilities Act in 1990 (West, 1991), people with disabilities will continue to feel the bite of discrimination as a result of the absence of flexible income support programs, disincentives to enter gainful employment, weak economic incentives to employ people with disabilities, inadequate housing alternatives, and few supports to encourage postsecondary educational advancement and training (DeJong & Batavia, 1990). Within this context it appears that case management may not be the intervention of choice, especially when resources available to a target population (such as those experiencing severe and persistent psychiatric disabilities) are limited. Yet given the need for policy and interpersonal advocacy, the time may be right for many social workers to relax their clinical orientations and to assume the roles of dedicated advocates of client-defined needs, desires, and choices. About the Author David Moxley, PhD, is Associate Professor, Wayne State University, School of Social Work, Detroit, MI 48070. References Baker, B., Seltzer, G., & Seltzer, M. (1977). As close as possible: Community residences for retarded adults. New York: Little Brown. Bercovici, S. (1983). Barders to normalization: The restrictive management of retarded persons. Balti-
more: University Park Press. Blatt, B., & Kaplan, F. (1974). Christmas in purgatory. Syracuse, NY: Human Policy Press. Braddock, D. (1987). Federal policy toward mental retardation and developmental disabilities. Baltimore: Paul H. Brookes. Castellani, P. (1987). The political economy of developmental disabilities. Baltimore: Paul H. Brookes. DeJong, G., & Batavia, A. (1990). The Americans with Disabilities Act and the current status of
U.S. disability policy. Journal of Disability Policy Studies, 1(3), 65-75. Farkas, M. D., & Anthony, W. (1989). Psychiatric rehabilitation programs: Putting theory into practice. Baltimore: Johns Hopkins University Press.
Freddolino, P., Moxley, D., & Fleishman, J. (1989). An advocacy model for people with long-term psychiatric disabilities. Hospital and Community Psychiatry, 40, 1169-1174. Gardner, J., & Chapman, M. (1990). Program issues in developmental disabilities: A guide to effective habilitation and active treatment. Baltimore:
Paul H. Brookes. Linz, M., McAnally, P., & Wieck, C. (Eds.). (1989). Case management: Historical, current, and future perspectives. Cambridge, MA: Brookline Books.
Matza, D. (1966). The disreputable poor. In R. Bendix & S. Lipset (Eds.), Class, status, and power (pp. 198-230). New York: Free Press. Rapp, C. A., & Wintersteen, R. (1989). The strengths model of case management: Results from twelve demonstrations. Psychosocial Rehabilitation Journal, 13, 23-32. Rose, S. (1992). Case management: An advocacy/ empowerment design. In S. Rose (Ed.), Case management and social work practice (pp. 271297) . New York: Longman. Rothman, D. (1971). The discovery of the asylum: Social order and disorder in the new republic. New York: Little Brown. Rothman, D. (1980). Conscience and convenience: The asylum and its alternatives in progressive America. New York: Little Brown. Rothman, D., & Rothman, S. (1984). The Willowbrook wars. New York: Harper & Row. Scheerenberger, R. C. (1983). A history of mental retardation. Baltimore: Paul H. Brookes.
Turnbull, H., Turnbull, A., Bronicki, G., Summers, J., & Roeder-Gordon, C. (1989). Disability and the family: A guide to decisions for adulthood. Baltimore: Paul H. Brookes. West, J. (1991). The Americans with Disabilities Act: From policy to practice. New York: Milbank Me-
morial Fund. Wolfensberger, W. (1972). Normalization. Toronto: National Institute for Mental Retardation.
DISABILITY POLICY AND SOCIAL WORK PRACTICE
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Accepted February 3, 1992
103
I
)
VI EWPOI NT
DISABILITY POLICY AND SOCIAL WORK PRACTICE Three articles in this issue discuss disability policy in the United States and its implications for social work practice. Patricia Fishley's "I Am John" reflects the evolution of society's care, treatment, and support of people with developmental disabilities. John's history, told from his point of view, is a dramatic history of hope. Despite periods of cruelty, neglect, and abuse, this brief sketch of society's response to people with developmental disabilities reflects some positive policy and programmatic outcomes, albeit on an incremental basis and for a specific target population, produced by a tireless social movement. Susan Meyers Chandler's "Brown versus New York: The Rashomon of Delivering Mental Health Services in the 1990s" highlights social workers' provision of dignified and respectful support to people experiencing psychiatric problems. It challenges social workers to reflect on whether their practice ensures self-determination for the people they work with in spite of society's inability or unwillingness to ensure that all people obtain the basic resources of life: housing, training, income, employment, and health care. Whereas the story of John reflects a history of hope, the story of Joyce Brown comments on misdirected professional action. Allen Rubin's "Is Case Management Effective for People with Mental Illness? A Research Review" is sobering and humbling. It concludes that social workers may be using an interven-
tion—case management—whose effectiveness still has not been demonstrated with certainty. In reality, social workers do not know much about the impact of case management on the quality of life of people with severe and persistent psychiatric disabilities. Joyce Brown may not benefit from case management in a society that cannot provide all its citizens with adequate and acceptable life-sustaining resources, including decent housing and a reliable income. "1 AM JOHN"
The field of mental retardation, and later that of developmental disabilities, has evolved considerably since the 18th century and most dramatically since it became a social movement in the United States during the early to mid-1960s. "I Am John" captures three policy epochs of this field: custodialism, normalization, and social integration. Custodialism is well documented by such authors as Rothman (1971, 1980) and Scheerenberger (1983). The policy aim of custodialism was clear: control the person, whether control was to protect society from the person with mental retardation or to protect the person from society. The asylum (later to become the state institution) was seen as an innovation and as a reform movement sparked in part by the mistreatment and neglect of people with mental disabilities by local citizens and by poor houses.
CCC Code: 0360-7283/92 $3.00 ©1992, National Association of Social Workers, Inc.
Downloaded from https://academic.oup.com/hsw/article-abstract/17/2/99/710348 by Rutgers University Libraries/Technical Services user on 12 January 2018
99
People with mental retardation were once auctioned off to the lowest bidder by local governments seeking to rid themselves of long-term responsibility for dependent people. In some communities, gangsters drove these individuals out of town during early morning raids. "Passing on," in which officials passed people with mental disabilities from one town to the next, was widely practiced. The asylum, based on moral treatment principles, was seen as a specialized environment for the management of people who could be restored to some normality or rationality. The demise of this rehabilitation ideal resulted in the conversion of the asylum into a holding tank. Institutions as "snake pits" were not uncommon, and the many exposes, especially the dramatic photographic essay Christmas in PurgaWry (Blatt & Kaplan, 1974), illustrated inhumanity to dependent, fellow human beings even through the late part of the 20th century (Rothman & Rothman, 1984). Abuse, neglect, and the absence of habilitation were several forces leading to the demise of the institution. Citizen advocacy, professional involvement, and judicial activism led to this demise and to innovations in legislation such as the mental retardation, developmental disabilities, and rehabilitation acts of the 1960s and 1970s (Braddock, 1987). Yet society's inability to promote the well-being of people with mental retardation and developmental disabilities was reflected in the many problems created by deinstitutionalization. The demise of the institution and the subsequent deinstitutionalization of people with developmental disabilities produced the normalization movement. Based on ideas imported from Scandinavian countries and introduced into the United States by Wolfensberger (1972) and others, development began of comprehensive community-based programs to meet the broad community living needs of people with developmental disabilities (Castellani, 1987; Gardner & Chapman, 1990). Based on the ideology of normalization, these programs, especially residential programs, sought to help people with developmental disabilitiesachieve a physicalpresence in the community, increase their participation 100
in mainstream social activities,and develop skills that would help them become participants in communities. Whether this actually occurred is an empirical question (Baker, Seltzer, & Seltzer, 1977; Bercovici, 1983), yet without such a physical presence, any subsequent Integration would have been unlikely. The 1980s was a turning point for the developmental disabilities movement. This decade witnessed the emergence of integration, the movement away from merely helping people with developmental disabilities achieve a presence in their communities to assisting people in becoming active participants. Specialized programs began to fall into disfavor as the movement embraced programmatic strategies based on supporting people in mainstream environments. Innovations such as supported employment, supported housing, family support programs, and inclusiveeducation emerged to assist people with developmental disabilities in becoming employees, home owners, regular (and not special) students, and family members. "I Am John" portrays the complex evolution of social policy. The implications of this article for social work practice are threefold. First, social workers must direct their energies to helping people with developmental disabilities become members of communities of their own choosing. Social workers must promote the selfdetermination of people with developmental disabilities and listen closelyto clients or to their representatives about what they want to achieve for themselves (Turnbull, Turnbull, Bronicki, Summers, & Roeder-Gordon, 1989). Second, more programmatic and support alternatives are now available to people with developmental disabilities than at any time in U.S. history. Sheltered environments are yielding to mainstream work settings, segregated leisure programs are yielding to inclusive recreational settings, and group homes are yielding to individual homes and apartment settings. Social workers must help people with developmental disabilities form and sustain support systems based on inclusion and community involvement, if this is what their clients want. Third, developmental disabilities policy is still evolving and social work practice must catch up
HEALTH AND SOCIAL WORK/VOLUME 17, NUMBER 2/ MAY 1992
Downloaded from https://academic.oup.com/hsw/article-abstract/17/2/99/710348 by Rutgers University Libraries/Technical Services user on 12 January 2018
with its idealism. Certainly, audiences can view the character Benny of "LA. Law" achieving status as a citizen by successfully defending his right to vote, by achieving self-worth as a contributing member of a legal team, and by even adopting a homeless young person. Yet, social workers must question why people with developmental disabilities are not participating in such cherished institutions as the Olympics and why they require their own program of athletic competition. More threatening, however, is that institutions are being revived in some states, and in some cases these institutions are being located adjacent to prison facilities. Retrenchment in state budgets is leaving many people with developmental disabilities and their families with diminished resources, a situation that is resulting in increased rates of institutionalization in some states. Social workers who are committed to this field of practice must undertake partnerships with families and clients that will result in improved quality of life for people, who like John, want to be valued and active members of society. "BROWN VERSUS NEW YORK: THE RASHOMON OF DELIVERING MENTAL HEALTH SERVICES IN THE 1990s"
Chandler discusses the attempts of New York City to involuntarily hospitalize a homeless person, Joyce Brown, and illustrates two of society's inadequate responses to caring about and for people with severe and persistent psychiatric problems: psychiatric hospitalization and homelessness. Brown's situation reflects the numerous perspectives operating within U.S. mental health systems about what constitutes mental illness and how communities should respond to this social problem. Her situation reflects Matza's (1966) notion of the "Columbus complex," in which society periodically reawakens to discover that people coping with psychiatric problems are once again being mistreated, abused, or neglected. However, as noted by Matza in relationship to poor people, society soon forgets again about their plight. Brown's visibility on the streets and her challenge to "middle-class" values as articulated by
Mayor Ed Koch served as a rallying point for her "protection." From the standpoint of the medical model, this protection meant forced incarceration. From the standpoint of civil libertarian and perhaps antipsychiatric perspectives, this meant not invading Brown's privacy. From a consumer standpoint, this meant offering her alternatives that were acceptable to her and that respected her values, desires, and wishes. Policies in this case study reflect different definitions of mental illness, desirable response, and the role of the professional in "serving" people with mental illness. The article highlights the misinterpretation by mental health professionals of Brown's opposition to the alternative she was offered and to the way she was being treated as resistance to treatment by a "hostile" person. "Brown versus New York" highlights the poverty of many of our responses to people with psychiatric problems, especially to those who are also homeless. A society that cannot provide adequate housing and income to all of its members will have to tolerate homelessness, institutionalization, and premature death as "normar outcomes. Allowing people to squat on heating vents or coercing people into institutional settings are direct consequences of the inadequacy of the social services system and of the inability of society to provide a decent income. Given the functional difficulties that can be created by psychiatric problems, it is not surprising to find that people coping with psychiatric problems are the most sensitive to even the smallest decreases in social benefits. This article offers an alternative to the polarities of homelessness and institutionalization. Social workers must design services and supports that are acceptable to clients. According to Chandler and others, social workers must seek extensive client input in the identification of needs and desires, make certain input is acted on by the client and the professional, work with the client as a partner throughout the service delivery process, and provide services and supports that are flexible and that respect the preferences of the client. This article also underscores the importance of social workers as leaders in shaping policies
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and practices that are geared to the promotion of client-driven support systems. These support systems must emphasize increased attention to economic supports, disability entitlements, and consumer involvement, a view articulated by the National Mental Health Consumers Association; must eliminate coercion into mental health treatment, a view articulated by the National Alliance of Mental Patients; and must emphasize success in environments and in roles chosèn by consumers themselves, a vision articulated by the psychiatric rehabilitation movement (Farkas & Anthony, 1989). "IS CASE MANAGEMENT EFFECTIVE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS? A RESEARCH REVIEW"
Case management as a programmatic innovation hos emerged in mental health systems as a popular approach to working with people with psychiatric problems. Especially in community support systems, case management is seen as a means of integrating and coordinating benefits and services that cut across the boundaries of service delivery systems (for example, vocational rehabilitation, income maintenance). Rubin's review highlights the problems that have arisen in ascertaining empirically whether case management indeed helps people cope with psychiatric disabilities to increase their quality of life. Issues raised include a lack of consensus on the ultimate aims of case management, a plurality of models of case management, and a limited number of outcome studies that have clearly delineated the case management model serving as the independent variable and that have used systematic designs to evaluate the model's effects. Perhaps "case management" may not be the best term to apply to the diversity of models that have been identified as case management. Rather, case management may be used as a label for a form of social work practice that is interpersonally oriented but that involves community-based service delivery, linkage of clients to resources, direct involvement with consumers based on the development of a strong relationship and partnership, and advocacy to help consumers access needed resources. It may be more 102
productive to view case management more narrowly as the coordination of multiple service providers who are delivering services and supports to the same person (Linz, McAnally, & Wieck, 1989). In John's situation, case management may be productive because a range of locally based and administered services and supports for people with developmental disabilities are available through federal and state mandates in many communities. Within such a network of services and agencies, a need may exist for someone to work with clients and providers in the overall coordination of service delivery. However, in the case of Joyce Brown, case management may not be relevant, because many local communities lack the support systems to serve people with psychiatric disabilities. Compounding this problem are bureaucratic barriers and social factors that impede the access of people with psychiatric problems to income benefits, training programs, public housing resources, and other entitlements. Whereas case management may be effective in other fields of practice, what may be needed in the field of psychiatric disability are dedicated advocates who represent the preferences, desires, and wishes of people with psychiatric problems as if they were their own. This conception of advocacy is consistent with Rose's (1992) model of case management, a strengthsoriented approach to case management (Rapp & Wintersteen, 1989), and the conception of interpersonal advocacy tested by Freddolino, Moxley, and Fleishman (1989). People coping with severe and persistent psychiatric problems are likely to face formidable barriers in achieving a decent living in their communities of choice. The availability of dedicated, committed, and flexible allies who will assist them in achieving what they want for themselves is imperative. Perhaps attaching the label of case management to such proactive, advocacy-oriented practice is counterproductive. IMPLICATIONS FOR PRACTICE
These articles have important implications for social work practice. People with disabilities face monumental barriers in obtaining employ-
HEALTH AND SOCIAL WORK /VOLUME 17, NUMBER 2 / MAY 1992
Downloaded from https://academic.oup.com/hsw/article-abstract/17/2/99/710348 by Rutgers University Libraries/Technical Services user on 12 January 2018
ment, education, housing, and income. Given this reality, they form a large minority group that experiences perhaps the highest level of discrimination in society (DeJong & Batavia, 1990). Despite the enactment of the Americans with Disabilities Act in 1990 (West, 1991), people with disabilities will continue to feel the bite of discrimination as a result of the absence of flexible income support programs, disincentives to enter gainful employment, weak economic incentives to employ people with disabilities, inadequate housing alternatives, and few supports to encourage postsecondary educational advancement and training (DeJong & Batavia, 1990). Within this context it appears that case management may not be the intervention of choice, especially when resources available to a target population (such as those experiencing severe and persistent psychiatric disabilities) are limited. Yet given the need for policy and interpersonal advocacy, the time may be right for many social workers to relax their clinical orientations and to assume the roles of dedicated advocates of client-defined needs, desires, and choices. About the Author David Moxley, PhD, is Associate Professor, Wayne State University, School of Social Work, Detroit, MI 48070. References Baker, B., Seltzer, G., & Seltzer, M. (1977). As close as possible: Community residences for retarded adults. New York: Little Brown. Bercovici, S. (1983). Barders to normalization: The restrictive management of retarded persons. Balti-
more: University Park Press. Blatt, B., & Kaplan, F. (1974). Christmas in purgatory. Syracuse, NY: Human Policy Press. Braddock, D. (1987). Federal policy toward mental retardation and developmental disabilities. Baltimore: Paul H. Brookes. Castellani, P. (1987). The political economy of developmental disabilities. Baltimore: Paul H. Brookes. DeJong, G., & Batavia, A. (1990). The Americans with Disabilities Act and the current status of
U.S. disability policy. Journal of Disability Policy Studies, 1(3), 65-75. Farkas, M. D., & Anthony, W. (1989). Psychiatric rehabilitation programs: Putting theory into practice. Baltimore: Johns Hopkins University Press.
Freddolino, P., Moxley, D., & Fleishman, J. (1989). An advocacy model for people with long-term psychiatric disabilities. Hospital and Community Psychiatry, 40, 1169-1174. Gardner, J., & Chapman, M. (1990). Program issues in developmental disabilities: A guide to effective habilitation and active treatment. Baltimore:
Paul H. Brookes. Linz, M., McAnally, P., & Wieck, C. (Eds.). (1989). Case management: Historical, current, and future perspectives. Cambridge, MA: Brookline Books.
Matza, D. (1966). The disreputable poor. In R. Bendix & S. Lipset (Eds.), Class, status, and power (pp. 198-230). New York: Free Press. Rapp, C. A., & Wintersteen, R. (1989). The strengths model of case management: Results from twelve demonstrations. Psychosocial Rehabilitation Journal, 13, 23-32. Rose, S. (1992). Case management: An advocacy/ empowerment design. In S. Rose (Ed.), Case management and social work practice (pp. 271297) . New York: Longman. Rothman, D. (1971). The discovery of the asylum: Social order and disorder in the new republic. New York: Little Brown. Rothman, D. (1980). Conscience and convenience: The asylum and its alternatives in progressive America. New York: Little Brown. Rothman, D., & Rothman, S. (1984). The Willowbrook wars. New York: Harper & Row. Scheerenberger, R. C. (1983). A history of mental retardation. Baltimore: Paul H. Brookes.
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Accepted February 3, 1992
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