Chapter 10 Case Management/Counseling Reading this excerpt from a human service student’s journal is a very appropriate way to begin a discussion of case management/counseling: I was having a real hard time studying and I was sure I was going to flunk my courses. I couldn’t concentrate because my family was going through a divorce. I felt like I was being pulled apart by my parents. Who was I supposed to be loyal to? I knew I was getting to depend on cocaine too much. I was stoned most of the time. I figured I better talk to someone soon before I blew my stack. I started asking my friends and my dorm supervisor for the name of a good therapist. People would ask me if I wanted to see a psychiatrist, a psychologist, a social worker, a family therapist, a drug and alcohol counselor, or what. I’d ask what the difference was but no one gave me a clear answer. So they didn’t know and I didn’t know! I felt more confused than when I began looking for help. Thus far in this book you have met many human service workers. The majority of them were delivering direct services and spending most of their day working one-on-one with clients. Although doing similar work, they were likely to be referred to variously as: · Case workers · Social workers · Counselors · Advocates · Therapists · Case managers · Clinicians · Therapists All this semantic fuzziness can be confusing to a client who must figure out whom to go to with a problem. And a worker searching the job listings in the newspaper or a web site can never tell from the title of the position exactly what tasks or problem areas it will include. The general public, accustomed to name brands, finds it difficult to understand how a middle-aged woman with a doctorate in psychology and a young man with an associate’s degree in human services can both assert that they do “counseling.” In an effort to make job titles uniform, some professionals in the human service field have suggested that a distinction in title should be made according to how much a human service worker deals with highly charged emotional material rather than with the ordinary problems of daily life. They might say A social worker or therapist who has an advanced degree helps clients deal with deep-seated intrapsychic problems. A case manager or counselor (a less academically trained person) helps clients make decisions and then use social resources to implement them. But we don’t think that is a sensible distinction! All human service workers, regardless of their backgrounds, job titles, or their clients’ problems, must inevitably deal with inner emotions as well as external pressures. Of course, with more study, experience, and training, a clinician can work more effectively with the deep emotions that surround problems. Human service problems stem from the interaction of biological, emotional, and environmental stresses. If we ignore one set of forces, we get a lopsided view of a problem. And lopsided views lead to ...

1. Chapter 10 Case Management/Counseling
Reading this excerpt from a human service student’s journal is a
very appropriate way to begin a discussion of case
management/counseling:
I was having a real hard time studying and I was sure I was
going to flunk my courses. I couldn’t concentrate because my
family was going through a divorce. I felt like I was being
pulled apart by my parents. Who was I supposed to be loyal to?
I knew I was getting to depend on cocaine too much. I was
stoned most of the time. I figured I better talk to someone soon
before I blew my stack. I started asking my friends and my
dorm supervisor for the name of a good therapist. People would
ask me if I wanted to see a psychiatrist, a psychologist, a social
worker, a family therapist, a drug and alcohol counselor, or
what. I’d ask what the difference was but no one gave me a
clear answer. So they didn’t know and I didn’t know! I felt
more confused than when I began looking for help.
Thus far in this book you have met many human service
workers. The majority of them were delivering direct services
and spending most of their day working one-on-one with clients.
Although doing similar work, they were likely to be referred to
variously as:
· Case workers
· Social workers
· Counselors
· Advocates

2. · Therapists
· Case managers
· Clinicians
· Therapists
All this semantic fuzziness can be confusing to a client who
must figure out whom to go to with a problem. And a worker
searching the job listings in the newspaper or a web site can
never tell from the title of the position exactly what tasks or
problem areas it will include. The general public, accustomed to
name brands, finds it difficult to understand how a middle-aged
woman with a doctorate in psychology and a young man with an
associate’s degree in human services can both assert that they
do “counseling.”
In an effort to make job titles uniform, some professionals in
the human service field have suggested that a distinction in title
should be made according to how much a human service worker
deals with highly charged emotional material rather than with
the ordinary problems of daily life. They might say
A social worker or therapist who has an advanced degree
helps clients deal with deep-seated intrapsychic problems. A
case manager or counselor (a less academically trained person)
helps clients make decisions and then use social resources to
implement them.
But we don’t think that is a sensible distinction! All human
service workers, regardless of their backgrounds, job titles, or
their clients’ problems, must inevitably deal with inner
emotions as well as external pressures. Of course, with more
study, experience, and training, a clinician can work more
effectively with the deep emotions that surround problems.

3. Human service problems stem from the interaction of
biological, emotional, and environmental stresses. If we ignore
one set of forces, we get a lopsided view of a problem. And
lopsided views lead to inadequate interventions.
For example, Timothy, a counselor in a residential prison-
diversion program, has been asked by Barry, one of the
residents, for a change of roommates. Before Timothy began to
juggle rooms to accommodate Barry’s request, he encouraged
Barry to clarify the problem he was having with his present
roommate. Timothy asked Barry about:
Barry’s expectations of his present roommate and what he
thought his roommate’s expectations were of him
The similarities and differences in their habits, routines, and
lifestyles
The extent to which they both tolerated differences in styles
The methods of conflict resolution they had already tried
when they had a disagreement
The stresses of study, family, work, or social life that may
have been aggravating their problem
After several conversations with the two men, some separately
and some together, Timothy suggested that the tension between
them might lessen if they set up a more workable system for
cleanup. He offered to help them design a chore chart. They
also agreed to make some mutually acceptable rules about
playing the radio and going to bed. Through their sessions, one
of the young men realized that some of his anger at his
roommate probably stemmed from his past irritations with his
brother and that, in fact, there were many parts of living

4. together that he enjoyed. They agreed to try to use the chore
chart and a few rules they both could agree on for two weeks.
They also agreed to check in with Timothy for ten minutes each
day. Thus, both young men found possible solutions to a
relationship problem that at first seemed insurmountable.
There might have been other root causes for the tension.
Perhaps Barry brought home a great deal of anger from his job
and that was the primary source of tension between the
roommates. If that had been the case, Timothy could have
referred him to a vocational counselor and a youth employment
agency to help him change jobs or cope better with the one he
had.
Although the counseling assignment of beginning human service
workers might involve helping clients find and use resources,
they should never lose sight of the fact that a client’s
unexplored feelings can subtly sabotage even the simplest
solution.
10.6 Case Management/Counseling in the Era of Managed
Health Care
At a recent public forum on managed health care, audience
members lined up in front of the microphone to tell their
legislators what was on their minds. A local real estate agent
came up to the microphone and said:
I had a blocked valve in my heart and they had to do
extensive surgery. I was in the hospital three times, the last
time for seven days. When I was released, they put me in
cardiac rehab. I see a physical therapist and do stress
management three times a week now. My bills must come to
thousands of dollars but I have paid almost nothing out of my
pocket. Without my managed health care plan, I would be dead
or totally bankrupt. I am so damned grateful for the plan.

5. An elderly man faced the audience and stated with strong
emotion:
I absolutely refuse to give up my regular Medicare and be
forced into a private managed health plan, even though I could
probably get some financial help with my prescription costs. I
have a friend who died waiting while his plan argued about
whether he needed a certain procedure. My internist is very
independent and doesn’t belong to any of the plans. I won’t give
him up! He knows me and my health conditions so well. And I
want to go to the specialists he recommends, not be forced to
choose a doctor from some impersonal list.
Health care delivery is a much debated subject that no reader of
this book can afford to ignore. It is vital—for both your
personal and professional life. But if you are a young person
whose parents have reasonably high incomes and jobs that offer
them health insurance, paying medical bills probably hasn’t
been much of a worry. If you are in college now, although you
may not be thrilled with its services, your school most likely
has a free health clinic funded by the fee you paid along with
tuition.
But if you took time off between high school and college,
worked at an entry-level job, and turned 19, you might have
been surprised to discover that you had been dropped from your
parent’s health insurance, and your entry-level job didn’t offer
any medical insurance. As a young person—with the illusion of
invulnerability—that probably wouldn’t have bothered you very
much until:
You came home from a camping trip with a strange rash that
wouldn’t heal
You broke your leg in a waterskiing tumble

6. You faced the stark reality that you needed help controlling
your drinking or drugging behavior or your starving and binging
behavior
You wanted to try some new techniques such as acupuncture
or hypnosis for an intractible sports injury (Becvar & Pontious,
2000)
Recent Developments in Health Care Delivery
Throughout most of the last century, medical care has been
delivered by independent private doctors along with a mix of
private and for-profit hospitals. The bills for medical care have
been paid by the patient who received the treatment. Only very
poor people (or those who are currently in or have served in the
armed services) received free or subsidized care in clinics.
During the second half of the last century, hospitalization
insurance, paid for by individuals, sometimes with the help of
their employers, became part of the funding picture. As early as
the 1920s, there were a few scattered small-scale experiments
that offered prepaid doctor visits with a panel of medical
practitioners. But it was not until the Depression that a large-
scale innovative program, the nonprofit Kaiser Permanente—the
grandparent of all health maintenance organizations (HMOs)—
came into being (Lowman & Resnick, 1994). This early HMO
had a populist flavor to it. The designers of the plan wanted to
deliver accessible, high-quality care to a large portion of the
neglected population. This experiment and others patterned on it
were enthusiastically received years later, as health care costs
and the demands for services spiraled out of control. Congress
passed the Federal Health Maintenance Organization Act (PL
93-222) of 1973, which established nationwide standards and
offered financial incentives to fledgling HMOs.

7. health maintenance organization (HMO)
A health care institution or an association of doctors that
contracts with its members to collect a fixed sum of money
monthly or yearly in exchange for doctor visits, tests,
medications, hospital care, and preventive services, as needed.
While employer-supported and private health plans expanded
their reach, social activists have long been prodding Congress
to pass health care legislation that would cover everyone in the
country and be paid for from income taxes—the kind of
universal coverage that Canada and several European countries
have had for many years. After much acrimonious debate
between the social service establishment and organized
associations of medical doctors, Medicare, prepaid health care
for those sixty-five years of age and older, was finally passed
by Congress in 1965. It still wasn’t universal coverage, but it
represented a beginning.
Even though we are not health care workers, we need to
understand the impact that serious health problems, such as
obesity, have on our clients. We try to help them anticipate and
avoid these problems.
The Rise of For-Profit Managed Health Care
During the first two years of President Bill Clinton’s
administration, tax-supported universal health insurance looked
as if it had a good chance of passing. But it suffered major
political and public relations setbacks. Fearful of more “big
government,” Congress wiped it off its agenda.
However, it was clear to everyone that health care options were
multiplying along with health care costs and that some type of
managed system was vital. As these private plans for both
medical care and prescription drug coverage grew in number,
they formed what is now admiringly referred to by stockbrokers

8. as the health care industry, the fastest-growing sector of the
economy. The number of people enrolled in these plans
continued to rise (Dee, 2007; Psychotherapy Finances, 1998;
Vallianatos, 2001).
Some Problems with the Expansion of the Health Care Industry
Although more people had prepaid health care coverage than
ever before and many were receiving care they never dreamed
of in the past, both human service practitioners’ and the
public’s attitudes about for-profit care have been conflicted
(Corcoran & Vandiver, 1996; O’Neill, 2001). There is an odd
mix of negatives and positives; there have been more medical
options available; people are living longer, but health plans still
need to turn a profit.
As one anonymous critic summed it up, “The doctor’s credo of
‘Do no harm!’ sometimes seems to have evolved to ‘Do no
harm—to the stockholders!’” A review of the issue published by
the National Association of Social Workers, titled “Humane
Managed Care?” suggests that those words might be an
oxymoron (Schamess & Lightburn, 1998). The following are
some of the criticisms that have been discussed in human
service agencies, by patient advocacy groups, and even the
medical establishment:
Some plans offer doctors financial incentives to keep costs
down by not recommending expensive tests or procedures that
might be of critical importance.
Panels of approved health care providers are not necessarily
screened for quality but simply for their willingness to accept
the fee for service stipulated by the company. Often a limited
list of providers means long waits for medical procedures or
visits.
fee for service

9. A prearranged amount of money that will be paid to a
health care provider each time he or she delivers a specific
service to a plan member in accordance with the plan’s criteria
for that service.
Many plans have been accused of rationing or denying
requests for respected experimental or complementary medical
procedures.
Most plans have gatekeepers (often untrained in the
particular medical specialty) who have the power to veto a
doctor’s choice of a treatment plan.
gatekeeper
A person in a health plan organization who decides
whether a prescribed medical service will be paid for, based on
its set of criteria for care.
When a requested service is rejected, some plans have no
genuine appeal mechanism for the consumer’s protest.
Mental health practitioners are often forced to affix a
diagnosis or label to persons seeking help. They might not
believe it is accurate but must do so in order to obtain approval
for counseling sessions with a person in crisis.
Computerization of personal health and mental health
information might be used to reject a prospective enrollee or it
might be divulged to a current employer without the patient’s
knowledge or consent.
Some plans have routinely rejected applicants who have “pre-
existing conditions” such as diabetes or cancer. Other plans
have cancelled coverage of already enrolled people who develop

10. serious health problems that need costly treatments.
The Current Status of Health Care Coverage
In 2010, in a very narrow, and mostly partisan vote, both houses
of Congress passed a sweeping health care bill. It was carved
out of many compromises but is not the universal coverage that
many hoped for. In addition, many Congresspersons who voted
against it have vowed to overturn the legislation or make it very
ineffective by denying funding. As the eighth edition of this
book goes to press it is anyone’s guess what will happen to the
new Health Care Bill. Whatever happens, it will affect you and
the people you work with.
In our current era, speed has become the new normal. Clients
often cannot understand why there are few “quick fixes” for
human service problems.