In December of 2021 I began work as a case manager at ——— in Missoula, MT. This was a behavioral health clinic which provided therapy and case management services to individuals with Serious & Debilitating Mental Illness (SDMI).
———'s office was split between two suites in a public building. One suite contained the receptionist, the therapy offices, and the owner. The other contained the case management workspace, consisting of one central area connecting a few small rooms, not much more than 1000 sq ft. There happened to be an open desk in the office that the trainer was set up at, so I chose to set myself up there. Having just gradauted with a degree in psychology, I was very eager to master the position.
The first week was a training period, during which I shadowed the trainer and discussed the job. Since he was at the desk adjacent to me, I was right next to him during most of the time I spent in the office (provided he was there too). During training, they did not yet give me the work laptop or work phone, which we would be obligated to use to organize our workload and submit our tasks, and which would take about a day to set up. They did not provide them during the training period because they had had a history of problems with new hires apparently sometimes joining on, simply to gain access to client information. As a result, they responded with increased restrictions, despite the detriment that this caused to the onboarding process.
Certainly, something was wrong with that process, whatever it was. They could not manage to get anyone new to stay through the training process. People kept quitting soon after joining. Certainly, the stress was far worse than people had expected, but I believe the company itself made decisions which unnecessarily exacerbated the difficulties learning the position.
I was with the trainer when he was training a new hire, who had been mistakenly fired the day before. She reported that they had accused her of some kind of theft or suspicious activity, fired her immediately, then realized they were mistaken, and asked her to come back. She returned to train for a day, before quitting due to the slight. All in all, the prevailing attitude of the other case managers was a weary and eager hope thatsomeone would actually stay for more than a week or two.
The explicitly intended workload for a case manager was 15 clients. Most had 20-30. As a new hire, you were supposed to start off with 10, and work up to 15, but I, and so far as I knew, any other new hires, started at 15. Apparently they had a waitlist to become a client, and gave about as many as they could to case managers.
I was happy to agree with the stipulation that we are not allowed to communicate with clients after 5 PM. We were recommended to leave the work phone in the office, off. This was necessary to prevent the work from immediately spilling over into the entire day, as clients were liable to push. This was the only way to maintain any sanity. The supervisor reported that it is normal to be something of an empty shell of a person at the end of every day.
During training, the trainer and I went through his client list, and performed the basic minimum, namely: at least one moment of contact with each client each week, and one in person meeting per month. It may have actually been every three months, as I was told the simplest way to ensure that meeting is checked off is to use it as a chance to update quarterly (3 month) client treatment plans. These plans were created during an interview with the client, where their mental state, financial situation, etc. are evaluated and a plan is set forth "for their mental health." For me, this meant a behavioral plan of interventions to reduce and remove symptoms. Indeed, when said outloud, anyone wanted them to mean that. When I got my caseload, however, where I could see the history of reports and work posted for a client by various members of their health team, such as previous treatment plans across previous case managers, it was clear that the norm was to outline an essentially empty plan, sufficiently filled out to meet the requirements of medicaid, but through which the client was given zero forward aim — maintainence, essentially, persistence as a client indefinitely.
One of my trainer's clients, with whom we were due to make an in person meeting during my training week, could not be reached by phone. This was not uncommon, as the he had schizophrenia, was homeless, and would often sell his phone to buy drugs. So we had to go on a drive, passing his regular hangout spots (particular streets) and shelters, to see if anyone had seen him recently. Him being nowhere found, the trainer was somewhat upset that it would be necessary to terminate him as a client due to his having made himself unavailable for contact for a sufficient length of time. This client had been the trainer's for many years.
There were some stories of real change. The trainer himself reported one client he had managed to take from homeless to employed and living in low-income housing. The general gist was that this was a multi-year process, which few clients of any given list reached.
Our clients had SDMI's, which tended to mean they were the kind of person you never see, either because they never go outside, or because they cannot go outside. Many of them had a number of conditions, rarely without comorbid physiological conditions, diabetes, auto-immune diseases, injuries, etc. As a new hire, I was told I was given a "relatively easy" list, which meant that they explicitly chose not to give me the girl that accuses male case managers of sexual assault the second she sees them, nor any of the active meth addicts. Some of my clients were, mainly, poor, horridly anxious, and alone. By and large, they were mostly normal-seeming people most of the time, who, however, had a case manager to do their paperwork for them: they had developed relatively functioning personalities in certain everyday contexts, such as a conversation, but exhibited a frightening canyon of confidence or competence when it came to those tasks which they had been enabled in avoiding.
To be fair, it was standard recommendation to "make the client do it" when it came to these paperwork tasks. I had just a few clients for whom their situation was severe enough that there was no conceivable way they could survive without a case manager. One client in his 80's perhaps, considered to have a "thought-disorder," though reports differed depending on how much history of the client one read, was a person that no one would ever have a conversation with ever, who was not paid to have it. In his case, this wasn't out of being crude or inappropriate, usually, but rather simply because he could not go more than a minute without starting to make very little sense whatsoever, mentioning the meaning of the numbers of the scores of a football game in 1977, and talking — nonstop. Many times it was unclear if he was relating a true story, a dream, or a hallucination he had had.
It was also very difficult to tell whether he knew he had the condition. His speech was in the most normal, albeit deeply rambling tone. Being of a Rogerian mindset, I couldn't help but want to interject at some point to say something like "Do you think that I think that the numbers mean what you think they mean?" (said with utmost genuine, sincere curiosity). I did occasionally manage to interject a sentence with him (he spoke from the moment he saw you to the moment he left), but his response never cleared that up terribly much, and the conversation could never pause long enough to stamp the fire out. Generally speaking it felt as if a motor was running inside him forcing him to speak, to make unusual connections, to use strange phrasing ("very strong information, very strong"), yet that somewhere in there, I felt, was the man inside the condition, watching it happen, looking out at me, occasionally managing to peak through in knowing but trapped tones. I have no idea if that's true, but I do know that I felt that sense stronger, when his symptoms were weaker.
In his case, I believe the research showed clear possibility for a serious improvement in his symptoms if he were to manage to reduce his carbohydrate intake, in combination with some kind of fasting. He was a very intelligent man, underneath the condition, and, for that and many other reasons, spent a great deal of time reading, desiring to go to the library often. For the life of me, I can only presume it was during this time reading alone that he experienced the noticing of patterns in numbers (later to relay them in conversation). During his reading, he appeared to be getting some kind of information about fasting, and frequently attempted it. However, he did not appear capable of managing more than 36 hours (if he ever reached that), usually breaking it with a slushee which probably even, numerically speaking, single-handedly overflowed his glycogen stores' max capacity with sugar, undoing a large part of the process initiated by the fast.
I encouraged him , when possible, to fast more, and to fast more knowledgeably, using salt and surrounding the fast with meals of meat rather than carbohydrates. He did seem perfectly capable of hearing people, understanding them, and to some extent acknowledging what they said (he merely moved on quickly). He had some qualms and unsure disagreements with my suggestion and was able to coordinate information with me about a conclusion. It's just not clear that he was able to stick to it (which is common, as doctors know, of lots of people), probably made harder by his condition. More primarily however, as Dr. Chris Palmer warns about here, he had a "diabetes instructor" who was, so far as I genuinely believe from my research over 6 years, decades out of date in her information, and discouraged him from fasting.
As one of the main functions of a case manager, I went with him to meet with her as his advocate and coordinator, having printed out some 16 research articles and review papers. I was not brazen enough to say almost anything the whole time, knowing ahead of time it would be a disaster. I did not give her the papers, realizing once in the room that it would be a stunning (though fully deserved) insult to literally give her research she hasn't read. The only comment I made was halfway through the interview, as she asked him about his diet, sharing either benign or unsupported health claims in response to each of the things he said, and responded to his consumption of saturated fat with a solemn statement that it was incumbent upon him to reduce his intake, having mentioned nothing much too serious at all of his carbohydrate intake, and discouraged his fasting, whereupon I (sweating and shaking in anger and anxiety at a registered health practicioner doing nothing if not probably hurting the man with her disinterest in knowing her own field) interjected saying "That is not supported by the evidence. We have recent review papers completely exonerating saturated fat from all negative health claims." (Gershuni, 2018; Hooper et al., 2020; DiNicolantonio et al., 2016) If she did reply at all, I certainly didn't hear it.
(One may, in the absence of evolutionary analysis, claim that saturated fat is in dispute as safe and healthy, rather than truly exonerated, at which point the conclusion should remain the same: medical professionals have no grounds on which to emphasize this reduction as a known ideal.)
She was unable to tell us whether he had type I or type II diabetes.
I later faxed that office the research papers, receiving no reply (as part of his official care team, which is supposed to be in collaboration). I tried to track his symptoms and determine whether there was a correlation between his longer fasting attempts and a reduction in measureable outcomes, like "failed metaphors per minute." These are hard to come up with an example with, but just imagine him saying "It's like a guy going into a bank and not wearing any shoes!", except the context doesn't map onto that at all. Biased though I may be, I felt I saw a correlation, having heard him describe his currently somewhat lengthy 18 hour fast, and having an entire conversation with me with very little sense of rambling, no spurious numerical associations, and notable cogency. [The conclusion I hold currently is that the average, moderately metabolically unwell American needs around 36 hours to really begin noticing the benefits from a fast, with someone severely insulin resistant needing more. (Hasselbalch, 2018). This is, however, very complex, with long lists of systemic metabolic changes, which continue to accrue weeks (even months) into the process (Phinney et al., 1983).]
I tried to bring this pattern up with his psychiatrist! She responded with a tone of condescending corroboration, agreeing that it certainly is neat how symptoms work, and gave no interest in utilizing the information, seeing it as extranous detail in a case where medication was the only intervention. During his monthly meetings with her, she let him speak for 55 minutes, as he rambled about love letters he tried to send and people sniping him from Costcos, at the end of which she would finally interject with 2 questions:
I was frequently encouraged to speak with my supervisor as much as I could. This was new to me as no workplace I'd worked at had seen it as a genuine necessity and positive to need to run things by the supervisor daily. Here, the stress was by default so high, and the social complexity so difficult, that case managers often needed to share situations with each other, to determine what was reasonable. She encouraged me to share the research, and shared in my annoyance at their nonresponsiveness, although she was not surprised, and reminded me that this is partly why case managers exist. (What was the case load of that diabetes instructor?)
I had no shortage of clients whose list of medications was 2 or 3 pages long, containing a stimulant, a depressant, an anti-convulsant, an anti-anxiety, an anti-psychotic, an anti-depressant and so forth, across every category. Their psychiatrist's plan was to put their brain into a vice, and force it into the desired shape.
I felt like the boy in A Christmas Story, getting into the field of mental health, preparing my secret decoder ring, after all the induction training, only to find out the secret hidden wisdom of the field was: "Be sure to drink your Olanzapine." To be fair, I also felt that I was surrounded by case managers who saw what I saw, and who felt the injustice, and appreciated the human capacity for transformation.
I had emailed, at one point, a clinical psychologist asking if such a pattern could conceivably be interferring with the orientation of psychological interventions (anxiety and depression's symptoms being necessary to pinpoint their source and target treatment), to which he responded that this is of course true, and a commonplace problem which can only be addressed if at all by communication between members of a client's treatment team—which is coordinated, namely, by the case manager, without whom, for instance, it's not clear the exacerbating effect (Ingole et al., 2009; Kumar et al., 2011) of the psychiatrist's anti-psychotics would be made known to the "diabetes educator" (not to say that the solution to that problematic connection is simple).
A client frequently had a series of medical and mental health professionals, the basic set being a primary care physician, a psychiatrist, and a psychotherapist, which appeared to be a Master's in Social Work.
I asked the supervisor, who had quickly become a very close mentor of mine, and a relationship I cherished, how often one of their therapists chose to meet for a client's appointment outside of the office, so as to see the practical reality of their situation , or to engage in real world behavioral exposure. She said that never happened. Case management, however, was aptly arranged to do such things, as we frequently saw clients at their residences, mainly due to the unavoidable and desperately avoided necessity of hand-signed releases of information.
One of the main problems with the way the position worked was the need for an ROI before speaking to anyone about anything related to a client, even their own therapist — even if the client asks you to share the piece of information. On paper this HIPPA rule was intended to protect client privacy, but the reality was that it interferred with progress at every single step of the way, enshrining a privacy about which many clients were in no position to have any care about in any way.
One client was given a time limit to gut and rebuilt their apartment, or else be evicted, because they had stacked old plates, food, and clothes so high that the majority of the apartment was deeply infested with mold and other questionable foliage and fauna of septic persuasion. Desiring not to be evicted and homeless, does this client need to hand-sign off on any communication with the multiple toxic cleanup companies (the first of which. after a week, evaluated and refused the job)? Each and every one.
An ROI, officially, must be hand signed by the client, and declare the designated party (therapist's name, psychiatrist's, Home Depot, taxi service, and so on). The problem was that, even for relatively well functioning clients, completing a task on their behalf was a series of endless potential breaches.
I had one client who needed a wheelchair ramp installed at their residence (before a certain surgery date, mind you). If you know exactly who to call to get that to happen, it could be straightforward, but at least for the first few years of the position—a similar case management company having declared to me that the minimum hire length was 2 years, as they believed it took that long to get fully trained—without much experience, you have to call people to figure out who to call. Plans get built, they turn out poorly, and you have to pivot to solve them. If you followed ROI procedures precisely, you would have to research, get a number, drive to the client, get it signed, and then proceed. Ideally, you'd stay there and sign many to get a job done, but time rarely ever allowed for this. What if the second number's hours are different? What if the first number is busy for an hour (which was prevalent)? Instead you'd have to rush out back to the office to other work, call the relevant people when possible, be redirected to a different company, and be back where you started.
The key point is that any task you needed to do basically required an additional in person meeting, moreso when the previous case manager (whose job you took over because they were bad at it) was bad at it, and allowed many important ROI's to run out of date! It was so cumbersome that many tricks had been tried over the years to make it possible to get things done. My trainer told me of one person who would get dozens of blank ROIs signed as they discussed the big picture of a clients need, so that when it came time to do something, they could fill in each collocutor as needed, and work autonomously to the clients end request. He chuckled at this, but I later found out that was a fireable offense.
Being found to be in breach of HIPPA could cost the company a fine of multiple thousands of dollars. So, in classically ill-thought out fashion, tyranny propogates down the hierarchy by each level's individual abdication of responsible problem solving. HIPPA is strict on us with punishment? Then we must strictly punish a subordinate, to save us. I will tyranize to save myself from tyranny. Interest in why a breach would occur was not involved.
While on the one hand the job was overloaded with work, at that same time a case manager would be liable to choose to drive to a client's residence if only to add the drive time to their notes.
Case managers were required to, numerically speaking, spend about 1 full day of the week writing down what they did in the other 4. Every single client related task was tracked, estimated by the case manager for the units it would be worth, categorized for where it occured and whether it was bidden or unbidden etc. etc., and a summary written of what occured. The rule of thumb was that a summary should be the 'number of units + 2' sentences, and also equivilant to 15 minutes, amounting to a weekly/monthly sum quota of medicaid billable units. If it takes 5 minutes to drive to a residence—the trainer explained—I could squeeze two sentences out of it (there and back), making more like 4 units.
This quota meant that instead of frantically trying to get work done, you instead aimed, worn down by the debatable emotional "manipulation," as my supervisor termed it, of at least a few of your clients, when things weren't going well, to frantically get non-work done, and fluff it up as you rush out your notes for the week. This procedure of arranging tasks, planning them out while considering client severity, predicting their unit value, and scheduling when you would do the notes for the tasks, was far more of the general thought process than the clients themselves, and took multiple months to get any sort of hang of. It also meant one would hope to do a few very large things in a day, like 3-4, so that you could spend less time on the scaffold work of inputting a new note. Opportunities to spend such concentrated time were not forthcoming, so a worse day might mean taking 10 notes, each 2 units, a few of which were nothing but a phone call, and stretching each and every one of them to meet the daily 32 units, spending one day (if you can remember all that's happened organizing 15+ different lives), on the notes, to meet a weekly 130 unit requirement (4 days of ~32 units by default, sometimes higher or lower depending on the specific employees other responsibilities and case load).
Ironically, so much "work" was required that no work could get done. Easily 2+ hours a week needed to be spent just organizing everything happening, a number obviously higher for new hires. Meetings and work-related discussions were includable as billable units, with a legitimately 20 minute conversation probably being billed for 4 units.
Indeed, the week long shadowing (which offered little practical experience with this juggling) was followed by an explicit 3 month practice period, with monthly (extra) scheduled meetings with the supervisor to see how it was going, and a 3 month meeting at which it would be determined if the employee was up to speed, or would need additional training.
I was fired 2 months in.
Somewhere amidst the chaotic subsumption of the previous (former) case manager's appointments and information, which needed tracing from their notes, one frantic morning I tried to schedule a meeting for a client, the severe one mentioned above, with his therapist, as he was hoping to change the date. He asked me repeatedly in passing over a week to do so, explicitly cogently explaining that he gives me permission to speak to her about it (he being a long-term client familiar in his way with the ROI system), and I did, after which I found out that the ROI itself was out of date. I went and got it signed, and continued along my day. The next day, Friday, I was told I had received a writeup.
It stated (1) that I was shirking duties onto my fellow case managers (referring, presumably, to the act of having other case managers fit certain clients into their schedule for ferrying to appointments, when the main case manager couldn't, which was allowed, normal, recommended, and accepted readily by other case managers who remember clearly the difficulty first starting out, and was only necessary a couple times as a result of decisions made by the former case manager), (2) that I was claiming to be a licensed therapist in my medicaid notes through my usage of technical terminology (such as analyses of the dynamics of a client's "complexes," which amounts to little other than a motivational analysis, which in that terminology is commonplace in the position), and finally, hypothetically most gravely despite their neglecting to specify, (3) I had breached HIPPA, even claiming that I knowingly lied about having a signed ROI when I had been asked.
For instance, one client had had a few seizures years before, and was on many medications, of course, it being unclear whether more were to come. I frequently asked my clients what they thought of the medications, and whether it made sense to them. Some had gone through the ringer enough that their list was resulting in quite the reduction of symptoms, usually taking 2 or more years of additions and adjustments. Others saw natural interventions as more sensible, often correlating with an interest in medical marijuana. In the case of this client, we had to determine the logistics of their ability to reduce their anxiety, and from where it was coming, which ranged from going outside at all, to anxiety of anger problems. When I first met the client, they took a week to communicate freely with me and swore that if the company switched their damn case manager again, they wouldn't be able to take it—opening up again to another person.
The more complicated of my notes for a client like this was an analysis of the causal order of their anxieties, in order to determine a point of intervention that was maximally first accessible. For instance, they were being primarily driven mad by their criminal neighbors, and needed to get out of the house to have space from them (and clear their mind from the cabin fever). They used marijuana to reduce their agitation at this, but it was unclear how much the marijuana was contributing to their anxiety (potentially causing or exacerbating derealization, too). They couldn't drive because of the possibility of seizures. They had no reliable phone to navigate. They couldn't expose out or practice their anger management except in communication with people, which they couldn't see because they were stuck in the house. So, there is a determinable order of the complexity of symptoms, which anyone with any sense helps the client sort out and plan through: is there a practical system we could devise to make it plausible for you to get out of the house without needing your partner?
The stated mantra, used as shield and motto in everything from medicaid notes to disputes with clients, was something along the lines that a case manager's job was to: plan, coordinate, assess, evaluate, monitor, relay, transport, and advocate. Nowhere in that description, supposedly, is it precisely said that intervention is included, although anyone who knows the psychological literature knows that planning is a psychological intervention. Nevertheless, it certainly never appeared to be the case that clients' therapists were helping them much, never leaving the office, and so generally case managers hoped to be able to do actual good with the client, beyond merely talking (not that talk therapy is without its power, when done well). In conversation with my supervisor before and during the meeting around the writeup, it eventually became clear that the recommendation was to try to make real differences, while being sure to state none of that explicitly to medicaid.
Afterall, medicaid cannot pay billable hours for therapy to a person who is not a therapist. So, when you engage in "cognitive restructuring by challenging a client's maladaptive thoughts," either write it to medicaid as "explained" or stop doing so much. Yes, really.
If you take a client for exposure therapy (to, say, crowds), you can do so, if you have an alternative motive for going there, or the client explicitly states the desire to engage in the activity. (Just spending time with clients could be happily billed as rapport building... Unless you did far too much of it) My supervisor eventually stated it very clearly: The problem is that I need to "write my notes like I'm writing for an eighth grader."
In that meeting it took a whopping 20 straight minutes of confused conversation before my supervisor and I (neither of us unintelligent people) could clearly state that verbal consent does not count for HIPPA, even temporarily (the crux of what I had done). I pointed out how long it took for us to clarify that, and explained that I had not been trained that way.
As I sat in the meeting thinking about the writeup (all of which was cutting into my still-expected meeting of unit quota), discussing it with the supervisor, where she agreed it was insane and that it was out of her hands, she explained that I had a choice:
At first I did not gravitate towards a rebuttal, but given that I had done nothing outside of the normal recommendations of my training, and had been quite proud to be managing the position more successfully than any of the other hires I'd seen, to be finally working in a position where I could make use of all the extracurricular study I had done (I kept a copy of The Structure and Dynamics of the Psyche on my desk), I felt it was necessary to refuse the writeup. I proceeded to finish my week's work, and write, in the final hour of time I had, with no space to think over the issue, a 1000 word rebuttal, which I wanted my supervisor to check over, but she assured me, in retrospect I think wrongly, that it was not her place (she was partly attempting to keep the situation out of attention to preserve my professional dignity).
I submitted the response to the supervisor, who at some point passed it to the owner, and presumably HR (who also had a case load).
I was called into the owner's office Monday morning, before any of my coworkers had shown up. By this point, already, the work phone had been cut off, making contact to clients, and more perniciously, coworkers, whose numbers would only be put into the work phone, impossible. It turns out this may explain why the manner of "quitting" was usually total disappearance without notice: the management had designed it to occur in a way that makes any communication between the quit or fired and the still employed impossible. The stated reason for this would be the negative past experiences the company had with harassment, by client and otherwise.
I entered the meeting, met the owner for the first time, as she said "I read your response.", a multi-page essay explaining what happened, how the accusations were either unfounded (totally inaccurate), or senseless (accusing me of doing something I had been trained to do), and connecting these mistakes to practical problems in the procedures used to train new hires. The product of that discussion, for a sensible manager, would be the clarification of procedural modifications necessary to finally cease losing all of the new hires, and turn around the business. Instead, she then said blithely "I think it says all that needs to be said. I'm terminating your employement.", whereupon things did not change, problems were not tracked to their root cause, and I was sent to my office to pack up my things and leave, before any other employees showed up.
I do not know if my coworkers were told that I was fired, or whether they were left to believe yet another had quit. Presumably that one client terminated services.
As part of the employee contract, which they refused to send me for verification, there are stipulations about the number of years before contact between a previous employee and other employees is allowed. I have never spoken to any of them since, and was denied thereby the ability to ask my supervisor for the extremely positive letter of recommendation she was poised to write me.
I later recorded a 3 hour interview with a news reporter for the local campus, but, being more of a sports reporter, though intrigued, he did not end up having the position to do anything with the story.