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American Journal of Orthopsychiatry 2003, Vol. 73, No. 1, 24–34

Copyright 2003 by the Educational Publishing Foundation 0002-9432/03/$12.00 DOI: 10.1037/0002-9432.73.1.24

The Social Grid of Community Medication Management Jeffrey Longhofer, PhD, MSW, Jerry Floersch, PhD, LISW, and Janis H. Jenkins, PhD Case Western Reserve University Practitioners involved in case management at a community mental health center organized 5 elements of a psychotropic medication experience. Using case records, interview, and observational data, the authors examined an underresearched and especially problematic area of the management process: the interpretation of a medication’s effect. They describe the divisions of labor, a grid of social relations, and spaces related to management, and they describe how the limits and potential of medications are realized in the intensity of monitoring and the knowledge produced in the day-to-day practices among all participants.

During the past 3 decades, the presence and power of medications in treating mental illness have become taken for granted. For the many who work or live everyday with serious mental illness, medications seem a natural part of existing, necessary to the support of people in communities (Gelman, 1999). And while some have argued that deinstitutionalization has been made possible by psychotropic medications (Brill, 1980), others see chemicals as yet another powerful form of social control, or even worse, as potent and dangerous neurotoxins with no clear benefit (Breggin, 1991). Whatever one’s perspective on the effects of medications on mental illness, the use of medications is pervasive and has produced entirely new forms of therapeutic and management relationships (Azrin & Teichner, 1998; Buchkremer, Klingberg, Holle, Schulze Mönking, & Hornung, 1997; Goldstein, 1996; Herz et al., 2000; Jordan, Hardy, & Coleman, 1999; Kotcher & Smith, 1993; Nageotte, Sullivan, Duan, & Camp, 1997; Stewart & Pearson, 1999), fiscal and insurance problems (Katz, Kessler, Lin, & Wells, 1998; Wells & Sturm, 1996), and public debate (Conrad, 1985; Gournay, 1995; Reid, Pham, & Rago, 1993; Shon et al., 1999).

This ethnographic study of suburban case managers examines psychiatric medication management in a community support services program. Case managers, in monitoring medications, move through space and time, their efforts varying in intensity from scheduling daily and weekly deliveries to transporting clients for shots and medication appointments and making numerous trips to pharmacies and interventions into acute crises. A single manager with a caseload of 15 had an average of nine clients taking two or fewer medications; six were taking three or more. On any given day, Community Support Services (CSS), a branch of a community mental health center, delivered medications—referred to in the case manager lexicon as a med drop—to approximately 24 clients who were considered “low functioning” and in need of monitoring; some received as many as three daily visits. In just 1 year 35 managers drove a remarkable 750,000 miles—30 revolutions around the earth! In working with 400 clients, they made approximately 14,000 med drops—an episode of delivering a single daily prescription—to clients serviced by one mental health center. Research on the prevailing medical model of medication management points to problems resulting when practitioners exclude clients from decision making (Chewning, 1997; Chewning & Sleath, 1996; Gournay, 1995; Morris & Schulz, 1992). Clientcentered models, on the other hand, seek active participation in management (Cameron, 1996; Gerbert, Love, Caspers, Linkins, & Burack, 1999; Warren, 1999; Warren & Lutz, 2000). Others have shown how clients differ significantly in levels of involvement in decision making about prescription compliance and symptom monitoring (Chewning & Schommer, 1996; Chewning & Sleath, 1996; Dowell, 1990;

Jeffrey Longhofer, PhD, MSW, and Jerry Floersch, PhD, LISW, Mandel School of Applied Social Sciences, Case Western Reserve University; Janis H. Jenkins, PhD, Department of Anthropology, Case Western Reserve University. Portions of this article were presented at the 6th annual meeting of the Society for Social Work and Research, held in San Diego, California, on January 18–20, 2002. Names of individuals and places have been changed. For reprints and correspondence: Jeffrey Longhofer, PhD, MSW, Mandel School of Applied Social Sciences, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106-7164.

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Jordan et al., 1999; Sowers & Golden, 1999). Some actively engage providers, physicians, case managers, therapists, and institutions (Chewning & Sleath, 1996; de Vries, Duggan, Tromp, & Lolkje, 1999; Lipowski, 1997; Sleath, Svarstad, & Roter, 1997), whereas others remain passive and readily defer to expert opinion and intervention (Ascione, 1994; Wells & Sturm, 1996). Likewise, practitioners have varying levels of involvement; these findings suggest a continuum, from active to passive, for both practitioner and client (Chewning, 1997; J. S. Cohen & Insel, 1996; Demyttenaere, 1997; Sleath, 1996). In this study, we argue that activity and passivity are multiply determined and vary through time: Sometimes practitioners are active, at other times they are passive. These states are not always determined by the changing position of the client along this continuum. And many factors, including gender and ethnicity, influence the subjective experience of atypical antipsychotics (Jenkins & Miller, 2002). Much of management research, however, has been limited to compliance and decision making in physical medicine or to management of iatrogenic problems related to psychotropic treatments of chronic mental illness (Bennett, Done, & Hunt, 1995; Boomsma, Dassen, Dingemans, & van den Heuvel, 1999; Gournay, 1995; Hamera, Rhodes, & Wegner, 1994; Roter et al., 1998; Steiner & Prochazka, 1997). In this literature it is often assumed that clients exert purposive control and organization of conduct or simply respond to external stimuli, such as expectations about patient role behavior. There is no interest in how compliance and related behaviors are produced or consideration of the deliberate and self-conscious nature of interpretation (e.g., role expectation) of external pressures. In short, meanings that produce compliance or medication behaviors for each actor are not analyzed; reasons, wants, purposes, desires, and intentions, the causes of behavior, are ignored, and their unconscious dimensions inevitably elided (Keat & Urry, 1982, p. 94). Some, especially those focused on the narrow problem (Atkin & Ogle, 1996; Bentley, Rosenson, & Zito, 1990; Berg, Dischler, Wagner, Raia, & Palmer Shevlin, 1993) of compliance, have paid little attention to the complex divisions of labor resulting from deinstitutionalization; indeed, this division of labor—among psychiatrists, social workers, nurses, clients, and families—remains virtually unexplored (Jordan et al., 1999). Chewning and Sleath (1996), in a review of the literature on medication management, have argued that more research is needed on the many and complex

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dimensions of monitoring. They wrote: “Drug monitoring is an important function of the health care provider team—physician, pharmacist, and nurse. However, it is an equally important function for clients. There is evidence of a parallel, private process of drug monitoring performed by clients, often using different criteria than those of the provider” (p. 393). Peter Conrad (1985) argued that the intensity of monitoring medications produces new divisions of labor, power relations, spaces, and demands on practice. We argue that management has both intensive and extensive aspects. In this study, we used ethnographic data to show how practitioner- and client-centered approaches to medication do not capture the complexity of the management process. Although the broader process of managing medications includes the presenting problem, prescription assessment, delivery, monitoring for compliance and effect, and reporting (see Table 1), we examine the roles of the case manager and the work of case management in one underresearched area: monitoring in the community for compliance and effect. Indeed, the limits and potential of medications are realized in the intensity and extensivity of monitoring, especially for effect, and the knowledge produced in the day-to-day practices and interactions between the key figure, the case manager, and attendant care workers, pharmacists, nurses, and psychiatrists.

Table 1 Five Elements of a Medication Event Element 1. Presenting problem 2. Prescription assessment 3. Delivery and access

4. Monitoring for compliance and effect

5. Reporting effects

Event Patient presents psychiatric symptoms. Among medications, a category and dosage are chosen. Patient needs private or public insurance and transportation to access pharmacy. Are the medications taken as prescribed? Intended desired effect? Unintended side effect? Written narrative: case recording. Oral narrative: communication among participants.

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Finally, we argue that medication management may be seen as a grid of social relations corresponding to what we call the five elements of a medication experience: presenting problem and symptom evaluation, prescription assessment, delivery and access, monitoring for compliance and effect, and reporting. We believe that this approach to understanding management moves us beyond often unproductive and dichotomous thinking about whom to center in practice, the client or the practitioner, and the narrow focus on decision making and compliance; for the client unable to self-monitor, for example, some degree of practitioner, family, or other informal support may be necessary.

Method This research, conducted in a large Midwestern community support service setting, where medication events and case management unfolded in necessarily open systems, used ethnographic methods to explore the everyday experience of medication events. Whereas experimental designs isolate and reduce management to closed systems—even the body might be seen as a closed system—or operationally defined variables, qualitative methods allow for interpreting monitoring events as they unfold in the community and context (Sayer, 1992, 2000). A team of five managers; their daily work; their bimonthly clinical and business meetings; their everyday office talk; and their numerous trips with clients to homes, banks, grocery stores, food pantries, and welfare offices were observed over 9 months in 1997. No part or aspect of CSS life was off limits. First, ethnography was used to establish the spatial dimensions of management; in the hospital, medication events, like most others, unfolded in the closed ward, subject always to the all-seeing staff. Former hospital patients, no longer confined to the total institution, move within and across institutions and communities, thereby placing new demands on management. Indeed, it can be argued that the very language of management and its associated technologies are products of these new divisions of labor (Floersch, 2002); hospitals did not have managers and clients, they had patients, nurses, and physicians. In this study, management— delivery and monitoring—was observed as it unfolded in the open system of suburbia. However, even in the absence of the hospital and locked ward, managers and clients continued to meet at the CSS “Med Room,” a unique site marking the intersection of the medical model and case management, the past and present. Narratives, culled from field notes and recordings, are used to explore community monitoring for compliance and effect. First, managers were observed in work with clients in the community and homes. Second, weekly team and monthly clinical meetings were observed; these, attended by case managers, team leaders, psychiatrists, nurses, and team clinical social workers, included lengthy deliberations of individual cases.

Client medical records were analyzed for the types of psychotropic medications prescribed, and a synchronic analysis was conducted; over 1 week, 329 medical records were examined to determine the frequency of medication type. Here, the purpose was to establish the intensity of interpretation in the medication management grid. Prescription patterns were used to establish the context for case manager interpretation.

The Setting: Community Support Services After deinstitutionalization, CSS became the dominant mental health model and case management the most common practice method. At this particular site medications were monitored under the rubric of strengths case management, one of the most popular CSS models in the country (Floersch, 2000; Rapp, 1998). The program offered services to approximately 400 clients. Along with 35 managers, several psychiatrists, nurses, and assistant case managers, the center spent (1997) nearly $4 million on a variety of programs and services: case management, psychosocial, vocational, residential, and medication. Unlike most urban CSS programs, this suburban location was rich in resources, evidenced by the manager annual salary of approximately $35,000. All managers were required to take an in-house examination on psychotropic medications. The majority had bachelor’s degrees, and a few had postbaccalaureate training. Managers had about 5 years of experience (median) and the average caseload was 15; here high salary and low caseloads meant negligible manager turnover, which is considered a major barrier to effective case management (Axelrod & Wetzler, 1989; Bigelow & Young, 1991; Chamberlain & Rapp, 1991; Dietzen & Bond, 1993). The mission of CSS was described in the High County Mental Health Center brochure as to “support and teach individuals in developing the skills and resources they need to be successful in the living, learning, working, and social environments they choose. The desires, goals, and aspirations of the people we serve are of paramount importance in guiding this process” (confidential communication, High County Mental Health Center).

Medications Medical records show clients were taking on average 2.5 different medications; they could expect to receive between one and seven (see Table 2). Two in 10 (19%) were prescribed one medication, and 39% were prescribed two. Twenty-five percent received three and approximately 16% were prescribed four and five different medications. It is with more than one medication that case manager effect interpretation is most complex; and nearly 80% were prescribed two or more. This practice, sometimes called polypharmacy (40% were prescribed three or more different categories of medications), is especially significant when it is assumed that categories of psychotropics influence specific neurotransmitters and therefore specific behaviors and emotions (Valenstein, 1998, pp. 145–147). Yet often no one knows why exact dosages

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10:50 a.m.—CM is checking to see if client’s meds are in the box. They were not. “They are still in my car.” The CM is arranging a med drop along with a money management session, “so I do not have to duplicate a visit.”

Table 2 Psychotropic Medications and Polypharmacy (N  329) Patients

Psychotropics prescribed

% of total

63 129 83 36 15 2 1

1 2 3 4 5 6 7

19.0 39.0 25.0 11.0 4.5  1.0  1.0

produce differential effects. For example, one staff psychiatrist reported that “the same dosage knocks one person out and doesn’t come close to arresting aggression in others.” Managers, taught the five categories (antipsychotic, antimania, antianxiety, antidepressant, and antiparkinson), also learned from the center’s medication manual that medications were correlated with “target symptoms.” Although managers were told that medications were aimed at specific symptoms, several mitigated the same: hostility, irritability, insomnia, hallucinations, delusions, and poor concentration and thinking processes.

The Med Room: A Spatial Component of Medication Management Much of the work of medication management took place in the med room, where the third element of a medication experience unfolded: delivery and access. In offices surrounding the room, the nurse and psychiatrist had dealt with the presenting problem and prescription assessment, the first and second elements. The med room was the site where managers, psychiatrists, and nurses collaborated and a place where the “prescription” became actualized by manager acquisition of specific medications. Below, we present daily activities in the med room. These events were recorded in just one 2-hr period. 9:30 a.m.—CM (case manager) had purchased meds yesterday and was placing them in the client’s bag. This client gets nightly med drops. 9:40 a.m.—CM picked up daily medication for two clients. 10:25 a.m.—CM is returning a med box and setting up two med boxes for weekend delivery. 10:30 a.m.—CM picked up the client’s bag of medications. 10:35 a.m.—CM is looking in a small file box to see if her client received Loxatine from the indigent program. Her client has not met his spend-down and needs meds today.

11:05 a.m.—CM looks in the locker and discovers client’s med box is missing. She wonders where it is. 11:10 a.m.—CM is picking up medications for daily med drop. 11:15 a.m.—CM is filling a med box for a client who does not want to keep meds at home because of suicidal feelings. 11:30 a.m.—Assistant case manager picking up meds for a daily med drop. The italicized text describes managers engaged in the work of delivery and access. They were purchasing meds, picking up meds, filling med boxes under nurse supervision, and using the “med stash”; the stash, a closely monitored cabinet that housed samples left by pharmaceutical reps, was available when client supplies were unexpectedly depleted. Although in the med room activity was closely related to compliance, it was also distinct; first one must have a prescription and the means (i.e., private insurance, Medicaid, Medicare, or cash) to access medication. The room, the central location for linking all elements of a medication experience to the larger grid, functioned spatially to connect the first two elements, problem identification and assessment, to the bank, the client’s home, the pharmacist, and back to the med room, where medications were sorted and stored. In short, in the med room, managers, along with nurses and psychiatrists, negotiated the conditions for access and delivery of medication, necessary and first steps toward more active observation for compliance and effect. The med room, unlike the hospital, was a space where monitoring seemed, paradoxically, least intrusive. Here, four nurses scheduled intakes for medical evaluations; they read and wrote notes; they refilled prescriptions; they gave 80 clients weekly or bimonthly shots and operated a makeshift pharmacy; they stocked the cabinet with samples from pharmaceutical companies. In this room, nurses filled med boxes daily; some clients came every day to the center—a discouraged practice—for their meds. Most routine medical questions were directed to nurses. They were often queried about adjustments in meds and, if necessary, they scheduled checks with psychiatrists. The room, for self-monitoring clients, had little meaning. The more “active” obtained medications, complied, and reported effects directly to psychiatrists. Most of the 400 clients, with varying degrees of self-monitoring (passive and active), however, required practitioner assistance. Injectable drugs, for example, administered either in the med room or nurse’s office, were for the manager the easiest to monitor for compliance—there were no bottles, bags, tubs, and med boxes. Although injections reduced reliance on pills, they did not eliminate them. Most patients who took injectables,

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principally antipsychotics, required antiparkinson medications to counter drowsiness, tardive dyskinesia, pacing, and dry mouth. Others, less active, used the room as a repository, where they came only to fill boxes under supervision. Some patients depended on someone to deliver; but once they had the medication, they were unlikely to receive intensive monitoring. In the med room one never imagined a time without medication. This was a space signifying chronicity where the marking of time was mostly irrelevant. Here, as with most chronic illness, clients “reciprocally experience their care as a problem in the health care system. Legitimating the patient’s illness experience—authorizing that experience, auditing it empathically—is a key task in the care of the chronically ill, but one that is particularly difficult to do with the regularity and consistency and sheer perseverance that chronicity necessitates” (Kleinman, 1988, pp. 17–18). And almost inevitably, where there is chronic illness, there is medication and where there is medication, clients, practitioners, and myriad others shuttle to and fro, continuously negotiating the spaces of chronicity: pharmacies, mental health centers, laboratories, doctors’ offices, and hospitals. One CSS practitioner summed up the symbolic meaning of the med room: “Mental illness is chronic and to be chronic is to need meds. If they don’t need meds, they don’t need to be here.” The room functioned differently than it had in the hospital; it lacked altogether the powerful presence of the practitioner. People came and went. No one dominated the space. Likewise, in the community, the manager’s gaze was fragmented; theirs was a constant ebb and flow between monitoring in public and private spaces, from the center to the exurban periphery. Physicians and nurses, now beholden to other observers, were reduced to recipients of reports from those with sometimes minimal skills and little knowledge of medications. In this way, it was very different from the segmented spaces of domination described by Foucault in his studies of prisons, hospitals, factories, asylums, or barracks (Foucault, 1973, 1979). Moreover, CSS clients were not fixed, as were the “disciplined bodies” described by Foucault; they were mobile and refused, unlike institutional bodies, to be defined by the functions of institutional time and space. At CSS new knowledge and practice was now aimed at managing bodies in motion and at accessing, delivering, and monitoring the effectiveness of medications. Finally, the med room embodied history in complex ways. It served both as a reminder of the power that monitoring medicine and psychiatry once had in the “total institution” and as a signifier of the project of deinstitutionalization, where we were at once reminded of the continued authority of the medical model and the simultaneous displacement of that authority with new forms of discipline and power—case management—and a new practitioner, the case manager. The rise of the manager and management coincided with the need to link former hospital patients with social, medical, and mental health services (Floersch, 2002). In addition, the often limited networks of clients has increased the likelihood of dependency (C. I. Cohen & Sokolovsky, 1978; Macdonald, Hayes, & Baglioni, 2000; Meeks & Murrel, 1994; Neeleman

& Power, 1994). As coordinators of services, managers forge intensive and sometimes exclusive relationships with clients. Research, moreover, shows that the therapeutic alliance and continuous relationship between manager and client is a predictor of quality of life and community tenure (Axelrod & Wetzler, 1989; Bigelow & Young, 1991; Chamberlain & Rapp, 1991; Dietzen & Bond, 1993). Thus, we should expect to find the manager at the center; they interact with clients in homes, welfare offices, banks, pharmacies, and grocery stores. Although access and delivery have become important management functions in community-based practice, more important is monitoring for compliance and effect. We show next, in the work of medication monitoring, how managers make interpretations.

Community Monitoring for Compliance and Effect Home visits, a common occasion for medication management and monitoring, were labor intensive. Managers, for example, watched while clients filled med boxes. And because there were no legal constraints on how medications were moved from site to site, anyone could do the job; the client, however, was responsible for filling the box. Managers monitored to correct errors made in placement of medication in proper slots for both day and hour. In one visit a manager and client negotiated monitoring roles. Note how attention focused on compliance and side effects. The manager asked, “How about meds?” The client responded, “Well, eventually I want to take them myself and be in charge of it myself. I am happy with these meds. I’ll take them. I am not crazy anymore.” The manager asked, “Is that a long-term goal?” The client answered, “Yes.” The manager asked, “Are the side effects bothering you? What is the difference with these meds?” The client thought for a moment and replied, “They make me gain weight.” After the patients took the medication, managers conducted what we are calling effect interpretations. Below, three examples are taken from daily team meetings. In the first, the manager reported that the “client called this week and reported that she is sleeping too much and can’t get out of bed sometimes. Maybe we should do a med check.” The manager’s knowledge of the client’s excessive sleeping and difficulty waking was cause for effect interpretation: linking a desired medication effect—less sleeping—to a needed medication adjustment. Here, the effect interpretation was aimed at the behavioral symptoms. Minutes later, in reference to a different client, a manager noted: He had an emergency med check yesterday. He was really frightened. When he hears voices, they are usually violent and aggressive. I think it was due to a decrease in his Haldol [conventional antipsychotic]. It looks like he will need both medications [Haldol and Lithobid]. This example of the effect interpretation—“it looks like he will need both medications”—involved reading multiple dimensions of client reality, including polypharmacy. In

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SOCIAL GRID OF MEDICATION MANAGEMENT making adjustment decisions, the manager derived the interpretation from behavioral (reference to violent), emotional (reference to frightened), and cognitive realities (reference to hearing voices). It was significant that managers did not comment on the polypharmacy. Which medication category, antipsychotic or antimania, produced the desired effects: less aggression and less fear? This is of particular significance because it highlights the complexity of effect interpretation. Behavioral, emotional, and cognitive factors combine to challenge managers to speculate about cause and effect across several dimensions of client experience. Was it the client’s fear that caused aggression, which caused auditory hallucinations? Did auditory hallucinations cause fear? Moreover, what was the role of medication? The manager thought that increased fear, aggression, and hearing voices were produced by a reduction in antipsychotics. Even under the best of consultation circumstances—which might include the presence of the self-monitoring client, the psychiatrists, managers, and family members—the above example highlights the challenge of making effect interpretations. Another manager, in reporting on a patient, said: “A week ago she pushed a resident. She pushed and cursed her in the hallway. I think she heard voices. It is just too stimulating sometimes around here. I think she is taking her meds. I mean, I stay with her and watch her take it.” Here, compliance monitoring is coupled with behavioral and cognitive effect interpretation. Notice in this example the ambivalence in the manager’s qualification, “I mean, I stay with her and watch her take it.” In the next case, body odor and “irrational” action were behavioral indicators producing a common effect interpretation: medications were not working to assure appropriate community manners. The following excerpt, taken from a team meeting, shows a manager frustrated and amazed, He had put one of his mattresses outside and it got wet from the snow and rain. It was ruined. I asked him, “Why didn’t you tell us? We could have found a home for it [the mattress].” It didn’t cross my mind what might happen next. After I left, he went to the trash bin, got the wet mattress, and put it back on his bed. It was soaking wet! He may be getting paranoid. He [is] so high need and so low functioning at times. Well, his shot is due soon. The medication’s desired effect was captured in a typical oral narrative, “his shot is due soon.” She hoped that the antipsychotic injection would reduce his disorganized thinking— irrational thinking and paranoia—and lead to a “cleaner body and apartment.” Managers would often condense complex community-based observations such as these into a single medication effect interpretation: “his shot is due soon.” Lorna Rhodes (1984) found in her study of practitioners and patients in psychiatric settings a dominant metaphor also found in this study: medicines “clear the mind.” This was a desired cognitive effect. For example, following the ethnographic work, in semi-structured interviews, managers were asked: “what do medications do in the body?” One captured a common perception when he said, “Sometimes the term,

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it’s called making them clearer is used. I think sometimes the meds can help with decision making, it clears up their heads.” Managers often observed “increased manic behavior,” “pressured speech,” and “exaggerated displays of anxiety” and these would lead them to ask: “Are you taking meds?” We think these effect interpretations were often indexed to compliance monitoring. Two other common expressions were “perhaps there isn’t enough in his system” and “maybe it [i.e., the medication] will kick in.” However, because the last two expressions often coincided with a manager judgment about inappropriate behavior, we coded these interpretations as monitoring for desired (i.e., target symptoms) effects, rather than simple compliance. Finally, manager interpretations must be reported to psychiatrists, nurses, other team members, and family members. During clinical meetings, attended by the psychiatrist and nurse, the important role of the manager in reporting was observed. They often dominated the discussion of effect in and outside such meetings. And because they were the only ones to regularly observe and discuss behavior unfolding in the community, they often became the sole and most important source of data for making medication decisions; indeed, because the client was not present during clinical meetings, the psychiatrist relied almost exclusively on manager-reported data—often from their situated knowledge. (For a discussion of situated knowledge, see Floersch, 2002.) For example, a manager talking with the psychiatrist reported: He is saying the meds aren’t doing anything—maybe nothing. He is still, I’d say, about the same as far as medicine. Still doing as well as he has been doing. When I saw him this week he talked a little bit about the nervous demon. But he is still convinced that, I mean part of him, that it’s bizarre and crazy. Most of him still thinks that it’s not delusional, it is real. The psychiatrist responded, “Good. He’ll be O.K. I’ll probably have to think about how to do two things. One is increase his Zyprexa and the other is to start scaling back on Mellaril.” Notice the position the psychiatrist assumed in this conversation. First, there was no dialogue between the psychiatrist and manager about how the latter interpreted medication effects, nor did the psychiatrist elicit a clear understanding of manager interpretations. Second, even though the manager observed that medications seemed to be having only minimal effect, the psychiatrist responded with, “He’ll be O.K.” Moreover, the conversation continued when the manager said, “Boy, when you mentioned that [i.e., scaling back the Mellaril] at med check, he like choked. He is going to be a nervous wreck.” To this, the psychiatrist remarked: I would like to be able to get some kind of an impact on him from the Zyprexa. I’d like to be able to demonstrate some—uh—effect where he would say, “I feel different,” or “I feel calm,” or “I feel something.” Because of the stance that he has right now, it is like, “what medicine? And what Zyprexa?”

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The above dialogue does more than illustrate the complexity of reporting on medication monitoring interpretations. It suggests that the continual movement of bodies (managers and clients) in the community has produced entirely new relationships, divisions of labor, and power. The hospital psychiatrist and nurse, once the dyadic center of power in the “total institution,” now depend on the mobile manager’s watchful eyes, not only for reporting on compliance but most important, on effect. This marks, for us, a radical shift and demonstrates that deinstitutionalization required a corollary shift to new monitors, the manager, and new models of intervention, medication management. In sum, pharmaceutical guidelines identify the physical, behavioral, and cognitive symptoms for monitoring. However, psychopharmacological knowledge and training does not provide managers with sufficient theory or models for knowing how to monitor, when to monitor, where to monitor, and most important, what constitutes a valid effect interpretation, and from whose point of view.

Discussion The med room, the med box, and the med drop were aimed in unique ways at the community, where a more active monitoring for effect became the central task. Like all social relations, relations between mental health practitioners and clients remain “abstract and ungrounded until they are specifically spatialized, that is, made into material and symbolic spatial relations,” as they had clearly been throughout the era of the mental hospital (Soja, 2000, p. 9). This, in turn, is not a “simple matter of being coincidentally mapped into specific and fixed geographies, but it is filled with movement and change, tensions and conflict, politics and ideology, passions and desire . . . ” (Soja, 2000, p. 10). So it is for the managers and the managed in our mental health system. Indeed, it could be argued that it is because the mentally ill exist in these fluid spaces that new forms of management, knowledge, and power came into being, expressly for the purpose of negotiating the change, conflict, and desires that increasingly lacked specificity. Yet in lacking specificity, there seemed to be the continual need for it, a center, the mental health center, CSS, the med room, and transitional living. (Once called the halfway house, it is a liminal space, neither inside nor outside.) These are all spatially ambiguous sites that exist in a tension with urban, suburban, and exurban worlds. It might also be argued that the management of medication is part and parcel of achieving a kind of imagined community integration (spatial), necessary for tolerance; in short, if you are on your meds, you are tolerable. If you are on your meds, you may live responsibly as a good citizen, with good manners, in appropriate community spaces (Floersch, 2002).

Good meds, in short, equals good and tolerable behavior. Yet, To explain the relationship between the mental patient and society in terms of tolerance alone is to preclude an understanding of the psychosocial dynamic through which strangers, or those who bear the brand of otherness, are received and maintained in a space where nothing necessarily demands their presence. Not that the forms of a silent copresence, deaf or blind to others, cannot be observed. But if people coexist separated by a screen, if, in the absence of frontiers, there are barriers between one another, then we still need to know how and at what price to themselves and their partners. The social environment is a melting pot, not an inert shell. Contacts are formed there, positively or negatively, in accordance with the modalities which are generated by the interplay of the peculiarities, needs, expectations and feelings—experienced or projected— of groups, and which also influence the groups themselves. It is here that we must seek the causes and forms which determine how the mentally ill find their place outside the asylum. (Jodelet, 1991, p. 76)

Monitoring for effect required more than watchful eyes aimed at compliance in the community. As with all surveillance, the surveillant’s everyday behavior was organically connected to the object of gaze; in short, medication, rather than producing independent behavior (the intended outcome of most CSS practice models), often produced inseparable bonds between clients and managers and ever-increasing forms of dependence. Medication became the crucial link and the central most important basis for establishing, maintaining, and evaluating the capacity to live in diffuse suburban and exurban spaces; incessant driving and delivering, the central markers of modernity and suburbia, set the tempo for surviving in “community” spaces. Although at CSS, monitoring required the full deployment of workers—psychiatrists, nurses, attendant care workers, secretaries, and drivers—all worked in conjunction with case managers in moving clients and resources across space, to and from medication and other appointments, to and from apartments, to and from jobs, and to and from pharmacies. Monitoring for compliance and monitoring for effect, moreover, presented unique requirements and problems related to reporting: who reports, to whom, how often, and what is reported? The nature and quality of reporting is a much-needed area for future research. A single medication experience can be represented as a complex practice totality. This study of a suburban CSS program identifies five elements of a medication management event and relations among them.

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In Table 1, the elements are represented as distinct actions along a chain of actions in a medication experience or event. Thus, understanding management requires sensitivity to the context or totality within which assessment, delivery, monitoring and reporting unfolds. Most research on medication management segregates one or another element; few examine the totality (e.g., Estroff, 1981). Compliance events, for example, are only among several complexly interrelated elements that may be easily misunderstood if not placed in relation to others. In his important and critical essay on compliance, Peter Conrad (1985) has argued that compliance research tends to focus on patients and thereby risks eliding the practitioners role in making patients responsible for failure. Our research suggests that though this may occur, it is more often not intentional displacement of the patient in management, but the tendency to view medication events more generally as one-dimensional or empirically transparent; in reality, compliance, like all events in the grid, is always in complex ways psychically, culturally, and professionally mediated. Although each element of an event presents unique management dilemmas, it is in monitoring for effect that managers confront enormous complexity. This study presented examples of clients seeking desired effects, perceiving effects, and, of course, experiencing myriad actual effects.And all parties to an event, aware or not, assessed and monitored effects. Moreover, at any one point, among any number of participants, interpretation was a continual and recursive process. Yet it is also clear from these findings that practitioners have no systematic may of undertaking interpretations, nor do they see the need to do so. Moreover, at behavioral, emotional, and cognitive levels, managers assess and monitor for desired, perceived, and actual effects. Even though they consistently use a commonsense language (i.e., “his shot is due,” “has the med-

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ication kicked in,” and “it clears the mind”), to struggle with this complexity, it never became a conscious part of their daily work. Among the most important findings of this study is the description of the interrelated elements of a single medication event in the context of community monitoring. Only in understanding the totality of medication events in the open system of community management can adequate interpretation effects be made and systematized. The second significant finding of this study is the identification of a grid of community and institutional relations that constitute “medication case management.” The data show how within the grid medication events continually and recursively unfold and often entail negotiation, conflict, resistance, noncompliance, and tentative and changing forms of effect interpretation and compliance. Further research, however, is needed to establish more clearly how unique configurations of events are mediated by ethnicity, class, type and severity of illness, social networks, quality and nature of caregiving, formal and informal supports, and gender. This study is an important first step toward the elaboration of a social relation’s framework for understanding community-based medication monitoring. The grid (Table 3) represents the social relations potentially correlated with each element of a client’s medication event and the overlapping roles and multiple potential sites for management. For those who lack the ability to self-monitor, there are 24 possible sites (a single site is represented as a cell in the grid) for determining who will do what. The intensity of monitoring is determined, in part, by client capacity to act alone at each site. Power, however, differentially distributed throughout the grid, depends on social policy, funding mechanisms, the organization of mental health services, and, of course, the clients’ unique life circumstances. Each support service

Table 3 The Social Grid of Medication Management Community social relations

Elements of a medication event 1. 2. 3. 4. 5.

Patient

Informal supports (e.g., friends, family, pharmacist, employer)

X

X

Presenting problem Prescription assessment Delivery and access Monitoring for compliance and effect Reporting effects

Note.

X  who in the medication grid does what.

Formal supports (e.g., case manager, nurse, psychiatrist, nutritionist) X

X X

X

X X

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setting and associated community (rural, urban, or suburban) produces unique management of the elements. Settings dominated by medical practice, for example, may require exclusive use of pharmacological resources. Realistically, however, managers play the pivotal role. Effect interpretations, always unfolding in open systems, make a priori knowledge claims about medication management nearly impossible. It is in this way that the “activity” or “passivity” of actors, clients or practitioners must be determined by careful consideration of the reasons, wants, purposes, desires, and intentions of actors, sometimes including unconscious ones. Thus, our choice of a patient- or clientcentered approach cannot be predetermined and applied mechanically to any particular setting or person; this choice should be the outcome of careful, collaborative, and highly skilled medication management, not preconditions for it. Where self-monitoring is not possible, for example, others in the grid may share power or exercise it on behalf of clients, not always in helpful or caring ways. The use of this power must be aimed at more than attempting to achieve behavioral outcomes. We must avoid, at all costs, the subordination of emotions, caring, and relationships to the production of appropriate behaviors for wellmannered or managed “living in communities.” Moreover, throughout the life course of any specific illness (e.g., Karp, 1996), monitoring is variably and complexly determined by a multitude of continuously changing conditions: course of illness, gender, ethnicity, social class, ability to work, family, community and cultural context, neighborhoods, quality of human relationships, emotions, social networks, type of medication, polypharmacy, funding streams, and CSS practice models. The continuously changing nature of these variables in open systems makes especially problematic outcome-based approaches to evaluating management effectiveness: outcomes at what point, along which axes, to produce which effects? Finally, although Chewning and Sleath (1996) have argued otherwise, it is not clear from our data just how the roles, active or passive, can be differentiated. Yet coding a monitoring event in these terms is significant and has enormous implications for those who rely on managers and others for everyday monitoring. What is certain in these debates is that we do not fully understand the social relationships among those involved in medication management. We do know, however, from limited studies in physical medicine that management, when it is effective, includes clients in the process (Bentley et al., 1990; Chewning & Sleath, 1996). Not thoroughly studied are the relationships

among the elements of a medication event and the complex and overlapping relations that comprise the grid. This research is a step in that direction.

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Received July 26, 2001 Revision received February 14, 2002 Accepted June 26, 2002

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