The Use of Critical Ethnography in Managed Mental Health Care Settings

How social workers in managed mental health care settings exercise their professional authority may have profound consequences for the provision of ethical and value-based services to vulnerable populations. Building upon Gidden's theory of structuration, this article describes the use of critical ethnography as a specific research methodology that may support social workers in the exercise of their authority. This article examines the historical roots of critical ethnography and provides a detailed examination of its underlying assumptions and research procedures. The article concludes with a case example of a critical ethnography conducted within a managed mental health care setting. Keywords: critical ethnography, managed care, mental health, social work, professional authority ********** Front-line social workers in managed mental health care contexts often experience cultural incongruence between management values and their own professional values. Among the most profound are those conflicts that exist between managerial and professional values (Furman, 2003; Scheid, 2003; Shapiro, 1995). Nonetheless, social workers may have opportunities to shape the procedures and practices of their managed mental health care organizations. This article will describe the utility of critical ethnography as a set of methods that may be used to assist social workers in becoming more consciously aware of how they take up their professional authority in managed mental health care contexts. The revised code of ethics of the National Association of Social Workers (1999) stresses the professional obligation of social workers to incorporate the core values (i.e., service, social justice, dignity and worth of the person, importance of human relationships, integrity and competence) of Social work at all levels of practice, including their practice in organizations. The importance of upholding the core principles and values of social work practice is particularly crucial in today's managed mental health care settings. Indeed, the proliferation of for-profit managed care plans and the funneling of vulnerable individuals and groups into these plans has resulted in decreased quality care for persons with severe mental illness, including persons with fewer economic resources and those from marginalized racial and ethnic groups (Himelstein, Woolhandler, Hellander, & Wolfe, 1999; LaRoche & Turner, 2002; Mechanic, 2002, Mechanic, 1999, Mechanic & McAlpine, 1999; Sullivan, 1999). Arguably, since its inception, social work has grappled with conflicts surrounding its professional identity. Indeed, as Cloward (1972) commented: "Among the various dilemmas confronting social workers, the most profound, although the least acknowledged or examined, is the conflict between our presumed role as helping agents and our bureaucratic role as agents of social control" [as cited by Racine (1984, p. 42)]. Perhaps nowhere is this conflict more evident than in managed mental health care settings, where social workers are increasingly replacing medical personnel as the more economical and hence preferred providers of mental health treatment (Cohen, 2003). Despite these challenges, the current privatization of managed mental health care may provide social workers and other mental health professionals with opportunities to more proactively develop and create ethically-based programs and services geared to vulnerable populations. For example, effective case management and decision-making processes, roles that social workers typically assume in managed care settings, may be pivotal in ensuring quality services to consumers (Dobmeyer, McKee, Miler, & Wescott, 1990; Manning, Wells, and Benjamin, 1987; Rogers, Wells, Meredith, Sturm, & Burnham, 1993; Brady and Krizay, 1985). Therefore, the ways that social workers take up their organizational and professional authority in managed mental health care settings may have important consequences to consumers. …