Organizational Culture, Emotional Labor, and the Work Role of Mental Health Case Managers in a Managed Care Company

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Title: Organizational Culture, Emotional Labor, and the Work Role of Mental Health Case Managers in a Managed Care Company
Physical Description: Book
Language: English
Creator: Mihalick, Justin
Publisher: New College of Florida
Place of Publication: Sarasota, Fla.
Creation Date: 2012
Publication Date: 2012


Subjects / Keywords: Emotional Labor
Organizational Culture
Managed Care
Mental Health
Emotion Management
Genre: bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation


Abstract: The purpose of the managed behavioral health care industry is to implement processes and standards for ensuring cost savings in the provision of psychiatric and substance abuse treatment to individuals enrolled in insurance plans. These for-profit companies employ licensed psychotherapists, social workers, and psychiatric nurses in call-center workplaces to carry out specific administrative roles. This study focuses on an organizational unit of mental health clinicians whose work involves an area of growing emphasis in commercial managed care, the coordination of patient care through telephonic case management. Using ethnographic interviews, I explore normative workplace rules and beliefs governing how case managers regulate and display emotions while performing their jobs. My findings indicate these clinicians are positioned to experience dissonance between personal feelings about patients' cases and what the company encourages and expects them to feel as employees. I examine the workplace culture and cultural practices that are found at these areas of dissonance between individual emotions and the requirements of the job role in the managed care corporation.
Statement of Responsibility: by Justin Mihalick
Thesis: Thesis (B.A.) -- New College of Florida, 2012
Bibliography: Includes bibliographical references.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The New College of Florida, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Local: Faculty Sponsor: Vesperi, Maria D.

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Source Institution: New College of Florida
Holding Location: New College of Florida
Rights Management: Applicable rights reserved.
Classification: local - S.T. 2012 M6
System ID: NCFE004635:00001

Permanent Link:

Material Information

Title: Organizational Culture, Emotional Labor, and the Work Role of Mental Health Case Managers in a Managed Care Company
Physical Description: Book
Language: English
Creator: Mihalick, Justin
Publisher: New College of Florida
Place of Publication: Sarasota, Fla.
Creation Date: 2012
Publication Date: 2012


Subjects / Keywords: Emotional Labor
Organizational Culture
Managed Care
Mental Health
Emotion Management
Genre: bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation


Abstract: The purpose of the managed behavioral health care industry is to implement processes and standards for ensuring cost savings in the provision of psychiatric and substance abuse treatment to individuals enrolled in insurance plans. These for-profit companies employ licensed psychotherapists, social workers, and psychiatric nurses in call-center workplaces to carry out specific administrative roles. This study focuses on an organizational unit of mental health clinicians whose work involves an area of growing emphasis in commercial managed care, the coordination of patient care through telephonic case management. Using ethnographic interviews, I explore normative workplace rules and beliefs governing how case managers regulate and display emotions while performing their jobs. My findings indicate these clinicians are positioned to experience dissonance between personal feelings about patients' cases and what the company encourages and expects them to feel as employees. I examine the workplace culture and cultural practices that are found at these areas of dissonance between individual emotions and the requirements of the job role in the managed care corporation.
Statement of Responsibility: by Justin Mihalick
Thesis: Thesis (B.A.) -- New College of Florida, 2012
Bibliography: Includes bibliographical references.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The New College of Florida, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Local: Faculty Sponsor: Vesperi, Maria D.

Record Information

Source Institution: New College of Florida
Holding Location: New College of Florida
Rights Management: Applicable rights reserved.
Classification: local - S.T. 2012 M6
System ID: NCFE004635:00001

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ORGANIZATIONAL CULTURE, EMOTIONAL LABOR, AND THE WORK ROLE OF MENTAL HEALTH CASE MANAGERS IN A MANAGED CARE COMPANY BY JUSTIN MIHALICK A Thesis Submitted to the Division of Social Sciences New College of Florida In partial fulfillment of the requirements for the degree Bachelor of Arts in Anthropology Under the sponsorship of Dr. Maria D. Vesperi Sarasota, Florida May, 2012


ii In memory of my beloved father, Dr. Ronald Mihalick and for my mother Carolyn Mihalick from whom I have learned so much.


iii Acknowledgements This undertaking represents the completion of a long journey, and many people played a role in making it possible. I am indebted to my mother, Carolyn Mihalick, for her calming wisdom and assistance. My sister, Michelle Verdisco is my greatest advocate and the person who first encouraged me to make the bold move of calling Dr. Vesperi to propose this project. I am thankful for the support of my brother, Brian Mihalick, and the loving encouragement and sage advice of my uncle and aunt, Michael Mihalick Jr. a nd Zona Mihalick. I benefited also from the interest in my work expressed by my many special aunts, uncles, and cousins. I would like to thank my 95 year old grandmother, Eileen Mihalick, for encouraging and helping me like no one else could. Grandma, now all of your ten grandchildren have completed college. I only wish I could write a thesis about your life, for it would be an impressive work. Thanks to the members of my faculty committee. To my adviser, Dr. Maria Vesperi, I am grateful for your confidenc e in me and your patience. You showed me that the world of philosophical ideas is compatible with heartfelt concern for people. I will always value the anthropological perspective you taught me and my peers. Dr. Tony Andrews, thank you for broadening my ed ucation and teaching me how to analyze evidence and to support arguments with facts. In addition to being one of the nicest professors to work with, you gave me some of my best memories of anthropology classes at New College. To Dr. Laura Hirshfield, thank you for being a brilliant (and totally awesome) professor. Your guidance was


iv invaluable. You opened my eyes about many issues regarding work, inequality, and emotions and clarified everything from Goffman to Foucault. Thank you for working with me and bei ng on my committee. I owe special thanks to Jan Wheeler who is a wonderful editor and teacher. I also want to acknowledge the New College registrars, Kathy Allen and Marilyn Brislin, for generously helping me navigate the administrative hoops of the colleg e. This project would have been much less successful were it not for Kelly Samek. Kelly, you have been involved in every chapter of my New College story, and your professional success continues to inspire me. Your faith in my abilities has been unyielding Your advice for the past seven years has been as beneficial to me as your willingness to listen to and love me. I should give you my diploma for all the "emotional work" you put into me, but you already have several and don't need another one in Latin. Y ou are and always will be my family. To my other fictive kin, my "sister" David Lease, you did as much as Kelly Samek to keep me sane. You are not simply brilliant and fabulous but someone whose friendship I treasure. Thanks also to my other boys, Matt Hue y and Elkin Cabas, who helped to keep me grounded, particularly when Elkin shared the travails of his master's thesis with me. Finally, my appreciation goes to the case managers who participated in my research. Your generosity with your time and openness w ith me about your experiences made this project possible. I hope what I represent has value for you and the many other mental health professionals who work in managed behavioral care.


v Table of Contents Page Dedication ii Acknowledgements iii Table of Contents v Abstract vii Introduction 1 Chapter One: Workplace Cultures and Emotion Management 3 Emotion Management Theory 4 Organizational Uses of Emotional Labor 15 Emotional Socialization and Occupations 19 Chapter Two: Methodology and Research Design 27 Ethnographic Interviewing 27 Introduction to the Workers and the Occupational Context 29 Direct Work Experience at the Office 33 The Interview Process 36 Chapte r Three: Contexts of Work and Feeling 41 The Meaning of Managed Care 41 The Managed Behavioral Health Care Industry 45 The Corporation: HealthCo Inc. 50 Office Physical Description 52 The Organization of Clinical Work at HealthCo 53 Utilization Review Teams 55


vi The Intensive Case Management (ICM) Department 57 Objectives for Intensive Case Management 60 65 Miscellaneous Duties: Crisis Calls 67 Work Challenges 69 Chapt er Four: Managing Feelings in Managed Care 77 Utilization Review as Emotional Labor 77 Int ensive Case Management: Rules of Feeling and Expression 88 Pe rsonal versus Corporate Emotions 96 Conclusion 98 Works Cited 102


vii ORGANIZATIONAL CULTURE, EMOTIONAL LABOR, AND THE WORK ROLE OF MENTAL HEALTH CASE MANAGERS IN A MANAGE D CARE COMPANY Justin Mihalick New College of Florida 2012 ABSTRACT The purpose of the managed behavioral health care industry is to implement pro cesses and standards for ensuring cost savings in the provision of psychiatric and substance abuse treatment to individuals enrolled in insurance plans. These for profit companies employ licensed psychotherapists, social workers, and psychiatric nurses in call center workplaces to carry out specific administrative roles. This study focuses on an organizational unit of mental health clinicians whose work involves an area of growing emphasis in commercial managed care, the coordination of patient care through telephonic case management. Using ethnographic interviews, I explore normative workplace rules and beliefs governing how case managers regulate and display emotions while performing their jobs. My findings indicate these clinicians are positioned to exper what the company encourages and expects them to feel as employees. I examine the workplace culture and cultural practices that are found at these areas of dissonance between individual em otions and the requirements of the job role in the managed care corporation. Dr. Maria D. Vesperi Division of Social Sciences


1 Introduction This thesis concerns emotion management and the occupational culture of mental health clinicians who work at HealthCo 1 a for profit managed beh avioral health care company in the United States. The purpose of the managed behavioral health care industry is to implement processes and standards for ensuring cost savings in the provision of psychiatric and substance abuse treatment to individuals enrolled in insurance plans. These companies employ licensed psychotherapists, social workers, and psychiatric nurses in call center workplaces to carry out specific administrative roles. This study focuses on an organizational unit of clinicians whose work involves an area of growing gh telephonic case management. Using ethnographic interviews and qualitative data, this thesis explores the normative workplace rules and beliefs governing role at the managed care company. have periodic voice contact with insurance plan members who are identified by the company as being patients at high risk for hospitalization or as having complex needs. While case managers are required to have the edu cational background and credentials to diagnose and provide mental health services, they are not hired to be telephone therapists. Their role is to improve treatment outcomes by motivating patients to attend outpatient appointments and to comply with medic ation regimens. These case 1 The name of the organization and all employee names have been changed to protect worker s nationwide has also been left unspecified.


2 in a call center, patients encountering social, bureaucratic, financial, and personal barriers to receiving mental health care. Thus, handling cases a nd communicating with patients can elicit feelings and emotional responses on the job. The management of emotions in this work is culturally patterned by both the ideology of organizational context and by that of professional clinical and psychotherapeutic discourses in which the workers were trained prior to becoming managed care employees. Because the priorities of the managed care corporation are ever evolving in step with business as well as governmental/regulatory demands, the work standards and practi ces of case managers are frequently being changed. In these circumstances, case managers are in a position to experience dissonance between personal feelings about patients/cases and what the job encourages or expects them to try to feel. In addition, they and what the job role encourages or requires them to try to feel. This thesis examines the organizationa l culture and workplace cultural practices that are found at these areas of possible dissonance.


3 Chapter One: Workplace Cultures and Emotion Management For several decades, scholars in sociology and related fields have used the methods of ethnography to study emotions in contemporary work organizations. This research began in earnest in the 1980s with Arlie Russell ce work, The Managed Heart: Commercialization of Human Feeling (1983). Hochschild introduced the concept emotions to meet job requirements or organizational objectives (Glomb et al 2004). This review describes and assesses findings that have emerged in the ethnographic and qualitative literature regarding the organizational uses of emotional labor, emotional socialization in jobs, and the costs of emotional management for workers. Ethnographic and qualitative research on emotional labor has covered an assortment of worker groups and working conditions. 2 The preponderance of fieldwork has been conducted in the United States. Emotional labor scholarship is a cross between the sociol ogy of work and the sociology of emotions. It is also 2 The populations that have been studied include flight attendants (Hochschild 1983), bill collectors (Hochschild 1983; Sutton 1989), Disney employees (Van Maanen 1991; Raz [1997] 2003), store clerks (Rafaeli and Sutton 1989; Godwyn 2006), funeral directors (Cahill 1989), medical school students (Smith a nd Kleinman 1989), high tech engineers and managers (Van Maanen and Kunda 1989; Kunda and Van Maanen 1999), police interrogators and detectives 1993), insurance salesm en (Leidner 1991, 1993), paralegals (Pierce 1995; Lively 2000), social workers (Heimer and Stevens 1997), Israeli psychotherapy students (Yanay and Shahar 1998), supervisors teaching job skills to the developmentally disabled (Copp 1998), nightclub strippe rs (Wood 2000), nail technicians at Korean American owned salons (Kang 2003), welfare bureaucrats in Sweden (Graham 2003), African American college professors (Harlow 2003), and American government employees (Guy, Newman, and Mastracci 2008).


4 a product of cross disciplinary fertilization. Industrial organizational psychologists have made noteworthy contributions to sociological discussions about emotions in workplace settings (see Rafaeli an d Sutton 1987; 1989; 1991; Sutton 1989; Van Maanen and Kunda 1989; Van Maanen 1991; Ashforth and Humphrey 1993; Kunda and Van Maanen 1999; Rafaeli and Worline 2007). Cultural anthropologists have added theoretical insights (see Lutz 1986; Lutz and White 19 86; Middleton 1989; Lutz and Abu Lughod 1990; Tarlow 2000) and involvement has been less direct, coming in the form of research on Western and less industrialized societies (Thoits 1989: 323). The most relevant scholarship has developed in sociology and particularly in the sociological subfield of social psychology (Meanwell et al 2008). This diverse literature fits together in its co human feeling in service interactions (1983). Emotion Management Theory in occupations (Steinberg and Figart 1999 ; Meanwell et al 2008). This section will the social sciences. What do Hochschild and other social scientists mean when they refer to emotions? There is no absolute consensus abo ut the meanings of the terms


5 agreement that emotions and feelings are more than innate states of physiological arousal (Thoits 1989). Most social scientific research on emotions ref Hochschild cooperation with an image, a th ought, a memory a cooperation of which the encapsulates what emotional phenomena are by citing f our elements of the bodily sensations, (c) the free or inhibited display of expressive gestures, and (d) a cultural label applied to specific constellations of the first three ele (Hochschild 1990: 119). Her definition of emotion builds on symbolic interactionism and combines it with insights from Freud. In joining the two, them to cultural cons tructions (1983: 28). Emotions and feelings are not Rather, they are distinct intra psychic phenomena that are subject to cultural and social patterning (Hochschild 1983). Pe helpful attempt at a precise definitional breakdown:


6 The general term feelings includes the experience of physical drive states (e.g. hunger, pain, fatigue) as well as emotional states. Affects refer to positive and negative evaluations (liking/disliking) of an object, behavior, emotions can be viewed as culturally delineated types of feelings or affects. Compared to emot ions, moods are more chronic, usually less include romantic love, parental love, loyalty, friendship, and patriotism, as well as more transient, acute emotional responses to social losse s their social acquisition and/or shapin g. Along with most sociologists, I (1989: 318 319) of emotion is not exact terminological referents, but the understanding that emotional phenomena are both physiological and cognitive. While emotions causes and meanings of physiological or psychological responses... [to allo w] and Worline 2001: 105).


7 In the 1970s, Hochschild began to ask questions about why emotional experiences in the complex fields of modern life are as orderly as they are (1975; 1979). Why are there not more instances of emotional upheaval or inappropriate expression in organizations? Why do peop le in public situations seem to feel, at feel? Why are emotions so frequently expressed and by most accounts felt in harmony with roles, statuses, groups, customs, and institutions? E rving Goffman addressed these questions in earlier decades when he observed that people perform acting and impression management in social interaction (1956; 1961). His dramaturgical model was the first to situate emotion in the context of social interaction and laid the groundwork fo approach to emotion (1979; Meanwell et al 2008). Goffman showed that people present gestures to one another that are appropriate to the obligations of social situations. He noted that people enact emotional facades that reflect agreed u standards that govern what outward gestures and expressions mean and which ones are called for in particular situations (Hochschild 1979). Goffman also noted that interactions be tween people stimulate internal emotional responses which are patterned, integral parts of their interactions. W hen transactions go well, positive emotions result. When they go poorly, unpleasant emotions, such as embarrassment, are experienced by one or m ore persons (Meanwell et al 2008).


8 try to conform inwardly as well as outwardly in their emotions. She c alls these attempts to manage their emotions, and their efforts are frequently successful manage f eelings in accordance with cultural guidelines. Hochschild specify which emotions are suitable for certain situations, encounters, and events. They are normative beliefs and standa rds that tell people how they should want to try to feel in situations (1979; 1983). They may also be considered as ideals for how one should want to feel in particular situations. However, conscious control and shaping of feeling, these guidelines relate specifically to what emotions people should try to feel (1979). Feeling rules are the conceptions, beliefs, and appropriate range, intensity, duration, and targets of private feelings in given acknowledg ed, so emotion work is usually performed somewhat latently though never entirely unconsciously (1979; 1983). display culturally appropriate emotions i.e. emotions for a


9 reflect cultural categories, beliefs, and values. Cognitive frames and feeling rule s operate together as sociocultural influences on how people manage internal emotions. They guide what people allow themselves to feel and thus what they frame consistent with si tuation is work in which individuals continually and privately engage. But they do so in obeisance to rules not completely of their own How do people practice emotion management in relation to feeling rules? surface ac individual emotion management (Hochschild 1983; Lively 2000). Both require deliberate effort, but are differentiated by how affect is generated (Meanwell et al 2008). In surface acting, the individual performs the outward appearance of a feeling or emotional state during social interaction. The goal is to facilitate social interaction, and it is outwardly directed toward others. Surface acting works, as n management create smooth interactions that elicit positive emotions, and failed acts of impression management create botched interactions that elicit negative With deep acting, the effort happens before social inter action commences, and it is more inwardly directed. To deep act, one cognitively acts on oneself and plays upon emotional memory. The individual tries to conjure up actual feeling as a method actor would when performing a theatrical role. Mental representa tions are manipulated to help one feel something about a situation, object, person, or


10 experience. One target of deep acting is to evoke and experience emotions that are believed to be appropriate or necessary The goal is to exhibit an expected or desired state of feeling and, specifically, to enable oneself to do so more readily, authentically, or persuasively in the presence of others. Deep acting can also be performed to make oneself not experience feelings that are considered to be inappropriate or unw anted. In this case the target is to suppress or neutralize the 1983). When evoking an emotion in deep acting, the individual places cognitive emphasis on a feeling that is initial ly absent (1979). For example, a presidential candidate who is indifferent to the task of presenting ribbons at the Iowa State Fair attempts to exhort feelings of enthusiasm by framing the honorees suppressing an emotion in deep acting, the cognitive emphasis is on a feeling that is initially present but not desired (1979). An example might be a gymnast who finished second in the Olympic Games who is about to speak at a post event press conference. Before facing r questions about what is for her a personal disappointment. In addition to cognitive work directed inwardl y, individuals can use others to reinforce their emotion work. Hochschild notes how individuals can set up manage feeling (1979: 562). The simplest example is the woman trying to s tifle


11 lingering feelings for a boyfriend who dumped her. She tells her friends about all his worst qualities in order to reinforce her efforts to manage unwanted feeling (1979). While Hochschild understands display rules, feeling rules, and cognitive fram es as the cultural influences on emotions, she borrowed from Freud the notion that emotions have an internal signal function. Freud, however, saw emotions as signaling irrational sexual and aggressive drives emanating from the unconscious and threatening t o become uncontrollable. Hochschild placed the signal function of emotion in the broader context of social life and the social self impending danger (from inside or outside) a 1983: 208). Hochschild similarly sees emotions as precursors to action, but she the concept of feeling rules. For Hochschild, emotions are intra In everyday life, emotion work has exchange value because acts of emotional expression are often considered to be owed by one individual to another (Hochschild 1979; 1983). Borrowing from Goffman, Hochschild recognizes that mutually agreed upon rules of display permit people to trade and ex change emotional facades performed through the medium of surface acting. By incorporating the concepts of deep acting and feeling rules, Hochschild posits


12 that deep acting, which enables exchanges of display, is also exchanged. Consequently, as a collectiv e system of guidelines, feeling rules perform two main cultural operations. They extend or determine the situational range in which certain emotive responses can occur without punishment; they determine the approximate sets of situations in which one has a happy, disappointed, angry, jealous, depressed, or indifferent. Secondly, feeling rules tell people what emotions they owe and are owed. It is from feeling rules that we believe or assume that, for example, family membe rs owe us concerned affect when we are in the hospital or that we owe our recently widowed friend displays of empathy and interest in her complaints, which in actuality we may find sniveling or irritating (Hochschild 1979). In the United States service eco nomy, the exchange value of emotion work acquires new implications. Hochschild posited that "when deep gestures of exchange enter the market sector and are bought and sold as an aspect of labor power, feelings are commoditized" (1979: 569). She calls the commoditization of emotion management under service Recognizing that the emotional style of a service can be integral to the service itself, she considers how this has driven work organizations to find new ways t o display. She argues that emotion work has taken on new forms of publicly recognized value: What is new in our time is an increasingly prevalent instrumental stance toward our nati ve capacity to play, wittingly and actively, upon a range of


13 feelings for a private purpose and the way in which that stance is engineered and administered by large organizations. (Hochschild 1983: In her 1983 study of flight attend ants and bill collectors, The Managed Heart Hochschild highlighted differences in the organizational use of human feeling according to class and gender (1983: 21). Gender as a category is particularly salient in the case of flight attendants, a once highl y sexualized and still largely female identified profession. She theorized a causal link between emotional labor and the estrangement of service workers from self. Through the use of a dramaturgical view of worker interactions with customers, The Managed H eart revealed how and show nurturance ex pectations which take form and are negotiated in the private lives of women and men management in the form of emotional labor can disrupt which he or she generates to display expected feelings according to work demands signal information about the self in relation to the social world (1983). Emo


14 t of which is sold for a wage (1983: 7). Her emphasis is on face to face service encounters, and she stresses that the outward countenance that produces the proper state of displaying organizationally sanctioned emotions by those whose jobs require interaction with clients or customers and for whom these interactions are an impor suppressing emotions to modify... emotional expression... in response to the display rules for the organization or job" (2000: 95). Other scholars imply that when individuals use their capacity to regulate internal emotions and external displays of expression for employment requirements or objectives, they are performing emotional labor (Kunda and Van Maanen 1999). Nicky James writes that t he value of emotional labor "lies in its contribution to the social reproduction of labour [sic] power and (1989:15). She adds, "Though it may remain invisible or poorly paid, emotional labour [sic] facilitates and regul ates the expression of emotion in the public domain" (1989: 15). Initially, the concept was applied to jobs requiring face to face or voice to voice interactions with customers, clients, or the public (Hochschild 1983; Rafaeli and Sutton 1989; Sutton 1991; Leidner 1991; 1993). Subsequently, research on workplace emotion management has been broadened to inclu de workers operating outside interactive service settings. For example, social scientists have


15 looked at office workers and managers who perform emotion management in relation to coworkers, superiors, and subordinates (Pierce 1995; Copp 1998; Kunda and Van Maanen 1999; Lively 2000). Scholars have also considered rather than solely Pierce 1995; Heimer and Stevens 1997; Yanay and Shahar 1998; Harlow 2003). Organizational Uses of Emotional Labor One way to consider how emotional labor is conceptualized is to review what scholars have learned about the purposes for which it is performed. This section highlights some work objectives and their associated emotional labor as revealed in the literature. These include: 1) to show deference; 2) to perform caretaking; 3) to repre sent an organization; 4) to provide a mood or style of customer experience; 5) to sell a product; 6) to incite another to action; 7) to facilitate interpersonal relationships with coworkers; 8) to make claims to occupational/organizational membership or to a professional identity, status, and authority; 9) to change emotional responses and feelings about specific stimuli which one encounters in the job; 10) to literally represent authentic experience. One purpose that emotional labor supports in organizatio ns is to enable workers to show deference. Expectations of deferential behavior and display are applied differently according to the occupational roles and statuses held by the workers in given situations vis vis one another or vis vis customers (Livel y 2000). To support displays of deference, workers may engage in individual


16 emotion management directed at their own feelings, interpersonal emotion self management of feelings as part of a mutually supportive exchange system (2000). Acts of deference can be a requirement in customer service transactions. Hochschild documents that flight attendants worked to manage their internal feelings to provide ou tward gestures of deference to passengers. When passengers vent anger, they exercise an unequally attendants must absorb this while continuing to show due deference. The flight attend acting in the situation (1983: 110). They also employed surface acting techniques provided by the company, such as workin name into statements or questions to signal that he or she is owed respect and that his or her expression of anger is owed concern by the airline. drive through worke rs followed surface acting scripts that helped them to be deferential to customers (1991; 1993). Other ethnographic examples of workers performing emotional labor to show deference are found in American owned nail salons (200 3), end service workers in luxury clothing stores


17 toy stores (2006). Deference can be important in hierarchical work organizations such as law firms or corporations. Jennifer gender and emotion in law firms shows that paralegals practice emotion management to provide multiple kinds of deferential beh avior to attorneys (1995). She finds that a the adversarial legal framework in which they operate An adversarial posture was often taken by attorneys in the paralegal attor ney workplace communication that she observed. Rules that obliged paralegals to show deference made it a job they must recognize the attorney as the authority and not challenge him or her as would an equ al. Thus they affirm the attorney's status by enduring the degradation of being treated as, interrupt their work, while they had no such right to interrupt attorneys (1995: 95). These findings are corroborated by based research on paralega ls (200 0). The paralegals Lively studied practiced reciprocal (rather than solely individual) emotion management to cope with workplace expectation that it would be reciprocated. Re ciprocal emotion management is one means by which paralegals handled their emotional reactions to status


18 inequalities that shape their daily interactions with attorneys (2000). In reciprocal emotion management, workers create networks with peers belonging to similar categories of occupational status and like work functions to help themselves manage the interpersonal strains and work related difficulties that result from their structural position in their organizational hierarchy (2000: 58). Another objecti ve associated with emotional labor is caretaking. Like all emotional la bor, caretaking is a relational rather than a task based effort (Steinberg and Figart 1999). It can b e applied to diverse interpersonal activities in workplaces. However, when considere d in r elation to certain service jobs, it caretaking su ggested by sociologists include validation, empathy, support, compassion, and consist These elements are all documented by Hochschild as job requirements of the early 1980s flight attendant. Delta Airlines trained its stewardesses in surface acting, including scripted language and formulas of dialogue designed to in sure that interest and empathy were conveyed. They also were taught deep acting Ellen Guy and Me redith Newman point out that various government employees must practice emotional labor as caretaking: Those who staff the phone lines at the Internal Revenue Service are


19 accordingly. This work is relational in n ature and is called emotional labor. (2004: 289) In their study of social workers who counseled patients and their families in the neonatal care unit of a general hospital, Carol Heimer and Mitchell Stevens found that social workers also must also engage i n forms of emotional labor to perform caretaking (1997). Caretaking overlaps with two other distinct purposes or objectives of emotional labor: to provide a mood or emotional style of experience to a customer and to represent an organization. Flight att endants are asked to represent the airline and to sell its brand through emotive gestures and feelings (Hochschild 1983). The 1980s technology firm of engineers and professionals studied by Kunda and Van Maanen were taught to show feelings that represented the organization (1999). Emotional Socialization and Occupations Cultural beliefs, social processes, and structural positions such as social or occupational statuses, all affect how individuals interpret, express, and, in some cases, experience emotions (Hochschild 1983; Sloan 2007; Thoits 1989). Occupational subgroups have proven a fruitful ground for studying emotional socialization. The literature has examined emotional socialization in work organizations and in institutions where workers acquire occup ational training and membership. In general, the empirical research on how workers manage


20 emotions underscores that learning a job involves developing normative feelings about work situations and experiences (Cahill 1989). In occupations requiring prolonge d training or formal lic ensing to enter, the research indicates that processes of occupational acculturation teach workers emotion management strategies. Several studies establish that the institutional dissemination of language and specialized knowledge c an provide unspoken train ing in how to achieve Sherryl Kleinman show that American physicians learned in medical school how to regulate their emotions through deep acting (1989). The medical students drew from the professional medical culture of affective neutrality and b iomedical objectivity to control or change personal emotional reactions to encounters with patients and human bodies. The students used scientific learning to re conceptualize patients as Yanay and Golan Shahar similarly find that Israeli psychology students who volunteered at a residential treatment center employ ed ideas about affective neutrality from psychotherapeutic books to define patients in ways that helped to suppress emotional reactions to and feelings about them (1998). Spencer in lectures and labs normalized working with the dead (1999). The students used the technical language of mortuary science to transform working with corpses into professional activities that did not have emotional associations with death. The program supp


21 considered appropriate for a funeral director (Cahill 1999). These studies suggest that deep acting strategies do not need to be explicitly taught or openly discussed. Rather, they can be tran smitted through occupational language and symbols implicitly. In these ethnographic accounts, the students/trainees adopt specific kinds of deep acting in response to situations they encounter, and the adoption of the strategies is modeled and indirectly r einforced by authorities (Smith and Kleinman 1989; Yanay and Shahar 1998; Cahill 1989). As Smith and Yet, in the organizational context, the literature corroborates that expression. Although some social scientists refer to organizational display rules They are subjective standards and definitions of correct emotional style. They have normative authority bec ause more powerful members of the organization e.g., managers, leaders, owners, or in some cases customers promote and maintain them (Sutton 1991). Authorities deliberately impart these rules to workers through various means, including formal training (Sut ton 1991). For workers in front line service delivery roles where the emotional style of the explicitly connected to work standards (Hochschild 1983: 5; Yanay and Shahar 19 98). Empirical research proposes that service work organizations establish and maintain expectations regarding emotionality in different ways including


22 selection, socialization, punishments/reinforcement, and transactions/interactions with customers (Rafae li and Sutton 1987). concepts (1983). Both Hochschild and Robert Sutton respectively note that commercial organizations attempt to influence what employees display and how they f eel. Sutton, coming from organizational behavior/management theory, suggests that organizations do this based on the logic that when workers actually feel the emotions that their jobs call for them to express (to customers for example), the organization wi ll have an easier time maintaining conformity, and it will not have to use resources for reinforcement and punishment (1991). Hochschild, in contrast, emphasizes that service organizations teach deep acting because it is more persuasive: Some institutions have become very sophisticated in the techniques of acting has always had the edge over simple pretending in its power to convince, as any good Recurrent Training Instructor knows. In jobs that require dealing with the public, employers are wise to want workers to be campaign, teaches his advertising student feeling can be managed. (1983: 49, 33 34)


23 These differing emphases are not mutually exclus ive and may be considered comple mentary. Employee se lection is recognized in the literature as one way that managerial authorities first address feeling and display rules. The hiring process ight attendants, based on participant observation at the Delta Training Center in Atlanta, describes how airline recruiters sought: example, says that applicants are expected to perso training, and the probationary hiring period (1991) The managers said they In her ethnography of gender and emotion management in law fir ms, Jennifer Pierce notes that the attorneys and human resources staff accounted for their


24 rela on selection give a window onto the organizationally determined role expectations for the emotional labor of the jobs in question. They also reveal that selection and recruitment c an operate as organizational means of telling workers what types of emotional management will be required on the job and what type of feelings about the work they are expected to have. The emotional labor literature abounds with descriptions of how organi zational feeling rules become internalized by workers through training the emotions of clients are clearly and directly the object of work and where the emotions of service prov Hochschild 1983). Hochschild relates that the Delta flight attendants underwent raining, the focus was on the In Initial Training, the focus was on the smile and the living room analogy; in sed on participant observation among door to door insurance salesman, Leidner notes how the company encouraged deep acting through attempts at cognitive behavioral conditioning, presumably to bolster the model of surface acting provided in the detailed sal es scripts that agents had to memorize: fundamentally to inculcate optimism, determination, enthusiasm, and


25 confidence and to destroy habits of negative thinking. The trainees were taught that through proper self conditioning, they could learn to suppress You should do everything exactly the way we tell you to, but success depends on your strength of character. (1991: 162) At t he bill collection agency studied by Sutton, managers determined that conveying urgency and feelings of concern to debtors was the best strategy for achieving collection (1991). Through formal classes and coaching by supervisors collectors recalled that after being pushed by supervisors to speak in an urgent tone for a week or so, they eventually rea cted inwardly to all debtors with moderate irritation (1991). Feeling rules are also taught through routinized scripts and work flows. hey failed to smile (1991: 160). The to control their anger, apologize, try to correct the problem, a nd in extreme


26 Conclusion The concepts of feeling rules and emotional labor are helpful for understanding cultural and psychological aspects of work in postindustrial American society. Ethnographic research shows that emotion management is a requirement of a great variety of jobs that deal with customers and the public. It also shows that forms of emotion management can be obligatory and organizationally directed in workplaces where customers are not involved. Most im portantly, the literature illustrates work role is always connected to ideology. Sometimes that ideology is entirely determined by that of the company, such as the flight attendant who must follow explicit work standards of emotional performance. In other cases, the ideological influences on emotion management are related to a professional culture. In either case, the feeling rules are not set by the individual actors, and there are consequences for their private emotional regulation as a result of the deep control and commercialization of their feelings exerted by the ideological structures of their work.


27 Chapter Two: Methodology and Research Design This chapter explains the anthropological methodology used for my thesis research. First I explain the method employed to collect data, which is ethnographic interviewing. I situate the methodology of in depth interviewing within the traditions of both cultural anthropology and emotional labor res earch. Secondly, I introduce and describe the occupational context and the qualifying characteristics of the people whom I studied. In the third section I address my own role within the research process and my own perspective in relation to the subjects workplace affected what data was gathered (or not gathered). I briefly examine theoretical biases that I held going into the interviews and highlight how I attempted to limit or counteract their i nfluence on my data collection. In this context, I clarify my sampling method by detailing how I recruited and selected informants for the interviews. Finally, I specify how the interviews were conducted and how the data was coded and analyzed. Ethnographic Interviewing In this thesis, I aim to understand and interpret the relationship between the organizational cultures of a specific group of workers and their experiences of emotions on the job. As the preceding literature review demonstrates, the methods of ethnographic research have been applied widely by sociologists,


28 psychologists, and anthropologists doing work in the vein of research on emotions in the workplace (Thoits 1989). Participant observation and in depth interviewing, which are t he hallmarks of ethnography, allow anthropologists who study occupational groups to system atically investigate frameworks of meaning that participants in work organizations share, negotiate, utilize, and contest in the contexts of their work roles (Spradle y 1979; Trice 1992). Interviewing methods are suited to capturing data about internal states such as emotions, and they give access to contextual data that survey s or experim ental methods might not permit (Bernard 2006). The ethnographic interview, however is not just a way to get validity Interviewing provides a process through which anthropologists can attempt to understand the ideational perspectives that occasion and produce emotions and moods for interviewees as reflected in their recollections and reconstructions of experiences (Geertz 1973; 1983; Hochschild 1983). By compiling and analyzing interview data and looking for common themes, categories, and patterns, the anthropologist se 1983). For the anthropologist investigating workplace emotions, one limitation of interview based research is that people are always to some e xtent performing, even in unguarded moments (Goffma n 196 1; Hochschild 1983). Consequently, it is important to remember:


29 atter of scratching Introduction to the Workers and the Occupational Context This project arose from an interest in emotional labor within managed mental health care companies and specifically the clinicians they employ to perform hybrid administrative clinical roles. As I will discuss, I worked at the organization whose clinical employees I interview ed for nin e years. M y original research focus was the bureaucratic and interactive service work of utilization review care ma nagers in managed mental health care. Little has been written on managed health care organizations, their clinical employees, or their work processes from a cultural anthropological perspective (for minor exceptions, see Lamphere 2005, Wagner 2005). I was interested in possible social psychological as mental health clinicians and their work obligations to perform cost containment activities on behalf of commercial health in surance organizations. If I found evidence of such conflicts, I planned use anthropological models t o assess potential cultural mediations of these conflicts. As it turned out, only one care manager currently assigned to a utilization review team voluntee red to be interviewed. I had nine volunteers who currently worked in the intensive case management (ICM) department which is a different type of care manager work role (at HealthCo every clinician is identified as a rtmental functions or individualized


30 duties). Structurally, the work of the intensive case manager has a somewhat less immediate relationship to cost containment within the operations of managed mental health care (see Chapter Three). The ICM clinicians ha ve telephone interaction with patients throughout their workdays, which is another difference from utilization review care managers. I refocused my inquiry toward intensive case managers and their particular emotion management in the corporate organizatio nal context. Two of my study participants yielded considerable data about the utilization review rol e at the company, and I discovered that most of the intensi ve case management clinicians previously worked as utilization review care managers Incidentally I also learned the office was in the process of expanding intensive case management duties to include more overlap with utilization review. This fact suggests the organizational culture related to utilization review care management permeates the speciali zed work role and departmental culture of the intensive case managers as well. Further clarification of these care manager work roles is provided in Chapter Three. To become a care manager at HealthCo, an applicant must be licensed as a mental health clin ician or psychiatric nurse. The company hires licensed practical nurses (LPNs) with two year degrees as well as registered nurses (RNs) with four year degrees, but most HealthCo care managers do not come from a nursing background. For example, the intensiv e case management department has approximately 50 clinicians. I did not receive a precise breakdown, but I was told only two (or four percent) of the 50 clinicians are


31 nurses. The preponderance of care managers at this HealthCo office are therapists/counselors or social workers. For a trained social worker or therapist to level degree is required. In addition to the 50 or so clinicians who work in intensive case management, there are roughly anot her 150 other care managers at the office who work on teams dedicated to utilization review. 10 clinicians and one administrative support worker. Of the 10 clinicians, one is a psychiatric nurse (RN), five are social workers (LCSWs), and four are licensed psychotherapists (LPCs and LMFTs). 3 degrees, while the psych iatric nurse has a BS in nursing. The manager of the intensive case management department, Diane Roberts, participated in my study. Holding an LCSW credential, she has worked at HealthCo in various roles for 14 years. I also interviewed two ICM supervisors both of whom are licensed therapists with eight and 11 years tenure at the company respectively. I interviewed six ICM clinicians, and their years worked at the company ranged from eighteen months to 16 years. The ICM clinician with onl y eighteen months at HealthCo Anna Wil son, represented an interesting outlier among the six in terms of length of managed care work experience. I was told she was unique in 3 The five so cial workers I interviewed hold the credential of licensed clinical social worker or LCSW LCSW has to complete the required number of hours of supervised clinical w ork and pass a specific LCSW licensing exam. Of the four psychotherapists in my study two are licensed marriage and family therapists or LMFTs and two are licensed professional counselors or LPCs. Both LMFT and LPC are state issued professional licenses t level graduates in psychology or related subjects can earn.


32 this respect among the ICM clinicians as a whole. The other five I interviewed ranged from eight to 16 years at HealthCo. I interviewed one utilization review clinician, an LCSW, who had been at the company for six years. The education, training, and work experience of the psychiatric nurse is the most distinct of the group. Psychiatric nurses have for mal education in psychopharmacology and practical medicine. Care managers with social work or therapy backgrounds usually have not had this training. Several participants told me they sometimes come to the nurse for quick answers to questions about medicat who are MD psychiatrists, to become available to answer these medically related medicines that much [with p atients] differences in the training received by marria ge and family therapists versus social workers may have significance in this workplace, the practical difference between a nursing background and all others seemed to be the most conspicuous, at least to the workers. The care mangers at HealthCo are predom inantly female. Only one of my ten participants, intensive case management supervisor Jason Jo nes, is male. I learned that only three (or six percent) of the roughly 50 clini cians working in the intens ive case management department were men. It should be n oted that the clinical director and two clinical managers at th e office were at the time of this


33 research women (for clarification of office hierarchy see Chapter Three ). Direct Work Experience at the Office I worked at this office of the managed behavioral care company as a customer service agent answering inbound phone calls for three years, and subsequently as a claims analyst for six years. Besides knowledge of what the office looks like, I came to the interviews wit h familiarity with the computer information system and the organizational jargon that the clinician s use. I also brought knowledge of the administrative aspects of what the office does, and participatory insight into categories and practices of the organiz ation. I had my own firsthand experience to draw on when it came to knowing how work ev ents generally transpire throughout the call center. This was an advantage because I did not have to ask care managers to define as many terms as an outsider might. I al so did not need my participants to explain sequentially some events they referenced, for I knew what kind of general prior conditions and signals had occurred. For example, when they talked about patients upset about claims problems or situations when they had to document things in the computer al outsiders might have needed This enabled me to move efficiently beyond basic level questions about administrative work routines and fo cus on what these workers had to do and know to be considered good at their jobs. Perhaps the greatest advantage I had was that I could focus on emotional expression and


34 experience in some depth without having to interrupt them for definitions of managed b ehavioral health care, insurance, or call center terminology. Yet, I was an outsider studying care managers. I had no experiential understanding of the training they had received as professionals, and I had limited knowledge of the clinical issues th ey encounter ed in their jobs or in their service w ork experiences prior to joining and no direct knowledge of how they viewed their work and what its challenges and rewards were for them. I did not know the specific rules of their work or how they operat ed in relation to them. Of my 10 clinician participants, I had a workplace friendship with one of them, ICM supervisor Barbara Smith. Over the years, we had on a few occasions gone out to lunch together at work. Two other participants, the ICM department m anager Diane Roberts and clinician Claire Slater, I had familiarity with before interviewing them. I had friendly interaction with them inside the workplace, though not beyond it. The remaining seven clinicians I had either never spoken with before or I kn mentioned. Nothing presented in this thesis comes from any personal communication I had with any HealthCo care mangers prior to my interviews. Furthermore, I do not offer any proprietary information of the company gleaned from my work experiences there. Having worked at this company for nine years, albeit in a different role from the clinicians I studied, my methodology has some relationship with my own personal experience. First and most obvious is th at I leveraged my work connections to recruit informants.


35 At the company, I interacted with numerous care managers. I developed a positive rapport with many of them which I believe was based on work related and personal factors. In both job positions at th is managed care company, I had opportunities to make their work easier. I routinely took the initiative to help clinicians by: probing, advising and redirecting callers who would otherwise interrupt them; answering or researching their questions about clai ms, insurance, and contract issues that arose often; handling administrative and computer system problems for them; and fixing their clerical mistakes. Some clinicians who I sat beside and interacted with as part of the same unit went on to receive promoti ons through the years. Some became management. Also, I had more social, cultural, and educational characteristics in common with clinicians at the company than I had with most other persons in my customer service role. Among the commonalities, I could r elate to their interest in and experiences of studying psychology/social sciences, social problems, or mental health issues. My father having been a clinical psychologist, a community mental health center director, and later a managed behavioral health car e their profession that many in the company, including management with non clinical backgrounds, did not have. So a salient factor in my forming rapport with them as a coworker wa s the cultural capital I had to engage them as friends. All the care mangers I encountered there were older than me, and, unlike myself, most had spouses and children. My family and class background positioned me to relate professionally and personally wit h care managers in the workplace.


36 When I began seeking interviewees, access was not difficult. I had two clinicians in management positions helping to recruit on my behalf. I also had personal rapport with non clinical employees who work or previously wor ked in support roles for care manager teams. One of whom I interviewed for this study to obtain information about the utilization review care goals, performance measures, and the language and concepts used. The Interview Process I conducted 11 interviews telephonically between October 2011 and January 2012. The first interview I completed was with a utilization review care manager. The next three interviews were with my participants whom I refer to as elites of the intensive case management department: two ICM supervisors, The last six interviews were with ICM clinicians. These interviews ranged be tween 50 and 90 minutes long. All participants called me from their homes or, in one case, the car. I recorded and transcribed the interviews, totaling 140 pages of single spaced interview text. In my research I sought to combine the advantages of a ground ed theory approach to research with a focused emphasis on the themes of workplace emotional expression and experience. My interviews had relatively open elatively unstructured interview s will illustrate individual processes of reconceptualizing


37 structured interviews designed to accommodate a predetermined theoretical model. The theoretical framework emerges largely fr At the same time, I had a predetermined focus on the cultural patterning of emotions in care manager work, and I had fully schooled myself in the emotion management theory of Hochschild. I deliberately avoided formulaic question s that would heavily bias my data toward the theses of emotional labor scholars. Rather than start with formal questions about the issues I sought to explore, I opened by soliciting a general Weiss 1994: one of the participants had worked in managed mental health care for six years or more, t their educational and mental health service experience. When I interviewed the department manager and two supervisors, I gave additional time to seeking details about hiring, interviewing, training, monitoring, and evaluating care managers, but I asked open ended questions of all the participants regarding the rules of the job and what is considered good, bad or unethical by the company: When you review applica nts for ICM jobs, are there characteristics or skill sets you look for? What are your job responsibilities?


38 How is your performance evaluated?


39 Did y ou conceal your feelings in that situation you mentioned? a member or provider?


40 Conclusion For this thesis, I conducted, recorded, and transcribed approximately 13 hours of interview conversation with trained and licensed mental health corporation in the United States. How I structured the interviews reflects an ethnographic methodology, and I focused them on how the clinicians perform their managed care work, their experiences of interactions with patients and others inside and outside of the company in their roles, and their emotional responses to work and their management of these responses. These interviews serve as the basis for an anthropological analysis of the emotional labor of clinicians em ployed in managed behavioral care.


41 Chapter Three : Contexts of Work and Feeling: Man aged Care, the Corporation, and Me ntal Health Case Man agement This chapter describes operate as workers and that impart ideological and symbolic constructions that influence their work place emotion management. First, I define and explain managed care as an organizational model that changed the provision of United States health care. Then, I characterize the development, practices, and goals of the managed mental health care industry. Next I describe the organization and operations of HealthCo and the particular office where my interviewees are based Finally I detail the formal objectives, duties, and rules intensive case management department as reported by my participants. In this context, I present ethnographic findings about HealthCo as an experienced workplace. The Meaning of Managed Care rs to administrative systems for limiting or reducing the cost of providing medical services to a specifi ed population. A salient feature of managed care is that service delivery and financing are coordinated. Under the systems of health insurance that wer e commonplace in the United States through to the 1970s doctors and hospitals acted independently of the insurance companies that reimburse d policyholders for their treatment costs. These insurance plans are referred to today as


42 for se rvice or indemnity plans. In practice, t raditional health ins urance systems uphe ld most that decisions about treatment should only be made by doctors in consultation with patients (Zieman 1998: 4). Under managed care models, providers of services and the organizations that control payments are integrated. Managed care is based on the concept that insured p ersons should only receive treatment if it and the necessity of care is determined in part by external review procedures or administrative mechanisms rather than by the practitioner acting alone. Doctors and hospitals in a managed care system must share clinical information with a payer i.e. a managed care company and reach a consensus w ith it about what treatment is considered to be necessary. Additionally, managed care models espouse the idea that plan members should be g uided systematically to the most appropriate treatment. One of the ideological underpinnings of managed care is that its mechan isms are supposed to serve as watchdog s over the quality of services provided to patients (Edmunds et al 1997; Findlay 1999; Ziem an 1998; Levy Merrick et al 2002). In this sense, managed care is sometimes defined as a system of integrated financial controls and clinical oversight that tries to match monitoring resources and treatment outcomes for quality and efficacy (Winegar 1992 )


43 The Institute of Medicine 4 offers a definition of managed care that recognizes the important fact that it represents a market based approach to measurement, and accountability on the delivery of health care to achie ve the this market, however, are primarily employer groups or governments rather than individuals or families. Managed care rose to prominence during the 1970s and 1980s as an alternative to traditional fee for service insurance. The rising cost of medical services a nd public demands for improved public access to health care precipitated the expansion of managed care organizations. With backing from the federal government in the Health Maintenance Organization (HMO) Act of 1973, managed care organizations proliferated and increased their numbers of care. Prototypically, HM O plan members who need specialist care have to be 4 The Institute of Medicine is a private, nonprofit organization affiliated with the National Academy of Sciences.


44 PCPs. circles, and they are predominantly known to t he public as HMOs. Examples of large managed care plans are Kaiser Permanente and United Healthcare. Some HMOs began as non profit entities, and some remain so. 5 But today the largest health plans that cover the vast majority of Americans are private compa nies or publically traded corporations that operate for profit. Health care is a trillion dollar industry (Dranove 2000). Beginning in the 1970s, many large insurance companies such as Prudential, Cigna, Aetna, Humana, Metropolitan Life, and Travelers, as well as the non profit Blue Cross and Blue Shield health insurance plans sought to buy or establish their own managed care plans. They started emulating the financing and service delivery mechanisms that were pioneered by HMOs (Edmunds et al 1997). Thus, the traditional insurance industry was rapidly superseded by the managed care industry. As Zieman observes: HMO plans quickly became known as managed care. Defined provider panels, a rigid list of covered medical procedures, fixed and discounted fee sched ules, and the insurer authorizing or denying services for coverage felt extremely managed to patients and providers who had been accustomed to the relatively free wheeling system of traditional indemnity plans. (1998: 7) 5 Blue Cross Blue Shield of Florida, for exam ple, is not for profit at the state level.


45 Managed care began in the private sector, but it eventually sold its services also to the public sector and has had significant impact on Medicaid (Frank and Glied 2006; Perloff 1998). The companies that deliver managed care systems have a natural interest in seeing decreases in the use of services. It is not unusual to see business profit interests of managed care organizations. While they have limited sway over demand for services, supply is something they can track and control. Logically speaking, the pressures to increase immediate profits and therefore to constrict the availability of services are strongest in managed care companies that are organized as for profit corporations with shares traded on stock markets. As Ho points out in Liquidated: An Ethnography of Wall Street American corporations are governed according to ideologies of shareholder value that privilege short term profits over term value as a social entity (Ho 2009). The Managed Behavioral Health Care Industry In the 1980s, a specialty industry emerged within managed care that became known as managed behavioral care. 6 Dur ing the late 1970 s and 1980s, 6 Substance abuse and mental health are overlapping but medically distinct areas of health care. is increasingly used in American health care as the rubric encompassing both psychiatric and chemical dependency services. Among the leaders in this trend were the o industry, and their concepts of care (e.g ., the


46 increases in the cost of mental health services outpaced those of other areas of health care expenditure (Fran k and Glied 2006). At this time, health insurance purchasers i.e., employers started separating out certain insuranc e functions according to disease or type of service and then commissioning separate arrangements for the administration of those particular benefits. This became a variety of important reasons, mental heal th and substance abuse became a commonly carved out managed care insurance product (Frank and Glied 2006). General medical plans began to outsource responsibility for mental health to new specialty vendors called managed behavioral health organizations (MB HOs). The health insurance companies started utilizing MBHOs on a contract basis to coordinate and usually assume financial risk for substance abuse services (Zieman 1998). Entrepreneurial minded psychologists, psyc hiatrists, and others with experience in the administration of mental health care started up the first managed behavioral health companies. They marketed their services to HMOs and employer groups on the basis of their specialized expertise, and they claim ed they could cut costs while improving the quality of mental health and substance abuse care (Findlay 1999). One reason that mental health came to be viewed as a good area for depen dency present unique challenges for implementing mechanisms of utilization review. Most physical conditions and diseases can be reported to a commonly used as a broad heading, particularly in government, and it does not have the spec ific association with managed care.


47 managed care company in terms of x rays, laboratory results, and biomedical symptomatic variables. The company can evaluate requests for continued hospitalization using these relatively concrete data and well established medical true for mental health. For a diagnosis such as clinical depr ession, lab t ests are not applicable can be a more contentious matter. Defining measurements of treatment progress and outcomes for substance abuse or mental illness pose special problems for managed care administrators (see Edmunds et al 1997). Fledgling MBHOs had and implemented what were then novel approaches to organizing mental health resources (Mihalik and Sch erer 1998). During the 1990s, m anaged behavioral health co mpanies demonstrated that they could reduce costs for health plan purchasers by shortening the lengths of stay in psychiatric hospitals and in inpatient and residential substance abuse treatment programs ( Iglehart 1996; Findlay 1999). Such reductions in hospital stays were achieved through case by case clinical utilization review. Managed care in mental health has sought also to impose some limits on outpatient services. It has had marked influenc e on psychological testing practices, bureaucratically blocking and challenging the need for traditional personality assessments services that were, in the pre managed care era, the stock in trade of clinical psychologists, the professional class uniquely licensed to administer them (Acklin 1996; Piotrowski 1999).


48 In the process, the managed behavioral health industry acquired many critics, not least among them the mental health professions. Many practitioners perceive managed care as undermining their aut onomy and circumscribing their expertise (see Schamess and Lightburn 1998). Observers, such as Professor of Social Work Gerald Schamess, also argue that managed care has helped to transform the ideology of mental health care in the United States: [M]anaged care reflects not only the triumph of corporate values over more humanistic ones but also the triumph of technological (managerial, biomedical) and cognitive behavioral perspectives over competing explanations of psychological dysfunction. Other theories about etiology and treatment (for example psychodynamic, gestalt, existential, humanistic) have been swept aside in the corporate search for simple, concrete explanations of psychopathology that better lend themselves to cost containment and product market 24) 7 At the same time, the jury remains out about whether managed behavioral health comp anies have lowered patient care quality in the course of cutting costs. In their survey of American mental health policy since 1950, Better but Not Well (2006) Frank and Glied report: 7 I n my interviews with HealthC


49 s has reduced the up save money has generated concerns about lowered quality of care, but studies to date have not consistently show n evidence of quality reductions (or improvements). There is, however, some evidence that people with schizophrenia fare less well than do other Medicaid beneficiaries enrolled in managed care. (67 68) In terms of empirical measurements of access and outc omes, the effects of managed behavioral care on patients cannot be assumed to be negative, particularly in the better funded private sector (2006). However, qualitative scholarship by social scientists suggests that in the Medicaid sector, where the resour ces of the mental health safety net are persistently threated by government cutbacks and community mental health centers struggle to make do on less, the bureaucratic impositions made on providers by managed care are not only unwelcome, but can be disrupti ve to care and harmful to vulnerable patients (see Ware et al 2000; Rylko Bauer and Farmer 2002; Wagner 2005; Willging 2005; Lamphere 2005).


50 The Corporation: HealthCo Inc. HealthCo is a for profit managed behavioral health corporation with shares trade d on the New York Stock Exchange. Its customers are health plan companies, employers, and state Medicaid programs. The corporation operates to satisfy contractual obligations to these client organizations and to generate profits for its shareholders. Healt hCo has offices nationwide, and the workers I interviewed are based at a regional branch that handles services for specific geographically based HMO/PPO 8 plans and state Medicaid programs. Workers at HealthCo refer to the individuals whom they service the persons who are eligible under benefit plans rganizations that contract with HealthCo for its services, such as the health plan companies. HealthCo acts as the enforcer of benefit limits set by its client insurance For example, a general medical company hiring HealthCo might stipulate that within an average of 30 seconds of the first ring. Under such a regime, if the for a given month is ever calculated to be greater than 30 seconds, HealthCo owes its customer a financial penalty. 8 PPO stan ds for preferred provider organization. In this context, HMO and PPO plans can be loosely understood as two different types of insurance products that an insurance/health plan company sells to employer groups or individuals.


51 HealthCo coordinates care through a network of independent practitioners and hospitals. These care providers are not employees or proper ty of HealthCo. have similar contract arrangements with other managed care companies. its websites an d call center staff (customer service agents and clinicians with the in given by providers not contracted with HealthCo. When providers and hospitals enter the network, they agree to be paid at discounted rates in exchange for the expected inflow of patients. They are paid on a per service basis after they submit claims to the company. In their contracts, they cons requirements for getting services preapproved. This means they agree to participate in utilization review processes as a condition of payment and accept If a facility does not obtain approval for a service, which is known in the HealthCo prohibit them from billing plan members for any services that the al inpatient days) or for which they neglected to request approval. But according to my participants, this occasionally happens anyway, causing patients distress when patients fo


52 this. If notified by patients of this, HealthCo tries to get the facilities to cease submitting medical rec ords to HealthCo, but they are never entitled to bill members. However, until appeal processes are resolved (which can take months), facility collection departments might send more bills to patients or even make intimidating collection calls. Most of the c ompany workers I interviewed mentioned that claim issues or billing misunderstandings can be a significant source of added stress for people who are dealing with mental health conditions. Office Physical Description Although the sociocultural data present ed comes from telephone interviews with 11 workers, my nine years of experience working at this particular location give me a memory of the physical office space. The office where my participants work is a regional branch of the corporation. The branch lea ses two floors of office space in a nondescript six story building in a suburban office park. The office park is a short distance from the highway that a large proportion of its workers travel every weekday, from home to work and back again. Inside, the pr ofessional environment is one that would seem familiar to millions of U.S. workers. Most employees sit in cubicle work spaces. Supervisors are seated in cubicles adjacent to their subordinates. Only employees designated as managers or directors typically h ave enclosed offices. Door less, partitioned spaces compartmentalize the majority of the floors, vaguely defining individual territories of functional teams various teams of


53 clinicians, customer service agents, data reporting and quality improvement staff, administrative assistants, claims specialists, and the like. Walled rooms are reserved for the corner offices of higher level executives or clustered in the center of the building for use as training spaces, kitchenettes, and other specialized common area s. A neutral corporate color palette of grays, taupes, and dark blue predominates. Each cubicle is equipped with standard computer hardware and accoutrements from the office supply store, such as plastic bins, wire file organizers, cylinders of pens, and s hort stacks of paper goods. Varying degrees of personal paraphernalia photographs, children's artwork, the infrequent plant individualize each cubicle work space. Bulletin boards punctuate the permanent floor to ceiling walls and provide communal informati on as well as hosting organized pictorial stories showcasing one recent office triumph or another. T he Organization of Clinical Work at HealthCo The office directly hires psychotherapists, social workers, psychologists, and psychiatric nurses to carry out jobs in its call center workplace. The company care managers perfor m are utilization review (UR) and case management which the company calls intensive case management (ICM). At this office, ICM is a separate and relatively smaller department. Most of the clinicians at the office work on teams dedicated solely to utilizati on review.


54 Care managers are divided into functional teams, and each team has a supervisor. Ranking above supervisors are two clinical managers. One manager is in charge of utilization review teams, and the other has responsibility for the intensive case management program. The clinical manager who oversees ICM participated in my study, as did two ICM supervisors who report to her. The organization promotes supervisors and managers from within, so these individuals characteristically began at the company a s entry level care managers. At the top of the office hierarchy are a clinical director and a medical director. The clinical director, who by industry custom is expected to hold a doctorate in psychology or a medical doctorate with certification in psy chiatry, is functions of care managers. The medical director, who must be a psychiatrist, has ultimate res ponsibility for oversight of all company decisions made about treatment recommendations and about whether to deny care. UR care managers hiatrists who work for the managed care company, either the medical director, associate medical directors, or what are called physician advisers (usually part time employees who maintain practices and hospital privileges).


55 Utilization Review Teams Util ization review care managers take incoming calls from hospitals asking care requiring preauthorization are psychiatric hospitalization, residential treatment, and day treatment programs. Certain services, if they are to be performed on an outpatient basis, also require authorization, for instance electroconvulsive therapy. While UR care managers do not deny coverage for care, they have the authority to approve it. They collect i nformation about a into the computer system. If they decide that the information provided by the fa cility does not support the need as defined by the company for an admission review. The medical director or physician adviser then schedules a telephone consultation with th e attending psychiatrist at the facility. Following this, the recommendations to the attending psychiatrist at the facility. Sometimes the issue that leads care managers to r efer cases to the company psychiatrist is not the perceived lack of medical necessity but questions about whether treatments being proposed by hospitals are sufficient or care bei ng given, as reported to the care manager by the facility, appears to be not intensive enough or not clinically sound. An example would be a patient who,


56 during his confinement for major depression, presents evidence of an acute medical problem that could warrant HealthCo recommending that the psychiatric treatment for mental health can safely (and perhaps more productively) be resumed. UR care managers have other minor responsibilities. They coordinate follow up care for patients who have finished hospital stays. This mainly involves checking that facilities have made outpatient appointments for members who are being discharged. Sometimes care managers liaison with a pa physician to promote harmonization of physical and mental health treatments, but this is rare. Additional duties are usually dictated by the requirements of All activities of the UR care manager require data entry into one or more computer systems. The fruit of their efforts is essentially documentation and data that can be aggregated for reporting and audits, and they spend most if not all of their workdays typing at the computer. They enter aut horizations into a system which the claims departments later use to determine if billed services should be paid to the facilities and professionals. It is atypical for UR care managers to communicate with patients. The routines of managed care are so ing rained in mental health care that hospitals and agencies including even community mental health centers have their own managed care compani es and obtain approvals for services. nly to these


57 specialized facility employees. They obtain clinical information and u pdates about from these facility employees. The UR care manager whom I interviewed described her phone


58 The case management program at HealthCo is embedded in clinical and corporate discourses of health care. The concept of case management deno tes resources to promot e quality cost Society of America website 2012). The Utilization Review Accreditation Commission ( URAC ) 9 the national non profit organization that accredits MBHOs zations use case 9 URAC formerly was an acrony m for Utilization Review Accreditation Commission. It is now simply known as URAC.


59 implementation, coordina HealthCo training class). 10 In the conceptual context of the managed care corporate boardroom, case management focuses on plan members who Resources Inc. website 2012). Whereas utilization review controls supply, case management seeks to shape demand. 10 The slide was emailed to me by one of my interviewees.




61 Our job is really to help them figure out what they need and figure out how to get what they need. (Barbara Smith, supervisor of ICM, 11 years at HealthCo) My job is to facilitate treatment. And most of the people that I work with need ongoing care. So it's just getting them connected with the best resource whether it's inpatient or residential or outpatient and to ki nd of ensure that they have continuing support. (Sally Billingsley, ICM care manager, 13 years at HealthCo)


62 I know I have done a good job when people get better. There is a movement. Someone is in a different place than when you first started working with them. And it may not be the ultimate place or a great place, but there is movement. If I had helped someone in some way and achieved some goal no matter how small it is that is positive, then I feel like I have done my job. (Margaret McEntire, ICM care ma nager, eight years at HealthCo) In the department, stress is placed on the benefits of case management for members and the potential value of the case manager as a facilitator of s praised, a supervisor offered: Today, one of the care managers had a really great collaboration. They did a conference call with a member, the mother and the provider. So it wa sure everybody was on the same page and to establish a clear treatment wanted to try to identify barriers that were causin g the member to go back to the hospital. (Jason Jones, supervisor of ICM, nine years at HealthCo) However, t is acknowledged to be lowering inpatient utilization and saving money for the c ompany. The ICM clinicians I spoke with articulated their awareness of this along the following lines:


63 The goal is to keep the admissions down. And making sure they have good follow up and making sure they are plugged in with providers and resources in the (Colleen Lee, ICM care manager, nine years at HealthCo) From the managerial perspective, this demand management objective of the program is not only abou t saving costs for the company; i t is also a worthwhile attempt to achieve better use of available resources: T ost involved. Administratively thing is working,


64 (Diane Roberts, manager of ICM, 14 years at HealthCo) financial goals for case management are aligned with what is clinically favorable for members. He also noted that if the ICM program successfully curtails hospita l admissions by reducing the need (or demand) for them, it has the side benefit for members of improving their personal finances. Most commercial insurance plans have smaller copayment requirements for outpatient office visits than for inpatient care. 11 He told me: The bottom line is lower recidivism cost. It is lower cost in care. That is really the bottom line. But to look at it as a global perspective, it is really about a twofold win win scenario. If you look at statistics, if you look at research, rea costs the insurance company a lot, and it costs the member a lot of money too with multiple copays since they usually must pay a copay for each hospital admission. And so it is really a win win scenario Jones, supervisor of ICM, eight years at HealthCo) they also suggested awareness that the company primarily employs them to 11 Cost sharing requirements such as large inpatient copayments, which can serve as disincentives to initiating treatment at a mental health facility are determined by the client employers and health plans who underwrite policies rather than by MBHOs like HealthCo. A is no


65 lower demand for expensive hospital services by encouraging patients to comply with less expensive ou tpatient treatments. In the life cycle of an ICM case, the first issue addressed by case services and clinical data entered by UR care managers into the company system, the ICM department generates names of patients who meet benchmarks department head Diane Roberts, summarized which patients are eligible: to address, like an eating disorder members enter the program when their medical case managers nurses who work at the general health plan helping members with medical conditions such as diabetes, HIV, cancer, heart disease etc. ask HealthCo to provid e mental health case management. The members identified this way are already taking part in telephonic case management with their medical insurance company. Thus, they tend not to require much effort to contact, at least initially.




67 Miscellaneous Duties: Crisis Calls who press an option on the automate d phone menu for someone who is regimented one. One would expect crisis calls to be emotionally taxing because of the possible encounter with a seriously distressed or sui cidal person. However, as the case managers explained to me, this is often a secondary concern for them When the phone lights up indicating a crisis call, it can be worrying for the clinician because HealthCo is contractually required to answer the calls of anyone selecting the crisis prompt within two rings. Failure to do this triggers a financial penalty, which HealthCo owes to its organizational customer.


68 If, for example, a case manager picks up a crisis call in three rings and achieves a beneficial outcome for the safety of a member, the company still pays a penalty i dentifying their needs as urgent, occasionally these calls come from people (members or provider office staff) with no discernible crisis. I point this out because, as case manager Colleen Lee explained, crisis calls also represent to case managers an inte rruption. They may be in the middle of doing something on the computer or on another phone call with a member: We have to pick it up in two rings. Otherwise we get dinged. And that is m need to pick up after the first ring, because if it is the second ring, they know you dropped have time to get your pen It is stressful, I have to is that feeling. You have to take it. It could be resolved in five minutes, or I might be on the line for a half hour if I need to get an ambulance out there depending o n the acuity of the situation, a nd then you still have your work load to do. We do a lo t of mul titasking, and for taking crisis calls, there is a certain template you need to fill out and [administrative] follow up you have to do. (Colleen Lee, case manager, nine years at HealthCo) ICM Work Challenges Clinicians doing case management at He althCo have to de al with


69 significant administrative and bureaucratic work requirements. T he department manager and the two supervisors I interviewed seem ed to be aware of this and they expressed sympath y for the challenges faced by case managers in completing the a dministrative side of their jobs T he case managers corroborated to varying degrees that their su pervisors and (importantly) their manager have communicated that one can do a good job helping members and supporting the goals of the departme nt while falling short in more regimented parts of the job. Examples of regimentation are documenting all contacts and member information in the computer system and remembering to recite formal disclaimers on phone calls: The big thing right now is to prov ide the disclaimer. People forget to do that. I have to direct them to do that. They are freaking clinicians. They are supervisor of ICM, eight years at HealthCo) issue. (Diane Roberts, manager of ICM, 14 years at HealthCo)


70 12 [To get the bonus] you have to be very meticulous in some of the things monitor your calls. And then they look at your documentations and those 12 OCD stands for obsessive compulsive disorder.


71 productivity measures. (Claire Slater, ICM care manager, 12 years at HealthCo)


72 and the people in [the main office] would proba bly die have really, really high case loads. And I ll. I did an initial call today, and we were on the phone an hour. But then I have some are not chatters. But when I have people going through something really hard, like I had one of my members call me for additional support. She just was really struggling yesterday. She called and we talked probably for an hour and a half. And the way I ga u ge it, if I meet all my contact standards, and contacts. (Anna Wilson, ICM care manager, 18 months at HealthCo)






75 Conclusion


76 T he organizational and symbolic context s in which my research participants perform their jobs are complicated, highly specialized and shaped by complex ideological influences Yet as this latter section describing intensive case management department underscores, they share common experi ence s in a conceptually bounded workplace and are subject to the same rules and sta ndards of work. This chapter attempts to provide a basis for an understanding of the sociocultural structures of the workplace of HealthCo care managers I t enables one to begin to probe questions about of how the company values, work practices, and structured work experiences are related to the emotions that care managers express and experience in their jobs.


77 Chapter Four: Managing Feelings in th e Cultural Contexts of Corporate Managed Care This chapter presents empirical findings and anthropological analysis regarding organizationally influenced emotions among care managers at HealthCo. I begin with a discussion of the work role of utilization review (UR) care managers, and I relate observations about their work as emotional labor. Then I shift focus to my interviews with the workers affiliated with the intensive case man agement (ICM) department. I present rules of feeling and rules of emotional expression associated with the case management work role at HealthCo, and I shed light on how these rules are transmitted in t he workplace. Then I briefly discuss specific patterns of emotion management experienced by case managers. Utilization Review as Emotional Labor T wo of my interviews yielded insights into emotion management among utilization review (UR) care managers, and these discoveries have relevance for understanding how all clinicians at the corporation are socialized into their managed care work roles and identities. As I have mentioned, most employees on the intensive case management team began at the company as UR care managers. 13 Training to perform this highly administrative position was their 13 Of the nine clinicians affiliated with ICM whom I interviewed, only one did not have several years of experience on a He althCo utilization review tea m. Most of the approximately 50 clinicians doing ICM at the time of my research had previously been assigned to UR teams. Though it would seem that r positions from UR, there is not


78 initiation into the corporati on, and for most ICM clinicians, it was also their first job at any managed care company. One of my research participants, Barbara Smith, supervised a utilization review team for seven years before she applied for lateral reassignment to supervise intensive case managemen t. She was a UR care manager for three years prior to that. She shared with me her perspective on the emotional requirements of performing the utilization review role at the corporation. I also interviewed a current UR care manager, Lisa Howe, who has been on the same UR team for six years. She has worked remotely from her home for three years, an option that HealthCo favors giving to employees because it can save the company money. It frees office space and resources, and it is believed to promote retentio n of experienced employees. However, at home workers are required to maintain an above average standard of performance. That Lisa has continued to be allowed to work from home for several years reflects her success productivity in this work role. These two interviews inform my observations about the organizational patterning of emotions in managed behavioral health telephonic utilization review. a salary grade difference betwee n an ICM and a UR care manager. I was told that ICM care managers are sometimes when there is a staffing need, such as during periods when the volume of inpatient requests are high or when UR clinicians are ill, on me dical leave, or on vacation


79 14 14 to facility an approval over the phone for treatment days, sends a case to a HealthCo psychiatrist to to o the fact that the HealthCo/managed care psychiatrist at the facility/program.


80 15 15 T he technical exceptions are psychiatric nurses who are care managers, b ut as mentioned in Chapter Two nurses represent a s mall minority of HealthCo care managers












86 16 16 In their study of the emotional socializati on encounter the human body, medical students experience a variety of uncomfortable feelings including embar rassment, disgust, and arousal. Medical school, however, offers a barrier against these feelings by studen ts, the entire socialization experience of medical school as well as the physiological tiredness that their grueling study and work routines can cause tends to dull their emotional responses to patients (1989).




88 My research suggests that HealthCo and its management set standards for employees about how they should feel and express emotion while performing their jobs. One concern of anthropologists and other social scientists who study corporations is how such standards are transmitted to employees (Trice 1992; Meanwell et al 2008). From my interviews with mental health clinicians affiliated with the intensive cas e management department, I have distinguished several company expectations about how these workers should feel and display emotions in common job situations. My data points to formal and informal ways that these rules of feeling and rules of expression are communicated and reinforced in this workplace.


89 The hiring process for intensive case managers represents and reifies company display and feeling rules. The supervisors and the department manager told me they screen candidates and make the hiring decisions ICM Supervisor Barbara Smith said the assessment of a job candidate begins as soon as he or some of it is just by how they answer the phone when you call them to make an appointment friendly phone voice and come Bo th supervisors said they look for clinicians who display an ability to stay prospective hires how they would handle a call with very agitated member: I look for someone whose [ interview] responses show they are going to to stay on the phone and not be intimidated by a member who is having some to engage a member.


90 The department manager, Diane Roberts, noted other hiring preferences that, while superfic ially unrelated to emotional expression, reflect workplace rules of feeling. Applicants are implicitly informed during their interviews that the job requires affective neutrality to a degree greater than that required for the role of psychotherapist. Diane normative belief that therapists must be empathy directed and fundamentally interested in people and their problems implicitly influences the selection, Light 1980) The psychotherapist needs to cultivate a therapeutic relationship with clients. However, the case manager role at HealthCo is defined by the company as advocacy.


91 While Diane is a licensed clinical social worker, she makes clear that she is not just expressing a predilection for her own educational background. Social Part of tra ining in social work is learning how to link clients to agencies or Stevens 1997). I would argue that the managerial preference for clinical social workers over psychotherapists par tly reflects the fact that HealthCo wants its case managers to maintain limits on interpersonal aspects of their interaction with members. While members are always owed supportive and moderately friendly expressions from case managers, the members are not owed a therapeutic relationship with the case manager. The logic employed is that the member has ls with members that will keep them out of hospital and to coordinate outpatient treatment providers (therapists, psychiatrists, and medical/non mental health providers) on behalf of members. In my research I uncovered some of the ways that intensive case managers at HealthCo acquire knowledge about which emotions ought to be


92 displayed and which ought to be minimized in certain situations. Incoming case managers learn that controlling emotion on the phone is valued by their employer, and this learning occur s in several contexts. It is taught in coaching given by supervisors. It is also communicated in formal training provided by the with experienced employees on the team, part icularly through their stories and accounts of the job. Supervisors provide semi formal training and coaching, and this disseminates perspectives and narratives about how to interact with members on calls. The calls of all case managers are randomly monit ored for evaluation purposes, but supervisors pay closer attention to the calls of newly hired and then play them back to new case managers as part of one on one training For exampl e, Diane Roberts informed me that supervisors train new case F were some things that we felt the care manager could improve on an d some things that were really inappropriate like getting too friendly or have to have a balance. To be able to engage people, you have to have a friendliness about you. But these are people who have mental health

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93 firm cal m tone). But you have to stay friendly. So those are training issues. In the feeling rules of the job, members are owed polite, supportive, and moderately friendly gestures during phone calls, even when they are rude, angry, or non responsive to case manag ers. While the company requires case managers to conform to this feeling norm, they are also instructed to moderate genuine feelings of caring and empathy for members that may arise. According th members therapists, nurses, and social workers who do the job are asked by the company to control the caring and empathy they feel for and display to patients. Diane Roberts emotions when talking to a member. Any of your personal emotions would not be manager to communicate feelings of frustratio the provider might be equally as frustrated. HealthCo attempts to acculturate workers regarding the feeling and display rules of case management thr

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94 Case manager Anna Wilson, a relative newcomer to manag ed care with only 18 months tenure at HealthCo, described how this training advocates an affectively neutral presentation: The motivational interviewing training was like this. If you get really excited almost like a game, because if they know the reason your calling is to get them to change, then they know your purpose. They know the motive behind everything You are supposed to talk to them in this roundabout way without conveying that you have a desire for them to be different. Anna also revealed how this attempt by the organization to teach particular r own performances in the job: I should not show [members] that I am disappointed or frustrated. I where there is a right or wrong answer. It should be more neutral in terms

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95 of I am just here in general with no opinion. If you say you are happy, main flaw might be that I do show emotion when I talk to [members]. I But I am genuinely thrilled when they make a step toward improved mental health or their we to walk. So really excited. But I was reminded by my supervisor last week we really This illustrates how formal and informal training provided by the company e stablishes situational rules about how case managers should try to feel inwardly a s well as outwardly. Personal versus Corporate Emotions I interviewed nine employees currently working in the intensive case management department, and eight of these s common emotional experiences. Eight of my participants related that they occasionally feel

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96 whe n it seems they cannot help a member particularly one whose needs they have identified but whom they cannot get to answer the phone they have trouble getting through the workday. T wo of the ways that clinicians manage their emotional reactions is to perfor m surface acting and forms of deep acting. Five of the clinicians reported instances of feeling frustrated when providers who they call do not seem to be cooperative or concerned about the needs of patients on their caseloads. Anna Wilson provided an exam ple of how she masks frustration on the phone with a bit of humor and a sugary faade: mes getting [members] connected with providers is hard. The goals of our This can be considered a type of surface acting, for the vocal tone she represented to me was unequivocally sweet and patient. but also with a shortcoming of the system i.e., limited provider resources. When case managers encounter this issue, HealthCo may or may not be implicated as an o bject of their feelings of frustration. HealthCo is, at least for certain insurance plans, responsible for contracting with sufficient numbers of providers to meet

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97 to case mana gers that their job mission is to coordinate outpatient providers for patients in ways that will reduce hospital admissions. To the extent that case managers accept this company definition of success, the company itself could become a target of frustration experienced when they encounter insufficient outpatient provider resources. Surface acting in the presence of others can help to manage feelings that are either considered inappropriate to express on the job or that can interfere mplete his or her work. Superficial pretending can be employed for various emotional labor requirements faced by case managers. In the example suggested by Anna, she performs on her phone call with the worker pset. For my study participants, surface acting is used to facilitate interaction on the phone between themselves and members or providers according to feeling and display rules set primarily by the company and HealthCo management. It is not considered app ropriate at the company for a case manager to direct expressions of unpleasant emotions (e.g., anger, unhappiness, disgust) at providers or members. Sur face acting serves its intended purpose when it helps the case manager create interaction during which p ositive feelings are elicited, thereby helping to manage experienced emotions that may not fit with workplace norms of feeling

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98 Conclusion In one sense the intensive case managers at HealthCo are privileged observers of the mental health system in the United States. They joined HealthCo with experience providing therapy and clinical services to clients with psychiatric and substance abuse needs. My interviewees had previously worked in hospitals, hospices, or community mental health centers where s ervices were offered to socially diverse populations. At HealthCo, they learned insider knowledge about how managed care insurance plans work. In their jobs as case managers, they interact with patients and witness stories of people whom the mental health on these stories are perhaps unique, for they are informed by a rare combination of experience providing services and knowledge of the complex administrative systems that determine coverage fo r care. Their work roles, however, are defined by the managed care corporation that employs them. To perform their jobs they must accept requirements and normative expectations of the organization, and in some cases these influence how clinicians actively shape their feelings about What is anthropologically new in the contemporary United States is that work organizations have come to provide the values and beliefs that denote the emotions that individuals feel. People are motivated by a need to be members of a collective to be part of a group. Work organizations make use of this desire. This has become commonsense in the wider culture, and both workers

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99 and managers expect this. Pop psychology i deas like emotional intelligence have become management buzzwords, and the job of managers is widely represented in management literature as "managing worker emotions" (Guy and Newman 2004; Goleman 1995). When looked at historically, one can see that in Am erican communities, non work related organizations such as churches, lodges, family membership, and even national governments had strong cultural influence on individual emotions, both in terms of setting standards for what was appropriate to express and i these community institutions often do not have the same resources to be able to influence emotions when compared with the financial and structural resources wielded by work organizations (Rafaeli and Worline 2007). This is compounded by the trend that Hochschild observes in The Time Bind: When Work Becomes Home and Home Becomes Wo rk (1997), a book in which she discusses how people have come to find emotional order and gratification at work, and ho me has become more like a job. Hochschild observes the trend of Americans in white collar jobs tending to work longer hours because they want to not because their bosses require it. Now home and personal life are what many workers find more emotionally dif ficult, a fact that may be related to the advent of management strategies geared toward creating an "appreciative" and social workplace for service workers (Hochschild 1997: 51). When considered in light of this, the workplace emotion management of HealthC o clinicians points to interesting directions for future anthropological research. What are the sources of feeling rules in contemporary

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100 corporations and occupational roles? To what degree does the organizational context actually establish them today? To w hat extent are company feeling norms and their associated individual and interpersonal practices of emotion management learned through the wider culture before the worker's entrance into the workplace? Pierre Bourdieu observes that the challenge and prob ability of enculturation (Bourdieu and Passeron [1970] 1990: 43, quoted in Cahill 1999: 43). American conventionalized and normalized for a wide range of socioeconomic classes (see Guy and Newman 2004). F uture eth nographic work on subjects lik e HealthC could explore the complexity of emotional socialization by examining the influence of professional discourses. zation like a mental health hospital or therapy practice are influenced by professional institutions that and political affairs which their body of knowledge and skill addres 1994: 33, quoted in Yanay and Shahar 1998: 348 349). The notion of for it could illuminate specific cultural processes of learning to self regulate feelings. Yanay and

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101 Shahar offer evidence that in professional service organizations, emotion management is influenced by profession bound ideologies as much, if not more, than the feeling rules transmitted in the organizational context. An even more promising concept for anthropologists as the learned emotional associations, attitudes, and management strategies that individuals have before they participate in occupational or organizatio nal socialization. Different jobs require different forms of emotional labor and Certain patterns of thought and behavior are acquired during childhood, and these can advantage i ndividuals for specific jobs through direct influence on patterns of emotional regulation. Perhaps due to her knowledge of the gendered aspects of emotional socialization, Hochschild pointed out back in the late 1970s the relationships between the reproduc tion of occupational and class identities and the cultural learning of emotion management during childhood (Hochschild 1979). Considerable work remains to be done to empirically explore this matter, and there is no better time than the present to revitaliz e it. The changes that have transpired in American society since Hochschild introduced the idea of emotional labor to the public in 1983 underscores the need for new ethnographic perspectives on the nature of emotional socialization and contemporary work i nstitutions.

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