Everyday Ethics
Everyday Ethics
Voices from the Front Line of
Community Psychiatry
Paul Brodwin
UNIVERSITY OF CALIFORNIA PRESS
Berkeley·Los Angeles·London
University of California Press, one of the most distinguished university presses in the United States, enriches lives around the world by advancing scholarship in the humanities, social sciences, and natural sciences. Its activities are supported by the UC Press Foundation and by philanthropic contributions from individuals and institutions. For more information, visit www.ucpress.edu.
University of California Press
Berkeley and Los Angeles, California
University of California Press, Ltd.
London, England
© 2013 by The Regents of the University of California
Library of Congress Cataloging-in-Publication Data
Brodwin, Paul.
Everyday ethics : voices from the front line of community psychiatry / Paul Brodwin.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-520-27478-5—ISBN 978-0-520-27479-2
eISBN 9780520954526
1. Title.
[DNLM: 1. Community Mental Health Services.
2. Community Psychiatry—ethics. WM 30.6]
362.19689-dc232012030149
Manufactured in the United States of America
22 21 20 19 18 17 16 15 14 13
10 9 8 7 6 5 4 3 2 1
In keeping with a commitment to support environmentally responsible and sustainable printing practices, UC Press has printed this book on Rolland Enviro100, a 100% post-consumer fiber paper that is FSC certified, deinked, processed chlorine-free, and manufactured with renewable biogas energy. It is acid-free and EcoLogo certified.
For the clients and staff at “Eastside Services”
The work of treating the chronically mentally ill in the community, often tedious, monotonous, apparently endless, and emotionally draining, represents a heavy load for any individual to manage alone.
—Mary Ann Test, Continuity of Care in Community Treatment (1979)
What matters is to give each person back the confidence that people can have in themselves, that they can lose in any social milieu, by some accident, by some event happening in your life. . . . Because I think that what is happening is people's heads is . . . they've come to the end . . . they're at the end . . . of nothing. You have to find a way out.
—Social worker quoted in Pierre Bourdieu et al., The Weight of the World: Social Suffering in Contemporary Society (1992)
Contents
Acknowledgments
Introduction: The Terrain of Everyday Ethics
PART ONE: BACKGROUND TO PRACTICE
1.Genealogy of the Treatment Model
2.Expert Knowledge and Encounters with Futility
PART TWO: TOOLS OF THE TRADE
3.Treatment Plans
Mandatory Narratives of Progress
4.Representative Payeeships
The Deep Logic of Dependency
5.Commitment Orders
The Practice of Consent and Constraint
PART THREE: FROM EVERYDAY TO FORMAL ETHICS
6.Coercion, Confidentiality, and the Moral Contours of Work
Bibliography
Index
Acknowledgments
This book is a collective project, and it would not exist without the longstanding generosity of colleagues and the support of friends. I owe my deepest debt to the staff and clients of the pseudonymous “Eastside Services.” Staff members allowed me to enter their tightly knit work group and share their frustrations and (rare) triumphs. They created a role for me—as friend, witness, and interested outsider—as they struggled to care for some of the most disenfranchised people in the United States. At the same time, individuals living with severe and disabling symptoms graciously accepted my intrusion into their lives. Their personal resilience and strategies for survival pushed me to rethink my personal and professional commitments. While writing this book, I have been honored to work alongside mental health advocates who self-identify as consumers, clinicians, activists, or all three. Their devotion to systemic reform is infectious, and I hope this book contributes to the changes that we all urgently need. In a book about the ethics of mental health care, I must scrupulously avoid identifying people even remotely connected to my research site. I thank them all, and I ask their forgiveness for any errors of fact or interpretation.
Long before beginning fieldwork, I benefitted from the guidance of many individuals. Robert (Skip) Nelson extended a warm mid-career welcome into bioethics. Carl Elliott, Tod Chambers, Ray DeVries, and Laurie Zoloth provided models of engagement and disciplinary self-awareness that helped me hone the fundamental questions about everyday ethics. Reaching further back, I owe my passion for this book to Arthur Kleinman, Byron Good, and Mary-Jo DelVecchio Good, the founders of the medical anthropology program at Harvard. Their mentorship and support over the years have been crucial to my professional growth. Steve Piker, now retired from Swarthmore College, laid the foundation for my career and provided my first model of humane anthropological scholarship.
Since completing fieldwork, my thinking has benefitted from a moveable conversation about anthropology, psychiatry, and social work. At the University of Chicago, Judy Farquhar and Summerson Carr have provided invaluable support, and they graciously invited me several times to present my work to their students. At the University of Paris, Livia Velpry and Anne Lovell shared their insights into the vexed worlds of consent, constraint, and community psychiatry, and I greatly appreciate their spirit of collaboration. Closer to home, my colleagues Kalman Applbaum and Michael Oldani invited me to join their research project on pharmaceutical compliance, and their ideas improved my analysis of this topic. Janelle Taylor, Erica Bornstein, and Richard Grinker offered useful suggestions and encouragement at various times during the long writing process. Sharon Kaufman's ideas and professional support also leave important traces on my own thinking.
The University of Wisconsin-Milwaukee provided a congenial atmosphere for research and writing, and I would like to thank all my colleagues in the Department of Anthropology. Department Chairs Robert Jeske, Patrick Gray, and Thomas Malaby, along with Deans Richard Meadows and Rodney Swain, helped create opportunities for serious intellectual work, and I am in their debt. The support of the university's Center for 21st Century Studies was crucial early in this project. At the Medical College of Wisconsin, the opportunities for dialogue among humanities, social sciences, and medical practice have improved this book, and I am grateful for the friendship and administrative skills of Art Derse, David Seal (now at Tulane), and Julia Uihlein.
I thank Reed Malcolm and Stacy Eisenstark at the University of California Press for seeing promise in my manuscript and expertly shepherding the book to completion. Thanks also to Rebecca Lester and an anonymous peer reviewer who helped me clarify my main argument and make the book more accessible. I also thank the National Science Foundation, which funded my research (BCS-0522263). Cherie Sixbey, director of the Assertive Community Treatment Association, invited me to address numerous audiences