A more sophisticated reading of expertise will illuminate the exact relationship between psychiatrists and case managers as well as the trouble it causes for the latter group. From an anthropological perspective, expertise is something that people do, rather than something they possess (Carr 2010). It is an enactment—a performative claim made in the midst of social life—not a cache of individual knowledge. Through verbal and nonverbal communication, people project an authoritative framing of cultural objects and try to convince others to follow their lead. Success, however, depends not only upon their individual charisma or fluent command of dominant codes; it also depends upon institutional supports: the roles people occupy and their accompanying status. In the context of Eastside Services, the psychiatrist is supported by the ideology woven into the program template and the more general hierarchy of multidisciplinary health care. Indeed, the following chapters illustrate how this psychiatrist inhabits his prescribed role and verbally enacts his expertise during staff meetings. In many cases, the case managers accept (or are forced to accept) that they are less aware, less knowing, and less knowledgeable than the psychiatrist (see Carr 2010: 22).14
Case managers obviously do not control the most highly valued knowledge within ACT—that is, biopsychiatry. They also cannot deliver the verbal performance often demanded by psychiatrists. In a private interview, one psychiatrist who devoted his career to ACT expressed his continual frustration with case managers. During a busy staff meeting, he will ask for particular details about clients’ symptoms. He wants a quick reply, summarizing the information most relevant for medication management—just the sort of reply that medical students and residents are trained to provide. But the case managers instead respond with long rambling stories about the person’s social problems and minute details about her appearance and preoccupations. The psychiatrist must take a deep breath and patiently extract the two or three facts that he actually needs. Case managers simply do not have the training, institutional support, or performative skills to qualify as experts on ACT teams.
The team functions smoothly so long as all parties conform to a few rules of engagement. The case managers are expected to accept the psychiatrist’s rendering of clients’ conditions and needs. When asked, they should offer their rich knowledge of clients’ living conditions, habitus, and immediate social environment, so the psychiatrist knows what to expect in that day’s appointments or how to deal with an emerging crisis. In the ACT model, the highest-ranking professional routinely depends on lower-ranking staff. That very dependence, however, gives case managers an opening to present authoritative readings of clients’ inner mental states. After all, the two types of clinicians have different ways of knowing and different kinds of knowledge. Case managers, therefore, have traction to push back against the psychiatrist’s interpretation and recommended actions. The low-ranking staff can advance alternative interpretations of clients’ inner states, their potential for recovery, and the sources of their suffering. The conflict of interpretation between case manager and psychiatrist often drives staff room debates and can sow deep divisions in the team.
To some extent, such conflicts reflect the differences between situated and disciplinary knowledge (see Floersch 2002). Case managers develop their knowledge through the infinite improvisations demanded by ordinary work: the slow accumulation of practical experience with particular clients, as well as the core ACT tools (the treatment plans, schemes for money management, and paperwork for commitment examined in the rest of this book). Such knowledge is parallel but marginal to the official knowledge of professional psychiatry (or professional social work, for that matter). The psychiatrist, by contrast, sees clients primarily in her office and usually for medication management. The conditions of her work better fit her disciplinary training, compared to the situation faced by case managers. But the categories of situated versus disciplinary knowledge eventually break down. Psychiatrists too must cultivate something beyond formally coherent textbook knowledge, to do the job well. Their connoisseurship of pharmaceutics is intuitive and based on decades of experience At Eastside Services, to choose another example, the psychiatrist must have an intuitive grasp of the agency’s positions within the local ecology of mental health services. Only then can she judge when a commitment order will likely succeed or fail and which addiction treatment center will accept a particular client.
The conflict of interpretations between psychiatrist and case manager reflects fundamentally the difference between expertise and craft (see Rice 2010). People learn the skills of case management almost at an unconscious level and in specific circumstances. Such learning does not depend on an explicit articulation of categories, basic principles, or algorithms. People instead learn through trial and error as well as guidance about particular cases from more seasoned colleagues. Day by day, they learn how to attach salience to the details of clients’ apartments, appearance, and expressions. At Eastside Services, the craft-like quality of their skills becomes clear in the way they work through crises, such as treatment refusal, worsening symptoms, and the disruptions caused by eviction or arrest. Case managers rarely compare a given case to a previous crisis or try to fit the manifold details into a more abstract conceptual scheme (such as a checklist of risk factors for suicide, or the precise line between persuasion and coercion). To figure out how to handle a crisis, people simply expand the range of relevant details. Their conversation circles more and more widely, taking in more of the person’s life-world and social connections, until a provisional solution somehow appears.
The craft of case management involves assembling and reassembling components of their clients’ lives. Case managers start anew with each new crisis; although guided by intuition and experience, they never articulate such guidance in its own terms. They cannot separate the body of knowledge authorizing their interpretation from the details of the case at hand. Their knowledge is actually better termed “know-how,” and it exceeds any professional jargon or classificatory system. (In any case, most Eastside case managers actually have very little course work in severe mental illness from their social work or counseling training.) People’s skill in the craft of case management depends on the tools that they use. Their clinical disposition gets animated only when engaged in the details of work.
Because of their craft-like approach, case managers have a different angle of vision compared to the psychiatrist. The differences often push them to contest the psychiatrist’s interpretation of clients’ problems, but they enter this contest with several disadvantages. Of course, they lack the signs and habits of expertise, as authorized within the ACT model. In some ways, moreover, the psychiatrist cannot even fully take in all that the case managers know. Their ways of making and transmitting knowledge are simply too different (see Marchand 2010a). The result is typically miscomprehension and bewilderment—a breakdown in teamwork that the psychiatrist often resolves simply by fiat. Discord, instead of dialogue, usually marks staff room debates. The division of labor on ACT teams, so clear and complementary in the program manuals, becomes a permanent fault line on the landscape of practice. Anthropologists may wish to compare craft to expertise, or situated to disciplinary learning, as simply different types of knowledge. ACT case managers, however, experience the difference as a continual contest over how to represent and respond to clients’ needs.
FAULT LINES IN THE GROUNDWORK OF PRACTICE
The genealogy of an institution exposes its development through successive historical regimes, but without searching for underlying laws, hidden meanings, or progress along the way. From this angle, a social institution is an assemblage of different components that came together over time. They do not fit together seamlessly, and lining them up chronologically may not reveal a grand unfolding scheme. An institution—even a single workplace—carries the imprint of history, conceived as a series of moments and discrete practices that somehow left their mark on generations to come (see