Everyday Ethics. Paul Brodwin

emergency room, homeless shelter, rooming house, meal site, the county jail, and the office of probation and parole. The more limited goal is to pose some basic questions about everyday ethics. What long-term structural contradictions underlie the problems that clinicians face in their routine work? Are the tools provided by the ACT model actually sufficient for the job? And when they fall short, does their failure provoke ethical reflection?

      The landscape of practice at agencies like Eastside Services derives only partially from the formal blueprint for Assertive Community Treatment. The architects of ACT portray the model as a unified technology, designed to perform as planned in its defined tasks, given proper upkeep and well-trained operators. But as even the program's supporters admit, it is impossible to replicate the Madison model perfectly. With dissemination come infinite variations, driven by state finances, the shape of the regional mental health system (hospitals, foster homes, drug treatment facilities, etc.), the organizational climate of the agency where the ACT team operates, the training of its staff, and the shifting needs of clients (Mowbray 1997a and b, Lewin Group 2000). Most ACT teams do not, in fact, conform precisely to the original blueprint. They have drifted away as they assimilated to the surrounding ecology of services and funding.

      At Eastside Services, the frontline staff practices with a bundle of inherited tools, each with a distinct lineage. Medications and the mechanism for compliance come from biopsyschiatry, and the technique of case management comes from broad developments in American human services since the 1970s (see Chapter Three). The paperwork technologies of assessment forms and treatment plans come from ACT manuals (see Chapter Four). The money to pay for services is cobbled together from federal entitlements and state and municipal programs—an amalgam reflecting 40 years of debate about public responsibility for dependent persons (Chapter Five). The directions for working with clients are inscribed in state law, itself the product of by both ACT advocates and civil libertarians who sharply narrowed commitment criteria (see Chapter Six). Today's ordinary tasks emerged from successive phases in the long development of community psychiatry services. Staff members and managers depend on this mixture of inherited ideas, regulations, and techniques in order to meet the demands of the day. Not surprisingly, people cannot make the ingredients mesh perfectly. The rest of the book follows the conflicts that erupt when the outlooks and routines of psychiatry, social work, law, and the public welfare system bump against each other.

      These conflicts create difficult obstacles for the course of everyday work, and they can undermine its legitimacy even in the eyes of frontline staff. Clinicians get tangled up in several contradictory goals and expectations. The ACT manuals articulate a straightforward clinical goal: to lengthen the remission period of chronic psychiatric disease. The program's genealogy, however, shows why this simple goal is so hard to carry out. As the original CSP ideals got translated into programs on the ground, the case manager became responsible for funneling to clients the entire range of services (treatment, housing, food, counseling, social connections, and daily activities) that were once bundled in a single brick-and-mortar institution. The task, of course, is impossible. No single program can piece together again the full array of supports available in the old state hospitals. Nevertheless, today's case managers inherit the impossible mission of providing everything their clients need in the “community,” ambiguously defined as anywhere but the hospital, jail, or homeless shelter.