Finally, the difficulties of research and writing have been tempered by a small local network—a source of challenge, support, and inspiration. The patience and persistent inquiries of Tom Reed, Richard Frank, and the pseudonymous “Neil Hansen” have all found their way into this book. Most importantly, my deepest thanks to Huong DangVu, whose life work illuminates the contours of care and its human core.
INTRODUCTION
The Terrain of Everyday Ethics
This book is an ethnographic study of ethical decision making in community psychiatry. In developed societies worldwide, the majority of people with severe psychiatric symptoms spend most of their lives outside hospital walls. But in the United States, people who are poor, alienated from their families, and dependent on public services face enormous obstacles to decent outpatient care. They rely on a fragmented collection of emergency rooms, crisis centers, and case management programs. The pace of work in these settings is rushed, the resources inadequate, and the possibility of failure ever present. I spent two years alongside frontline mental health staff engaged in a near impossible task: to safeguard their clients’ lives so they will not return to the hospital, the shelter, the street, or the jail. The dilemmas of everyday work and how clinicians struggle through them are the book’s chief topic.
Their dilemmas testify to the massive social abandonment of the destitute sick in the United States. Chronic illness combined with extreme poverty often pushes people to the hidden spaces of the formal medical and welfare systems. The declining core of older North American cities is a magnet for people dependent on public services, including the chronically mentally ill. Such neighborhoods resemble an asylum without walls—the tragic and unintended outcome of deinstitutionalization—where medical personnel and social workers practice their trades. The neighborhoods concentrate people who are alienated from dominant norms of productivity and self-control. Inevitably, some of them spend time in shelters, where the impermanence and grinding uncertainty magnify their despair. They cycle through prisons and emerge with stigmatizing legal records that make housing and employment even harder to find. Some become homeless and drift to the marginal zones of the city, sites of violence and social extrusion.1
Yet the abandonment of the destitute sick is never absolute. Wherever they live, they will eventually meet face-to-face with a certain class of clinician. Members of this class are professional but on the lower rungs of the medical hierarchy, under-trained for the suffering that they face daily, and inserted into narrow roles within bureaucratic schemes of service delivery. This book asks what happens at the literal interface between frontline clinicians and individuals with severe psychiatric symptoms and profound social disenfranchisement.
The chapters look at the encounter from the clinicians’ side. The choice to examine their angle of vision fits some special conditions of the ethnography of contemporary “human services.” The bland opacity of that phrase hides the contradictions that envelop professional and client alike. What exactly does it mean to provide services for people living with severe mental illness? To tell people to swallow their medications, to count the number of beer cans in their trash, to hand over five dollars in spending money, to hospitalize people against their will: such services involve so much more than the dictionary definition of useful labor. These gestures of work bring into play fundamental issues of coercion and resistance, authority and responsibility, and the need to push back against objectively hard circumstances. Because the immediate stakes are so high, the different actors in this field face off with incommensurable definitions of normality, pathology, and the obligation to care. Clinicians, clients, reformers, and critics all follow different agendas, and they have vastly unequal power to shape the very terms of debate. In this fractured and contested realm, any ethnographic account is inevitably situated and delivers only partial knowledge. For obvious methodological reasons, the researcher can gain the trust and (relative) acceptance of only one group of people at a time.
Listening closely to frontline practitioners clarifies another key aspect of U.S. community psychiatry. Today’s landscape of practice bears the marks of a long history of reform as well as the invention and diffusion of new models for outpatient treatment. The models typically come with precise blueprints; they are “manualized,” in the jargon of contemporary health services. Clinicians are audited by regulators higher up in the public mental health bureaucracy, and they get reimbursed according to complex and ever-changing rules. Frontline staff work under heavy constraints, and a popular textbook for psychiatric case managers bluntly described their plight:
Two of the most oppressed groups in mental health are clients and their case managers. . . . Basically, they are the lowest paid, the lowest on the organizational hierarchy, and the least credentialed, yet have the most cases and the most ambitious goals established for their work. They also have to complete the most paperwork, go to the same meetings as others, and are the most supervised members of the organization. They have the least control over their jobs and have the least influence over organizational or client matters. (Rapp 1998: 55)
Lower-level mental health professionals have little autonomy or control over their jobs, and their complaints expose the fault lines in today’s community psychiatry. Staff at a walk-in clinic, for example, resent having to perform the “dirty work” of gatekeeper for welfare benefits. Despite their revulsion, they cannot escape the scripted role as agents of social control. Mental health technicians in psychiatric emergency rooms chafe under the scrutiny of higher ranked staff. These workers denigrate their own job as “babysitting,” but short-term custodial care is demanded by a system where the average inpatient stay lasts for seven days Counselors and case managers complain when new corporate metrics of efficiency undercut their own ideals for the job. Their sense of moral violation—forced to abandon a caring self-image for the sake of more billable hours—suggests how neoliberalism reshapes the very mission of work. Clinicians’ complaints thus articulate the immediate conditions they face and the structural obstacles to changing them.2
A perverse logic now governs publicly funded services in the United States for people with severe mental illness.3 Clinicians with the least training, lowest pay, and least control over their work inherit responsibility for the most disabled and marginalized individuals. This book examines everyday clinical routines in an agency offering Assertive Community Treatment (ACT), arguably the best-researched and most celebrated model in community psychiatry. Even in this workplace, however, people’s needs far outstrip available resources. Case managers with a four-year college degree have limitless obligation for people with decades of homelessness, debilitating symptoms, and long histories of imprisonment and hospitalization. They enter clients’ homes seven days a week and gain an intimate knowledge of their vulnerability, inner worlds, and tactics of survival. They accompany clients to parole hearings, negotiate with landlords and family members, and often attend their funerals. But they have little expertise in pharmaceutics, the main type of treatment. They cannot solve the housing scarcity, the devastated economy, or the gang violence prevalent where their clients live. Emergency room staff, police, and the courts typically ignore their advice. Their efforts run up against the fragmentation, scarcities, and organizational illogic that characterize post-asylum care as a whole. In the end, the abandonment of clients rebounds onto their case managers, and it creates the distinctive impossibilities of this line of work.
EVERYDAY ETHICS AT THE CLINICAL FRONTLINE
What people say about their jobs reveals the rough edges of today’s community psychiatry. Their ethical comments in particular illuminate some of the deepest and most intractable problems. In the middle of daily routines, frontline staff can veer off into spontaneous commentaries about the rightness or wrongness of their work. Their speculations cover a huge ground. People measure the gulf between their own values and what the job forces them to do. They try to draw a line between