Andrea’s resistance gradually grew stronger over the following year. The staff in turn stopped trying to compromise with her. Preserving a semblance of collaboration with her gave way to direct tactics of control. People regarded her not as a child needing benevolent protection but as a source of dangerous noncompliance in the sense of both refusing her prescribed medication and resisting the agency’s power (see Trostle 1988). Andrea had begun to accuse Ryan of making sexual advances, so the Eastside supervisor shifted the case to Verna Johnson, a considerably younger woman trained in counseling psychology. By then, Andrea insisted on home visits on the sidewalk in front of her building, and Verna described the new status quo to staff meeting:
Verna: I was able to get the pills in her hand. She put them up to her mouth, and I said, ‘Take your pills!’ . . . She started talking. She said she had a private life, she doesn’t want us around, she doesn’t want us in her house. . . . I said, ‘I just want to see you take your pills.’
Supervisor: The reality is, she’s on a commitment. And we have to get in her apartment every month. . . . She never swallowed them?
Verna: No. She just started talking. And you know, once she gets started, you can’t stop her, you can’t talk over her. She put the meds back in my hand, and she walked away.
Supervisor: I think, until we re-detain her, we should do side-by-sides [assign two case managers for home visits]. She can get nasty. Remember doing street visits with her a few years ago? She came this close to getting into Dr. Young’s face.
Verna: Can she get violent?
Ryan: Look at it this way. The more agitation, the sooner they’ll take her back [that is, rehospitalize her and extend her commitment to treatment].
To bring the problem into focus, the team as a whole frames Andrea as certain kind of person. The collective portrait—created through formal diagnosis, updates, warnings, and war stories about her history with the agency—affects how clinicians interpret the moral stakes of work. The images accumulate over the years: a child who needs strong parenting, a violent personality, resistant and concealing. Around this time, I witnessed a sidewalk confrontation with her case manager and then listened to the latter’s interpretation. Andrea stood in front of her apartment with her head tossed back, gripping her purse, scowling at Verna. She again resisted taking her medications, but the tone was almost pleading:
Andrea: I’m not refusing the shot [the injection of antipsychotic medication]. I’m saying that it hurts, that it cramps up my leg and spine. I need to see a doctor about that. . . . I don’t have time to see you, I have lots of other things in my life, I have to see my mother and my family. I won’t see you but Monday and Friday.
Verna: Well, I need to keep coming on Wednesday. . . . [After again pressing the medication cassette into Andrea’s hands]: Are you going to take those meds?
Andrea: No. I’m not refusing the shot, like you said on the phone. I need to see Dr. Young.
Driving away from the scene, Verna interpreted it according to professional norms:
You see how she repeats the same thing. Arguing with her doesn’t work. She just digs her heels in even more. She’s decompensating. I wonder if she’s planning to go to Arkansas, where her mother lives. I’m wondering if she’s planning to leave town. I have to call Nancy Bauer [the county’s legal counsel in charge of commitments]. . . . It’s sad. Before, I could have a conversation with her about her family. I don’t know if I believed what she was saying. But she wasn’t so hyperverbal.
Portraying Andrea in psychiatric idioms of sickness and decline justified the required clinical tasks: documenting the visit, assessubg the symptoms, and planning for the next detention. The looming crisis eliminated any doubts about the legitimacy of the agency’s power. In the following weeks, the refusals became more ingenious. Andrea contacted the Public Defender’s office and tried to rescind her mandated treatment. She telephoned the mayor’s call-in radio show to complain about the agency. The team then told her they had filed for a sheriff’s pickup, but she continued to miss appointments.
As people prepared the legal papers for an emergency detention, one of Andrea’s former case managers wondered about the stalemate. At that time, Neil Hansen had no direct responsibility for the case, so he could afford to question the team’s basic approach:
I don’t know what we’re providing other than continual confrontation. We’re giving nothing but angst for her and ourselves. . . . What is it with Andrea? Why are they so treatment resistant? They manage never to be trained by the ringmaster. Why kill that? I admire that. I’d rather have Andrea screaming in my face than sedated and drooling. We kill the spirit chemically or sociologically. And to do that to another human being is so unethical.
Two years passed, with several more cycles of hospitalization, discharge, “stability,” refusal, “decompensation,” and rehospitalization. Neil eventually inherited the case, and he described to me how it all came to an end.
She wasn’t responding to phone calls from the case manager. She had advocated for only one visit per week back in December, and we gave in, because that was the only way to keep her. . . . The team wanted to wait another day to go to her apartment, but I said we should go right away. I went ther Jim [the secondary case manager]. I went to see if her car was in the garage, and when I saw that it was still there, I knew.
As soon as I opened the door, I could smell it. I had left Jim downstairs, I wanted to protect him from it. I didn’t want Jim to have to deal with it, so I went in myself. This is the fourth or fifth time I have walked in on someone who was dead.
I found her naked, curled on her bed. She just didn’t get to the phone. Her AIC level was 14 [signaling advanced diabetes]; it could have been anything. . . . It was weird to see my own client naked. I remember it clearly. If I were a painter, I could paint the whole scene right now.
So we called 911, and they called the fire department. They took over and called the police, calling it a “code 99.” The police came, and then they called the medical examiner’s office. . . . The hardest part is the oblivion. She has no one to claim her body. Allison [the agency supervisor] called Andrea’s brother two times, but no one answered. She’s been a client for 14 years, and now she just disappears? Where will she be buried? I’ve been looking in the daily paper, and haven’t seen any obituaries. It’s such a disconnect, that we have served her for so long and don’t know what’s happened to the body.
The story of Andrea’s death exemplifies the abandonment of the destitute sick in American society. People with severe psychiatric illness in the public mental health system die on average 25 years earlier than the general population.5 The combination of poor medical care, social isolation, and fragmented services is largely to blame. This group of people has limited social networks, often restricted to mental health professionals. Frontline providers are their only link to the resources still available in an era of shrinking public budgets. But the relationship is contradictory to the core. People with at most a master’s degree try to address the tangled webs of their clients’ medical, psychiatric, and social suffering. Operating at the bottom rungs of a strained system, they cannot conceivably give clients what they need. Yet they must impose services that clients explicitly do not want (cf. Bourdieu 1999: 190). Their spontaneous ethical comments bear witness to the core constraints of the job.
APPROACHES TO FIELDWORK
As they talk about Andrea’s difficult life and lonely death, these clinicians demonstrate how everyday ethics becomes visible to ethnographic research. First of all, the comments emerge in the midst of work, and they address immediate problems. People take up issues of coercion, paternalism and privacy—all classic themes in formal medical ethics—but from a position deep inside the treatment apparatus. The speakers do not stand back from the given situation or evaluate it according to a shared impersonal standard. They lean into the situation and search for a way through it. What they say reveals not moral judgment in a pure form, but instead braided with other habits of thought, feeling and plans for action (see