Chapter Two portrays the way Eastside staff members learn how to carry out the ACT mission: not so much from textbooks and formal training, but by watching their peers, improvising, and listening to offhand instructions. This chapter examines the texture of everyday work, including face-to-face transactions in clients’ apartments and rooming houses, debates in staff meetings, telephone calls from probation officers and landlords, and so on. Case managers slowly become socialized into the main ideologies of the treatment apparatus: the absolute necessity of psychopharmaceutics and the clients’ baseline need for residential and social stability. They learn to frame their work as good in the sense of technically competent as well as conforming to ideals of beneficence and care. But clinicians have a hard time staying moralized in this setting. The definitional chronicity of severe mental illness undercuts the perceived worth of their efforts. The mandate to act as gatekeeper of resources competes with their self-image as clients’ advocate and therapist. The friction between the dominant ethos of the workplace and the details of daily action can grow so great that people sometimes fall into a feeling of futility and simply leave the agency. Others are pushed to craft their own warrants for action and to develop their own ethical voice.
The next three chapters focus on the bundle of tools that clinicians use in order to bring clients into focus, intervene in their lives, and push them toward normative stability. Frontline providers are engaged in a kind of craft work. They rely on specific techniques and instruments to define the short-term goals and then to achieve them. This section of the book documents the heterogeneous assemblage and shows how it sets the pace of work and defines clinicians’ obligations. The tools of the trade involve not only medications (examined in Chapter Two) but also paperwork forms that enable various types of coordinated action. Clinicians must fill out the paperwork to accomplish the basic tasks of care. To figure out the schedule of home visits, for example, they must write a treatment plan. To keep clients housed and fed, they control their money via a particular bureaucratic instrument, the “representative payeeship.” When people’s symptoms worsen and their problems overwhelm the agency’s resources, the staff tries to have clients legally committed to the local psychiatric hospital.
Chapter Four takes up treatment plans, a paperwork technology that endows daily work with an orderly, almost transparent rationale. In the textbook ideal of treatment planning, clients’ diagnoses, life problems, goals, and recommended services should line up in a single logical chain, each link justifying the next. The very act of writing the plan demands a story of progress. But clinicians are often stymied when they try to insert a chaotic life into an organized story line. Vignettes from staff room discussion show the false starts and dead ends that plague the process of treatment planning. They show the thin margin of survival faced by many clients—their inadequate housing, isolation, and predation by gangs—and the limits of the ACT model in improving people’s lives. Clients’ resistance, moreover, can force clinicians to doubt the legitimacy of their own power. During the work of treatment planning, staff members animate the workplace ethos and the logics of care laid out in Chapter Two. Case studies trace the effort of individual clinicians to develop their own ethical voice. The cases also suggest why that voice is soft, fugitive, and often drowned out by the contingencies of practice.
Chapter Five documents the representative payeeship system and its contradictions. When Eastside Services becomes the “rep payee,” it receives all the client’s public welfare monies, and clinicians use this money as leverage to change people’s behavior. This arrangement is justified by a deep logic of dependency: the notion that clients objectively lack the capacity to act on their own behalf and therefore require another person to protect their own interest. Their social dependency, in other words, is demanded by their biological status. Clients enormously resent this system of de facto coercion. As clinicians try to manage the dependency, they inevitably stumble toward questions of value. Who deserves to control their own money, and who deserves to have control taken away? The micropolitics of the system push clinicians to theorize about the subjectivity of clients and the proper limits of their own power. When the issue explodes in staff room debates, clinicians are forced before their peers to articulate their own ethical calculus and simultaneously try to solve clients’ crises. Case studies in this chapter show the real-time emergence of everyday ethics as both a guide to action and a strategy to craft an acceptable self-image.
Chapter Five explores commitment orders, the most coercive tool available to clinicians. Commitment orders also have the oldest genealogy (far predating the emergence of the ACT model), and this chapter explores how historical debates about the power to treat people against their will color the ethical deliberations of today’s ordinary clinician. Do previous high-profile controversies about patient autonomy and professional obligation get repeated at the scene of work? If not, what other terms do clinicians use to justify or criticize their own authority? The chapter first reviews the history of commitment in American psychiatry, culminating in currently popular schemes for mandated treatment in the community (so-called “outpatient commitment”). It then shows how Eastside workers deploy the assemblage of commitment (the laws, procedures, and paperwork) with specific clients. Finally, it examines the paradox of consent that lies at the heart of their tactics of control and also elicits their strongest ethical misgivings. Extensive excerpts from the actual consent documents show the stakes of daily work as they appear to clinicians. The chapter searches for the different facets of everyday ethics that run from moral heroism to disgust when work routines undercut their preferred self-image. Similar to the other accounts of “tools of the trade,” this chapter pinpoints the conditions that encourage or stifle clinicians’ ethical voice.
Chapter Six gauges the distance between the sensibility of ordinary clinicians and formal ethics statements about Assertive Community Treatment. This chapter reviews four topics of great interest in the relevant bioethics literature: (a) the strong critique of ACT as inherently coercive, (b) strategies to balance the principles of patient autonomy and professional beneficence, (c) Ulysses contracts—a novel approach that lets patients consent in advance to nonconsensual treatment, and (d) confidentiality. Each topic raises the question, How would Eastside workers react to the bioethics literature, and what position would they take up in these debates? The answers in this chapter are frankly speculative, but they are based on the contingencies of daily work and the situated knowledge of the worker. First, the ideology of biopsychiatry builds a wall around the logic of practice, and it makes the strong critique of coercion unthinkable for most ordinary case managers. Second, the mainstream tactic of balancing principles captures the flavor of staff room debates, but such guidelines can never remove all ethical ambiguity. Third, Ulysses contracts would likely have great appeal at Eastside Services because they ratify the model clients’ selfhood already held by frontline staff. In the case of confidentiality, by contrast, the paperwork actually undercuts the clinicians’ ethical sensibility, and this final case is illustrated by several vignettes.
The book ends with a reminder for all readers. Community psychiatry is a neglected corner of the U.S. health care system, but the struggles of frontline clinicians at places like Eastside Services implicate all of us. Their everyday ethics pose the overarching question, How should we bear responsibility for the most vulnerable among us? The book conveys the feelings and actions of just a handful of people. Nevertheless, the American body politic as a whole has forced them into a near impossible position. They struggle with some of the most marginalized people in our society, but with pathetically insufficient resources. The core tools for work contain, sedimented within them, highly controversial assumptions about pharmaceutics, proper relations of dependency, and the legitimacy of coercion. Young case managers start to use the tools innocently enough but are soon caught up in pitched battles between their own tenuous authority and the resentment of their clients. Even worse, they face such problems essentially on their own. Their labors are hidden in small storefront agencies with no connection to medical schools and no access to the expertise of academic psychiatry and bioethics. They work in neighborhoods long abandoned by deindustrialization and the retrenchment of public services. If they shoulder a crushing ethical burden, it is because we have placed it there. Their expressions of bewilderment and despair should come as no surprise.
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