2. The structural conditions of work among frontline providers in contemporary public sector psychiatry are analyzed by Rhodes (1991) for emergency rooms and Brown (1989) for community mental health agencies. Current figures for length of stay come from the U.S. Department of Health and Human Services (2008). Robins (2001) and Kirschner and Lachicotte (2001) document the impact of corporate metrics upon the self-conceptions of frontline psychotherapists and counselors.
3. David Oaks, executive director of MindFreedom International (a human rights advocacy organization for people with experience of psychiatric hospitalization) opposes the use of the words illness, diagnosis, and symptoms. From his standpoint, such terms impose a biological reductionist account of complex human realities because they implicitly endorse a narrow range of medical responses such as medication and electroconvulsive therapy (Oaks 2012). In this book, I continue to use these words for the following reasons. The words illness and ill have complex meanings in English, many of them connected to the experience of suffering. The Oxford English Dictionary entry on ill includes “causing pain, discomfort, or inconvenience: offensive, painful, disagreeable, objectionable; difficult, troublesome and hard.” I wish to bring these meanings under the ambit of the word illness. The word also recalls the early achievement of medical anthropology (e.g., Kleinman, Eisenberg, and Good 1978) in contrasting doctors’ reductionist perspective (“disease”) to patient’s embodied experience, articulated in their own idiom (“illness”). The terms diagnosis and symptoms are indeed deeply nested in the medical model of psychiatry. Precisely for this reason, the words cannot be avoided in an ethnography of psychiatric workers. Anthropologists must nevertheless heed Oaks’s warning and not allow the words themselves to legitimate professional dogma.
4. Eastside Services (a pseudonym) is staffed by two supervisors, eight case managers, a part-time nurse and a part-time psychiatrist. The names and identifying details of all clinicians and clients have been altered. As an ethnographer, I attended 120 staff meetings and accompanied six case managers, for approximately four months each, on their daily visits to clients’ homes and meetings with psychiatrists, lawyers, and family members. I observed 20 sessions of counseling and medication management between the psychiatrist and clients. Other sources of data include 30 semi-structured interviews: 20 with case managers, 5 with the program director, and 5 with the psychiatrist. In this book, all quoted speech from staff room debates and clinician–client interactions is taken from field notes handwritten at the time. This speech is indicated by specially indented paragraphs. Private interviews were recorded digitally and later transcribed; data from these interviews are indicated by double quotes. Background information about the local mental health system was obtained at training sessions for new case managers presented by the state Department of Mental Health, as well as four regional continued education seminars for social workers about ethics and boundaries. On-site and summary daily notes were taken after each period of ethnographic observation. Transcribed interviews and field notes were coded with NVivo 2.0 software for qualitative data analysis. Further information about Assertive Community Treatment and its place within contemporary mental health services was obtained by attendance at relevant professional meetings at the regional and national level, in both the United States and Canada. Research was approved by the Institutional Review Board of the University of Wisconsin–Milwaukee and funded by a grant from the Cultural Anthropology Program of the National Science Foundation, “Everyday Morality in American Mental Health Care: A Comparative Ethnography” (BCS-0522263).
5. The excess mortality of Americans with serious mental illness who receive services in the public sector was detected by Lutterman et al. (2003) and reintroduced into contemporary debates on health care reform by Druss and Bornemann (2010).
6. Exemplary studies of the impact of structural constraints, professional competition, and collective interests upon the ethical commentaries that circulate in U.S. health care settings include Anspach and Beeason (2001), Bosk (2003 [1979]) and 1992), and Chambliss (1996)
7. Key statements of the anthropological and sociological critique of US bioethics can be found in Fox and Swazey (2008), Kleinman (1995), Kleinman et al. (1999) Marshall (1992, 2001), Muller (1994), DeVries and Subedi (1998), and Hoffmaster 2001.
8. See Cohen (1999), Lock (2002), Scheper-Hughes (2000), Rapp (1999), and Kaufman (2005), among many others.
9. Clinicians are also frequently the authors of important bioethics texts. But their bioethics writings strive to rise above and comment upon the details of everyday clinical work “from the perspective of philosophy” (Tauber 1999) or “general rationality” (Engelhardt 1986).
PART ONE
Background to Practice
CHAPTER 1
Genealogy of the Treatment Model
Everyday ethics emerges, by definition, against the background of ordinary practice. On a typical day, Eastside Services staff members make innumerable decisions about the right course of action for their clients. To do so, they must pose and then work through several questions. What does my client need, given what I know about his personality, his strengths and vulnerabilities, and the way he lives with his symptoms? Can I cobble together the resources to answer his need? Is there a standard, routine way to handle this sort of case, and can I conceivably follow it with the person standing in front of me? But then they face the hard surfaces of the job: scarce resources, dilapidated housing, opaque bureaucracies, rigid agency policies, and indifference or disdain from other public service workers (police, probation officers, hospital staff, and welfare officials). These obstacles prevent the case manager from carrying out her preferred course of action. Everyday ethics is the label for commentaries that emerge at this stage about right and wrong, the obligatory and the forbidden, and the legitimacy of professional power. Frontline clinicians enter this collision zone between the desirable and the possible when they discover that their knowledge and training are not enough to carry out the right decision, given the background structures of their job.
Staff members do not know, because they do not need to know, that all these structures have a history. Clinician and client do not stand face-to-face on a featureless plain, as generic healer to sufferer. A particular institutional history has produced the way they come to meet, the balance of power between them, and the social worlds they jointly negotiate. As a result, when blockages in work provoke clinicians to talk about right and wrong, they do not speak as generic ethical agents. They speak instead from their partial perspective, traversing the permanent, if buried, features of this particular landscape of practice. In the end, everyday ethics is historically produced, but in ways largely invisible to clinicians themselves. To understand today’s dilemmas requires tracing the tangled past of this mode of treatment. The shape of action for frontline providers is a layered domain where the outcome of prior policies and ideologies is woven in today’s ordinary work routines (cf. Rhodes 1993). The relevant past includes the deinstitutionalization of psychiatric patients starting in the mid-twentieth century, the tragedies left in the wake of this broad social movement, the new models of community-based services that arose as a response, and the diffusion of these models across American mental health services. Each strand in this genealogy informs the everyday ethics that emerge at the clinical frontline.
DEINSTITUTIONALIZATION: ORIGINS AND AFTERMATH
Deinstitutionalization in the United States occurred at the confluence of several distinct trends.1 During the late nineteenth century, the number of patients at state mental hospitals gradually rose due to urbanization and immigration. The rising censuses pushed such institutions away from their founders’ optimism and the humanistic goal of “moral treatment.” By the first few decades of the twentieth century, most state hospital patients were confined for years, if not their entire lives, and received little more than custodial