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ОглавлениеINTRODUCTION
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 justifiable and excessive control of clients. They debate who actually deserves services and who should be shunted aside in a system with limited resources. They criticize some of the core practices of their workplace as brutal and inhumane. They deliver their comments in many different registers: sometimes as a systematic argument, but often as sarcastic jokes, emotional outbursts, and private confessions. In whatever register, such comments make up the everyday ethics of the clinical team.
Taking a moral stance interrupts the flow of work, if only for a moment, and exposes the background justifications for action. Most of the time, frontline staff are immersed in the demands of the day. They must manage the crisis that just blew up in their face or carefully move a given case to the next step in an intricate dance of paperwork and phone calls. But when their efforts fail, or when success would mean abandoning other ideals, clinicians can start to question the very apparatus for work. A ripple of conscience pushes them to rethink just what the paperwork accomplishes or what warrants their power over clients. Most of the time, it remains just a ripple—not a full-blown critique of the workplace and its foundational values. Everyday ethics is a matter of second thoughts and fleeting moments of self-doubt. People reflect in passing on what they just did or witnessed someone else doing, and why it disturbed them. Afterward, they plunge back into the usual routines. For many people, the speculations leave nothing in their wake, and work resumes with all of its assumptions intact. Other people, however, never quite return to their previous confidence about clinical work and its ultimate worth.
This book examines the clinical routines of a 10-person work group based on the principles of Assertive Community Treatment.4 Eastside Services (a pseudonym) is part of a large multispecialty clinic serving the poorest neighborhood of an older industrial city in the American Midwest. The agency’s mission is to bring all needed medical, psychiatric, and social services to 75 clients who have severe, chronic mental illness (primarily schizophrenia). All the clients have extensive prior hospitalizations, but they currently live in the community, and many would have great difficulty obtaining medical and social services on their own. On the basis of their history, they risk becoming more psychiatrically unstable, homeless, rehospitalized, or incarcerated (typically for nonviolent offenses such as loitering, disorderly conduct, and drug charges). Other than a psychiatrist and nurse (both part-time), staff members are social workers and master’s level counselors who go to clients’ homes and deliver medications, watch clients take them, and assess their symptoms. Staff also take clients shopping, help them find new apartments when they get evicted, control their money and write their budgets, broker for services with other providers, negotiate with their probation officers and landlords, testify at commitment hearings, and do whatever else is necessary to help them succeed in community living.
To characterize ethics as “everyday” means simply that they concern the close-in landscape of practice and “the world most immediately met” (Highmore 2002). At Eastside Services, that world consists of certain tools, routines, and roles, examined in the following chapters. The ACT blueprint provides a standard set of paperwork tools (assessment forms, treatment plans, and legal documents for commitment). Clinicians are trained to use these tools and to inhabit specific roles, with definite boundaries and rules for engagement. They deploy this treatment apparatus in order to manage the onrush of new crises and carry out mundane tasks. At the scene of work, however, following the blueprint always gives way to infinite improvisation (Floersch 2002). The tasks loop together and depend on each other. Clinicians must constantly defend and reinvent their roles, given the inevitable conflicts between their agenda and clients’ own desires. Any given encounter can bring up lingering resentment and unfinished business. Case managers develop a tactical wisdom to maneuver through the tension and complete the minimal goals with the particular client in front of them. The conflicts are so ramifying, and the twists and turns of relationships so complex, that a single case can spark a range of ethical commentaries. A relationship that lasts for years, as in the following example, suggests the richness of everyday ethics and the problems it poses for ethnography.
MANAGING CRISES AT EASTSIDE SERVICES
Around noontime on a hot day in June, I drove through a maze of quiet city streets with Ryan Geary, an Eastside case manager. A few people sitting on their porches turned their heads as we parked the car, just as a middle-aged woman walked briskly toward us. Preoccupied and impatient, she took a small plastic medication container from Ryan’s hands, stuffed it in her purse, and then led us to her apartment building. Andrea Watkins kept up a running commentary on her finances: “Is the money deposited yet? I’m talking about the other money, the $179. I’m talking about the other two checks. I want an exact amount. I’ve been waiting since March. . . .” Ryan tried to parry her complaints, and as soon as we entered her apartment he redirected her to the task at hand. “Are you going to get some water and take your morning medication?” Andrea silently swallowed a handful of pills, took a gulp of water, and then sat down at a card table. It was the lone piece of furniture in the otherwise barren apartment. She began again to ask about her budget, and Ryan was able to give her one piece of good news. She now had enough money to buy the large freezer she had wanted ever since moving to this apartment. Ryan took advantage of the momentary silence to announce Andrea’s next appointment time and make his exit. Once outside, he summed up the visit for me: “She has what she wants. And she’s med compliant. So that’s where we want them.”
Despite the evident exasperation on both sides, this home visit counts as a success. It was a quiescent phase in Andrea’s history with Eastside Services, and it contrasts starkly with the crisis that swamped the work team five months earlier. At that time, Andrea had managed to avoid all contacts for several weeks. She had stopped paying bills and had barricaded herself in her (former) apartment without electricity or heat. The neighbors eventually started to complain about the odor and the cockroaches from her apartment that had infested other units in the building. The crisis escalated quickly. After many failed attempts to talk to Andrea face-to-face or by phone, the agency requested a pickup by the county sheriff’s office, and Andrea was forcibly hospitalized (technically, an “emergency detention”). The supervisor at Eastside Services showed me photographs taken during the eviction: the same images later used at her commitment hearing. City sanitation workers wore gas masks while throwing out her furniture. The toilet was clogged with feces, and mold streaked the kitchen walls next to a large freezer full of rotting meat. The health hazards and Andrea’s lack of concern easily convinced the judge at mental health court to mandate her to treatment for one year, first as an inpatient and then at Eastside Services after discharge. Setting the photographs aside, I asked the supervisor what would have been the ideal outcome for Andrea. With a mix of pragmatism and black humor, she told me, “She should have been kicked out earlier. That would have been a potential crisis point for us to intervene. When the system is most open, that’s the time to trample their rights.”
The supervisor succeeded in obtaining what she called a “good discharge” for Andrea. She remained legally bound to accept medication both orally and via a monthly injection of long-acting antipsychotics, and the agency was appointed her “representative payee” (see Chapter Five). It received all of her federal entitlement funds (from Medicaid and Social Security Disability Insurance) and used them to pay her rent and utility bills and to give her weekly spending money. With this modicum of control over her life, Eastside clinicians wove Andrea into a regular schedule of home visits. They found her apartment and bought a bed, chair, and table with emergency funds. Andrea started to meet with Ryan Geary after she refused all contact with her old case manager, whom she blamed for the total loss (without reimbursement) of her belongings. Guarded and suspicious, she sustained an uneasy but uneventful truce with the agency for many months.
During this period of “stability”—a key word at Eastside Services—Andrea’s name entered staff room discussions for the usual and routine reasons. Preparing her treatment plan, Ryan noted that she was “pleasant and appropriate” and met most of her appointments. Other case managers reported that her symptoms seemed to lessen—fewer accusations and less pressured speech—and that she was happy about getting new dentures. She still resented the agency’s control, but people now deemed it safe to compromise a bit with her demands. She asked for more spending money and to start paying her own bills, and Ryan told me how he would respond:
We are the payee, so technically we have the final say. But I don’t want to come across and say that. I want her to feel as though she has input. I’ll tell her, ‘The important thing is to have a place to live, so let’s concentrate on getting the rent paid.’ You have to be a parent to the clients.
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 Kaufman 1997, Lambek 2010). These are the ethics of engagement, finely calibrated to a specific work place and available resources. They point directly to particular clinical impasses and difficult decisions waiting to be made.
What clinicians say also signifies something a few steps back from the scene of action: their shifting relationship to the collective ethos of the work group. Eastside Services is a moralized workplace, like so many others in public sector mental health (Kirschner and Lachicotte 2001, Robins 2001). People easily endorse sentiments of responsibility and care: “You have to be a parent to the clients”. To witness a human being sliding into serious danger—Andrea barricading herself in her apartment, for example—animates clinicians’ well-intentioned perspective. Frontline staff members at this agency think of themselves as advocates whose expertise helps people avoid the worst outcomes of illness. A blockage of work or an uncontrollable crisis, therefore, threatens clinicians’ preferred self-image as well as their technical skills. By speculating about the rightness or wrongness of their conduct, clinicians take up an explicit position—perhaps for the first time—toward the pervasive but usually tacit type of self-regard in this setting.
So, everyday ethics is contextually situated, not abstract. It is indexical; it denotes near-at-hand events and relationships. Through informal reflections on the values driving their work, people discern their own commitment to collective ideals. It is also extraordinarily diverse, even in a single workplace and with a single case. People’s comments about Andrea Watkins run the gamut from matter-of-fact justifications to outright condemnations of the agency’s role. The register ranges from sarcasm to moral earnestness. Ryan’s assertion that he has Andrea at “just the right place”—medication compliant and satisfied with her housing—confidently legitimizes his actions. Neil’s shock at discovering Andrea’s lifeless body frames his work in entirely different terms. He struggles to make sense of his dual role as witness to clients’ mortality as well as insignificant cog in the municipal machinery that processes the disenfranchised. Some Eastside staff members joke nervously about trampling Andrea’s rights in order to avoid the greater harms of decompensation. Others attack the agency’s standard clinical practices as killing her spirit.
Because of this sheer diversity, ethnography must begin with the ensemble of expressions in a given workplace. Fieldwork should seek out not just the dramatic expression and the especially insightful clinician but also the ways everyone articulates (or questions) the justifications for the job. The boundaries of fieldwork obviously enclose a physical place—such as an agency or clinic—and everyone in it. But they also enclose a specific landscape of practice, the types of problems people repeatedly encounter, and the set of tools they use to meet the demands of the day. People say many things inside this boundary about right and wrong, the obligatory and the forbidden, and the legitimate use of professional power. They express it in their words, their silences, and through body language as well as emotional outbursts. Yet whatever they express emerges from the same conditions of work, and it constitutes a single, if internally diverse, repertoire.
What accounts for the range of positions that people adopt? What pushes some to champion standard practice and others to criticize it in the most radical terms? Personal biography surely explains part of the story. Religious commitments or experience with mental illness in one’s own life may well affect how someone evaluates a clinical decision or procedure. But people’s deep personal background and the psychological roots of ethical deliberation lie outside of this study. They point away from, instead of toward, the scene of work. Professional training and social position on the clinical team play a more immediate role. As medical sociologists have long shown, the competition between occupational groups often drives what later become labeled as ethical conflicts. Individuals’ structural position in the clinic helps determine how they identify ethical problems in the first place. Each health care profession, moreover, has its own ethos, so inter-professional conflict can unleash extreme rhetoric, as people defend simultaneously their own moral vision and their professional interest. Ethical debates at Eastside Services thus typically get mixed up with social competition between groups that exert unequal power and champion different visions of proper care for severe mental illness.6
ETHNOGRAPHY AND BIOETHICS: A KNOTTY CONVERSATION
Listening to Eastside Services clinicians as they pass judgment on their work reveals how they accommodate themselves to the collective ethos of the workplace and the local hierarchy of prestige and power. If the analysis stops there, however, it runs the risk of an embarrassing social science reductionism. One can legitimately regard everyday ethics as immersed in local practice, as an expression of professional ideals, and as a symptom of workplace politics. But to reduce it to any one of these levels misses what matters the most to frontline workers. It risks trivializing the passion and depth of their comments. It ignores people’s baseline propensity to evaluate how they are being treated and how they should treat others (Sayer 2010). The goal of ethnography should not be a smooth translation of insider’s ethical commentaries into one or another expert discourses in anthropology or sociology. A better goal is to open up those discourses to create a place for clinicians’ ethical sensibility, which after all carries its own penetration into the conditions of work.
The ethnography of everyday ethics, just like ethnography in general, fundamentally involves translation. Ethnographers take a fleeting moment of talk and fix it on the written page. They try to explain and generalize moments of interaction that, for the actors themselves, are self-evident and riveted to local circumstances (Ricoeur 1981, Jenkins 1994). Ethnographic translation, however, can follow several different tracks. Referring to literary texts, Walter Benjamin (1969) urges translators not to obliterate the intention of the original author; that is, not to replace it with the conventions and categories of the translator’s own language. “The language of translation,” he writes, “can—in fact must—let itself go so that it gives voice to the intentio of the original not as a reproduction, but as harmony.” In the same spirit, the ethnography of everyday ethics in health care must listen to voices from the frontline and then offer a translation that harmonizes with them. The written product should not obliterate clinicians’ own perspective (evaluative, indexical, and practical) in favor of the analytic and theory-heavy frameworks preferred by academics. It should instead complement the insiders’ perspective, so the insider’s and the ethnographer’s accounts ultimately take their place as equally provisional commentaries on the difficulties of clinical work. In the end, the language of the ethnographer-translator should be powerfully affected by the foreign tongue (to paraphrase Benjamin again). The chapters in this book document the ethical sensibility of clinicians, as expressed through their words and actions, and then frame them ethnographically in terms of the structural constraints of work. The goal is to amplify the voice of frontline workers, who have the most intimate knowledge of clients but the least influence in broader conversations about public mental health services.
A second goal is to advance the knotty and frustrating conversation between ethnography and medical ethics. So far, the cross talk between these two fields involves mostly attack, defense, and counterattack. The standard social science critique (inaugurated by Fox and Swazey 1984) claims that ethnography supplies a better translation of clinicians’ moral life than does formal bioethics. According to this argument, people engage with the ethics of medical care not by invoking abstract principles and values (autonomy, utility, care, etc.) but rather through local idioms and reflections on their immediate, practical activities. People’s moral perspective on medical treatment emerges from the concrete details of inequality and local notions of suffering, not high-order virtues or rules of conduct. Emotional experience and local institutional arrangements drive many of the social conflicts that later get formally labeled as bioethics disputes. Ethical discussions by both staff and patients are thus inseparable from their immediate life circumstances, social roles, political interests, and cultural beliefs.7
On this basis, social scientists have criticized the experience-distant language of formal bioethics for misrepresenting the way clinicians actually think about their conduct and obligations. An important stream of U.S. bioethics is committed to liberal individualism, contractual relations, and core principles such as autonomy, beneficence, nonmaleficence, and distributive justice. It prescribes rational and systematic deliberation as the proper response to moral uncertainty (Beauchamp and Childress 2009, Lo 2009). But its logic and vocabulary do a poor job of analyzing how medical workers actually reflect on ethical problems in the midst of practice. For the latter task, according to social science critics, ethnography is the preferred method. Long-term qualitative research has shown that clinical and ethical issues always become entangled and that ethical decision making is a shifting, shared, and implicit process, not the premeditated action of autonomous individuals, as envisioned by mainstream bioethics (Kaufman 1997). Ethnographies replace the remoteness of abstract moral theory with accounts of short-term decisions made in the face of local constraints. They explore how medical professionals identify certain social conflicts, but not others, as ethical dilemmas. They demonstrate that clinicians talk about ethics in specific cultural idioms, framed by their own class identities and institutional loyalties and rooted in a historical context.8
The ethnographic critique of bioethics relies on a categorical division between “moral talk” and “ethics.” For the above authors, moral talk is utilized by ordinary frontline practitioners as they handle particular illness episodes. Ethics, by contrast, is the codified, reflective language of elite experts, located far from the scene of clinical action (Kleinman 1999)9. Moral talk addresses everyday experience and gets expressed idiomatically in the midst of ongoing social life. Ethics is based on the human capacity for reasoning and gets expressed through formal systematic theory (see Hoffmaster 1992, Jennings 1990). The categorical division itself sums up the central argument. Conventional bioethics offers an inadequate and misleading representation of the ordinary moral experience of practitioners. Ethnographic research, by contrast, is uniquely fitted to the task.
The critique successfully carves out a space for the prime anthropological method in a terrain otherwise monopolized by law and moral philosophy. It nonetheless has several shortcomings. First of all, bioethicists themselves have responded to the ethnographic critique point by point (Turner 2009, Hoeyer 2006, and DeVries et al. 2007). They point out that it misconstrues the internal diversity of contemporary bioethics. For decades, mainstream bioethicists have argued against formal inductive methods (see Dubose et al. 1994). Some privilege the cultural and institutional contexts of moral deliberation (Churchill 1997). Others draw from narrative theory and philosophical pragmatism to explore how ordinary people make (and represent) ethical decisions (Chambers 1999, McGee 2003). The ethnographic critique mistakenly loads all the abstraction on one side (formal bioethics), and all the concrete details of history, practice, and structural constraints on the other (ethnography). That false dichotomy in turn fuels the call for ethicists to become more like empirical social scientists. Raymond DeVries sensibly responds that the two fields are not obliged to agree with each other or use the same methods. They should instead regard their distinctiveness as a source of strength, because, after all, they have legitimately different endpoints. The contextualizing and often debunking style of social science aims at something quite different than the normative analysis, advice giving, and regulatory activities of bioethics professionals.
Even on empirical grounds, the sharp divide between disciplinary bioethics and everyday moral commentary starts to break down. Routine clinical work is deeply infused with the categories and instruments of formal bioethics, as illustrated by the above vignette from Eastside Services. The paperwork required to commit someone, for example, is mandated by the state mental health code, which itself arose decades ago out of explicit debates about patient autonomy and the obligation to treat (explored in Chapters Two and Six). Efforts to reform the inhumane state hospital system of the 1950s and to protect patients’ rights once dominated newspaper headlines and courtrooms, but they never quite went away. They instead became sedimented into everyday routines about commitment and many other basic clinical gestures. Even mundane bureaucratic procedures bear the marks of prior ethical debates. Eastside case managers, for example, must show people a paper labeled “patient’s bill of rights” when they get admitted to the program. Clients must sign a written consent form every year in order to receive services. Techniques to hold back people’s money and to write the treatment plan involve similar paperwork and have embedded in them similar ethical rationales, explored later in this book. These forms of regulation continue to shape daily work, whether or not clinicians acknowledge them. In the end, spontaneous commentaries about right and wrong are coproduced by high-order mandates as well as the local context of practice. To set up a categorical division between abstract normative ethics and everyday moral talk obscures this reality (see also Brodwin 2008).
According to the standard ethnographic critique, universalizing ethical frameworks are irrelevant to frontline workers. But this claim seriously mischaracterizes the moral life of clinicians. Listen again to Neil Hansen commenting on Andrea Watkins: “[She] manages never to be trained by the ringmaster. Why kill that? . . . We kill the spirit chemically or sociologically. And to do that to another human being is so unethical.” Neil Hansen, a low-level case manager, refuses outright the norms and standard practices endorsed by his agency. In fact, he uses the word unethical precisely because in colloquial English it enacts a blanket condemnation. He engages with the rightness or wrongness of his job by distancing himself from the local context and usual justifications. His reaction suggests that people socialized in a given setting—as small as a clinic or as large as a “culture”—do not necessarily respect the moral walls that surround them (Moody-Adams 1997). The walls are not impenetrable. Insiders actually find ways to criticize standard practices and assumptions, often by reference to high-order virtues and universal imperatives. To make sense of how frontline clinicians struggle through their work, thick description is necessary, but not sufficient. Ethnography must also ask how they manage to wrench themselves free, if only for a moment, from the near-at-hand warrants for action and the local moral worlds (see Kleinman 2006).
To drown clinicians’ ethical voice in layers of social context is a mistranslation—even a betrayal. The notion of everyday ethics seeks an alternative. It takes seriously people’s ability to evaluate their actions and express concern about their world, using criteria not already present in the immediate context. For this alternative method to succeed, it needs a firm concept of the ethical as an aspect of social life. One of the first books about the anthropology of ethics distinguished between ethics wide and ethics narrow (Edel and Edel 2000 [1968]). The former term refers to broad values and ideals, along with the means to realize them available in a given society. This notion fits all too well with an old and now discredited anthropological notion of culture. It is overly general and assumes a false uniformity of attitudes within bounded social wholes (Howell 1997). Ethics narrow is conceptually stronger and provides a clearer guide for ethnography. The latter term privileges obligations and duties: the subset of values that people feel compelled to realize. It gets expressed in language that enjoins and prescribes, approves and prohibits, praises and blames. The premise of everyday ethics begins with this simple model of ethics narrow. It then applies the model to the realities of clinical practice: short-term decisions and trains of action calibrated to local constraints and also the imperative to intervene in episodes of illness. It extends the register beyond the verbal and into people’s lived engagements. Clinicians’ sense of right and wrong and the way they figure their responsibility for particular others constitute the realm of ethics narrow. The realm becomes visible to ethnography not only through words but also through nonverbal expressions and action. The values that people feel compelled to realize become evident in the way they enact, evade, or modify the mandates for work.
To theorize the ethical as an aspect of social life, hence amenable to ethnography, presupposes that all humans experience “contemplative moments of moral reflexivity” (Parkin 1985, see also Sayer 2011). During such moments, people are influenced by ideals (about obligation and duty, for example) that aspire to universal application. But transcendent ideals are constantly questioned and modified through the give and flow of face-to-face encounters. As an element in social life, high-order principles, virtues, and norms are always already relational. They get mobilized only when people start to figure their responsibility, and hence their proper conduct, in concrete circumstances. Indeed, some argue that ethical experience as such occurs only when people criticize local circumstances by invoking values that extend beyond the local (see Kleinman 2006). This process becomes visible especially when they feel a mismatch between the inherited ideals and what the immediate situation demands. Such moments prove that people are not social automatons or simple vehicles for the reproduction of existing arrangements and ideologies. Parkin’s moment of moral reflexivity is the baseline experience for the ethnography of everyday ethics. It creates the condition for people to become conscious (perhaps for the first time) of the formal values and ethical rules of thumb that permeate their local world. In this moment, people may seek out alternative values to rethink that world or reorient their action within it.
The ethnographer’s tool kit can illuminate what provokes people into this experience and hence to speculate about the ethical stakes of their action. Think of everyday routines and their breakdown, social hierarchies and the challenges to them, scripts for interaction and unruly or resistant actors. Such ruptures push people to evaluate the immediate situation and the possible routes through it. The criteria for their evaluation are complex, and they are difficult to express. Elucidating the concepts and rationales behind spontaneous ethical comments is the job of moral philosophy. The chief tasks of ethnography are different: to document the provocations, the range of people’s ethical response, and what their responses accomplish.
Ethnographers need greater clarity about that central term—an ethical response—in order to discern it in the messy contexts of everyday clinical work. As an expression in the midst of practice, the core characteristic of an ethical response is its subjunctive tone or mood. According to the philosopher Mary Midgley, the realm of the ethical immediately impresses with its seriousness and importance (2003: 123 and passim). An ethical expression announces that in the present circumstances, we cannot just act according to our whims, habits, or the usual conventions. Following any of these routes falls short of . . . the distinctively ethical demand. If we do not know how to act, or we know but the way forward is blocked, we feel acutely the gap between this demand and our present capacities. The perceived distance between the desirable and the possible, the ideal state and the present condition, categorically defines the ethical mood.
The ethical response also engages peoples’ central purposes as they understand them (Midgley 2003: 145). Confronted by ruptures in taken-for-granted routines and social orders, people must craft a response. Sometimes they successfully answer the challenge through their technical competence, persuasive skills, or sheer ability to maneuver through complex social institutions. Their response becomes ethical, however, when it addresses not only the situation at hand but also their more diffuse orientations toward the proper way to live and to bear responsibility for others. If, in order to resolve the problem, people must revisit other deeply held priorities concerning the good, the honorable, and the obligatory, then they are entering the terrain of everyday ethics. They do not thereby renounce other ways of solving the problem—based on clinical, technical, or legal logics—that continue to provide important recipes for action. But they discover that these standard guides or algorithms ultimately fall short. Even more, their response qualifies as ethical if they have robust knowledge of the range of alternatives. Responding in a certain way just because they cannot imagine any other path seems somehow empty of any value considerations. By contrast, evaluating the situation through one criterion, while acknowledging and rejecting others, typifies a distinctly ethical choice.
To imagine ways of acting beyond those prescribed by local customs or bureaucratic rules characterizes the ethical response. Ethnography insists, however, that such imaginings are not limitless; they grow from and return to the local social context and near-at-hand contingencies. Fieldwork must ferret out the circumstances that incite people to rework their values and articulate the emergent stakes of their action. It must document the circumstances that lead people to problematize their usual routines. Certain passages from Michel Foucault help clarify the question, even though he addressed ethics more in comparative civilizational contexts than as a matter of individual reflection. To regard one’s conduct as problematic means to question its meaning, conditions, and goals (Foucault 1997). What instigates such questions? Let us narrow the question to the face-to-face circumstances of health care work. What social, political, and economic factors cause everyday clinical routines and interaction to become ethically uncertain? Tracing the history of a particular treatment apparatus will show the fault lines in its legitimacy, that is, its vulnerability to ethical critique from individual actors. Learning the history of a given health care field– its categories, institutions, and personnel—must therefore precede the ethnography of everyday ethics.
The very ability to problematize a given situation suggests another dimension of the ethical response. When clinicians are forced to think explicitly about usually routine decisions, they also start to think differently about themselves as subjects and ethical agents. Problematizing the situation, in this sense, is a practice of freedom. When a social worker or psychiatrist discovers that the usual gesture of work subverts her own ideal self-image, she inaugurates a moment of moral reflection. At the same time, it is a momentary refusal of the sedimented values of the treatment setting and its dominant recipes for action. She carves out a small zone of freedom in the midst of workplace rules and professional norms. Foucault rejects the utopian notion that freedom means acting fully outside of power; a person, he wrote, does not begin with liberty, but with the limit (see Bernauer and Mahon 1994). So, when a clinician imagines alternatives to the prescribed routines or expectations, her freedom obviously exists in tension with specific social and historical constraints (Laidlaw 2002). What she achieves, moreover, is often evanescent and insignificant, even from the standpoint of the local work group. A hallway discussion, a staff-room debate, a push to alter the standard procedures for future cases—the real-world results of everyday ethics rarely go any further.
A more substantial change occurs in her relationship to herself. That is, she partially reformulates herself as an ethical subject. To ask whether a given action is right or wrong means to choose the kind of person one wishes to become. Foucault regarded ethical reflection as a site of self-fashioning. One chooses a moral goal and then moves toward it through practice of self-cultivation: a matter of monitoring, improving, and transforming oneself (Foucault 1990, see also Davidson 1986 and Paxon 2005). His approach suggests several questions for the ethnography of everyday ethics. When do ruptures in the flow of ordinary work provoke people to reassess their ethical agency? Do the objective constraints that clinicians encounter seep into their self-regard? How do people respond both outwardly—by trying to change conditions of work—and inwardly—by articulating their value commitments or inventing new ones?
This brief discussion does not aim at advancing moral philosophy and even less at establishing the proper norms for the conduct of mental health professionals. It instead seeks a better way for ethnography to engage with bioethics. The perspectives from Midgley and Foucault—thinkers from radically different traditions—show how to make clinicians’ ethical commentaries visible during long-term qualitative research. Fieldworkers should analyze everyday ethics as a social production but also encounter it on its own terms: its compelling quality, the deep purposes that get stirred up, the self-fashioning set in motion. The ultimate goal here is not to oppose ethnography to bioethics through a sort of disciplinary combat, but instead to amplify the voices of ordinary frontline clinicians and introduce them into debates where they are typically absent. This sort of ethnography resists translating everyday expressions into abstract social science jargon. It rather follows clinicians’ lead as they mix up reflections about local practice with other norms, ideals, and personal commitments.
OUTLINE OF CHAPTERS
Chapter One offers a genealogy of Assertive Community Treatment, a necessary prelude to the details of frontline practice. Complex social and historical conditions produced both the mission and the clinical apparatus of ACT. The core task at Eastside Services is to maintain people diagnosed with severe mental illness in their own living spaces and to delay or minimize their next psychiatric crisis. This mandate emerged from the past half-century of mental health reform in the United States, and it contains all the contradictions and unfinished business of that period. The chapter summarizes the failures of deinstitutionalization and then examines the subsequent efforts to revamp the system. Reformers assembled a novel mode of treatment by trial and error at the scene of work, as well as policy-level advocacy and lobbying. Once the model was assembled, ACT advocates set about implanting it across the country. That process, however, immersed ordinary clinicians in grids of surveillance and a rigid administrative logic that undercuts their clinical skills. The tasks of ACT inherently demand improvisation, but Eastside staff are disempowered and hedged in by bureaucratic rules. The ACT blueprint, moreover, casts the psychiatrist and case manager in complementary but unequal roles. Case managers’ distinctive knowledge always risks getting undercut by the psychiatrist’s greater authority. The genealogy of ACT explains these lines on the landscape of practice, and hence the deepest routes of clinicians’ ethical unease.
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.
NOTES
1. Sered and Fernandopulle (2005) describe how the current U.S. health care system neglects the sick poor. The spatial concentration of people dependent on publicly funded medical and welfare systems is analyzed by Dear and Wolch (1987). The survival strategies of homeless people with mental illness in North American cities is studied by many authors, including Desjarlais (1997), Rowe (1999), Lovell (2007) and Luhrmann (2010). For the dead ends and double binds experienced by people with mental illness as they cycle through the criminal justice system, see Rhodes (2004) and Human Rights Watch (2003).
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).
