of work for frontline staff. ACT advocates made alliances with the highest level of state mental health authorities, and in the state where Eastside Services is located they managed to get program services inserted directly into state law. By working closely with the state mental health division, the advocates/planners ensured that community support programs are mandated in each county and spelled out in precise detail.
Eastside staff members, like all ACT teams in this state, must conform to the current administrative code: a triumph of bureaucratic control over everyday clinical work. The state code establishes the makeup of each local work group and the required training for each member. It establishes the maximum client–staff ratio and sets exact criteria for admission, including diagnosis and levels of impairment. The code dictates the order of work with newly admitted clients (assessment, treatment planning, services, record keeping, and discharge) and defines each phase of work in minute detail, enumerated by headings, subheadings, and sub-subheadings. The legalistic language reaches deeply into program operations and explicitly prescribes case managers’ tasks. It lays out the precise steps to help clients find a job (make wake-up calls, counsel them about grooming, and help them buy clothes). It delineates the specific living skills they must teach clients: housecleaning, cooking, shopping, laundry, and money management.
The daily activities of case managers, therefore, are governed by bureaucratic as well as clinical logic. Case managers operate with a split identity as both clinicians and public employees (cf. Friedson 2001). Even as they deal face-to-face with a client in her own living area, case managers must obey explicit definitions of their duties devised by a remote cadre of mental health administrators. Frontline staff never escape the control and surveillance of officials located higher up in the system.12 Case managers at Eastside Services often lack the prerogative to determine their tasks or how best to carry them out. They do not control the criteria by which their work is judged. To a remarkable degree among health care workers, their labor is specified in advance and in writing. The state code standardizes and rationalizes their tasks, and (on paper, at least) leaves them little room to resolve ambiguities and contingencies on their own.
Weaving ACT services into Medicaid financing demands especially tight surveillance of programs on the ground. To qualify for Medicaid, programs must meet the state certification standards. ACT planners support such audits because they provide a reliable measure of the fidelity of individual teams to the original principles.13 At Eastside Services, the state evaluator arrives every year to comb through clients’ charts and billing records. Pushed by this scrutiny from above, the supervisors in turn create structures of surveillance over the case managers. Supervisors continually revise and correct treatment plans, and in both staff meetings and face-to-face reviews they instruct and discipline the case managers in other details of paperwork (see Chapter Four). These types of surveillance immerse frontline clinicians more deeply in the bureaucratic mode of control.
Case managers must wrestle with yet another aspect of the micropolitics of work. Their structural weakness is produced by not only distant bureaucratic control but also their position vis-à-vis the psychiatrist on the team (see Test 1979). As a medico-social intervention, Assertive Community Treatment rests on an inherently complex division of labor. The program’s architects acknowledge the tension between case managers and higher status psychiatrists, who are accustomed to directing nonmedical staff members. To mitigate the friction, Stein and Santos (1998: 60ff) advise psychiatrists to be “helpful and collegial, rather than dictatorial and demeaning,” to teach case managers about medications and side effects, to accept calls after hours, and to come in occasionally on weekends. According to this ACT textbook, careful attention to social relationships will foster a well-functioning team despite the inevitable hierarchy.
At first glance, the psychiatrist on the team is indeed the topmost authority, with the highest credentials and surest control of the jargon and practices at the core of the ACT model. But the relationship between case managers and psychiatrists involves more than their rank order in the hierarchy. The two clinicians rely on different warrants for knowledge. The psychiatrist draws on in-hospital training with people in acute crisis, as well as long experience with pharmaceutics. On this basis, she devises recipes for action and deputizes other staff members to carry them out. In such interactions, the psychiatrist acts as expert, and the case managers (mostly social workers) as a less knowledgeable lay audience. The case managers draw on substantially longer interactions with particular clients and much deeper knowledge of clients’ life world—their roommates, neighborhoods, usual moods, pastimes, hopes, social connections, and family histories. Case managers become proficient in particular perceptual skills, such as noticing small changes in a client’s appearance or words. They learn key political skills, such as navigating other public sector services, anticipating future blockages, and finding scarce resources.
A more sophisticated reading of expertise will illuminate the exact relationship between psychiatrists and case managers as well as the trouble it causes for the latter group. From an anthropological perspective, expertise is something that people do, rather than something they possess (Carr 2010). It is an enactment—a performative claim made in the midst of social life—not a cache of individual knowledge. Through verbal and nonverbal communication, people project an authoritative framing of cultural objects and try to convince others to follow their lead. Success, however, depends not only upon their individual charisma or fluent command of dominant codes; it also depends upon institutional supports: the roles people occupy and their accompanying status. In the context of Eastside Services, the psychiatrist is supported by the ideology woven into the program template and the more general hierarchy of multidisciplinary health care. Indeed, the following chapters illustrate how this psychiatrist inhabits his prescribed role and verbally enacts his expertise during staff meetings. In many cases, the case managers accept (or are forced to accept) that they are less aware, less knowing, and less knowledgeable than the psychiatrist (see Carr 2010: 22).14
Case managers obviously do not control the most highly valued knowledge within ACT—that is, biopsychiatry. They also cannot deliver the verbal performance often demanded by psychiatrists. In a private interview, one psychiatrist who devoted his career to ACT expressed his continual frustration with case managers. During a busy staff meeting, he will ask for particular details about clients’ symptoms. He wants a quick reply, summarizing the information most relevant for medication management—just the sort of reply that medical students and residents are trained to provide. But the case managers instead respond with long rambling stories about the person’s social problems and minute details about her appearance and preoccupations. The psychiatrist must take a deep breath and patiently extract the two or three facts that he actually needs. Case managers simply do not have the training, institutional support, or performative skills to qualify as experts on ACT teams.
The team functions smoothly so long as all parties conform to a few rules of engagement. The case managers are expected to accept the psychiatrist’s rendering of clients’ conditions and needs. When asked, they should offer their rich knowledge of clients’ living conditions, habitus, and immediate social environment, so the psychiatrist knows what to expect in that day’s appointments or how to deal with an emerging crisis. In the ACT model, the highest-ranking professional routinely depends on lower-ranking staff. That very dependence, however, gives case managers an opening to present authoritative readings of clients’ inner mental states. After all, the two types of clinicians have different ways of knowing and different kinds of knowledge. Case managers, therefore, have traction to push back against the psychiatrist’s interpretation and recommended actions. The low-ranking staff can advance alternative interpretations of clients’ inner states, their potential for recovery, and the sources of their suffering. The conflict of interpretation between case manager and psychiatrist often drives staff room debates and can sow deep divisions in the team.
To some extent, such conflicts reflect the differences between situated and disciplinary knowledge (see Floersch 2002). Case managers develop their knowledge through the infinite improvisations demanded by ordinary work: the slow accumulation of practical experience with particular clients, as well as the core ACT tools (the treatment plans, schemes for money management,
