knowledge is parallel but marginal to the official knowledge of professional psychiatry (or professional social work, for that matter). The psychiatrist, by contrast, sees clients primarily in her office and usually for medication management. The conditions of her work better fit her disciplinary training, compared to the situation faced by case managers. But the categories of situated versus disciplinary knowledge eventually break down. Psychiatrists too must cultivate something beyond formally coherent textbook knowledge, to do the job well. Their connoisseurship of pharmaceutics is intuitive and based on decades of experience At Eastside Services, to choose another example, the psychiatrist must have an intuitive grasp of the agency’s positions within the local ecology of mental health services. Only then can she judge when a commitment order will likely succeed or fail and which addiction treatment center will accept a particular client.
The conflict of interpretations between psychiatrist and case manager reflects fundamentally the difference between expertise and craft (see Rice 2010). People learn the skills of case management almost at an unconscious level and in specific circumstances. Such learning does not depend on an explicit articulation of categories, basic principles, or algorithms. People instead learn through trial and error as well as guidance about particular cases from more seasoned colleagues. Day by day, they learn how to attach salience to the details of clients’ apartments, appearance, and expressions. At Eastside Services, the craft-like quality of their skills becomes clear in the way they work through crises, such as treatment refusal, worsening symptoms, and the disruptions caused by eviction or arrest. Case managers rarely compare a given case to a previous crisis or try to fit the manifold details into a more abstract conceptual scheme (such as a checklist of risk factors for suicide, or the precise line between persuasion and coercion). To figure out how to handle a crisis, people simply expand the range of relevant details. Their conversation circles more and more widely, taking in more of the person’s life-world and social connections, until a provisional solution somehow appears.
The craft of case management involves assembling and reassembling components of their clients’ lives. Case managers start anew with each new crisis; although guided by intuition and experience, they never articulate such guidance in its own terms. They cannot separate the body of knowledge authorizing their interpretation from the details of the case at hand. Their knowledge is actually better termed “know-how,” and it exceeds any professional jargon or classificatory system. (In any case, most Eastside case managers actually have very little course work in severe mental illness from their social work or counseling training.) People’s skill in the craft of case management depends on the tools that they use. Their clinical disposition gets animated only when engaged in the details of work.
Because of their craft-like approach, case managers have a different angle of vision compared to the psychiatrist. The differences often push them to contest the psychiatrist’s interpretation of clients’ problems, but they enter this contest with several disadvantages. Of course, they lack the signs and habits of expertise, as authorized within the ACT model. In some ways, moreover, the psychiatrist cannot even fully take in all that the case managers know. Their ways of making and transmitting knowledge are simply too different (see Marchand 2010a). The result is typically miscomprehension and bewilderment—a breakdown in teamwork that the psychiatrist often resolves simply by fiat. Discord, instead of dialogue, usually marks staff room debates. The division of labor on ACT teams, so clear and complementary in the program manuals, becomes a permanent fault line on the landscape of practice. Anthropologists may wish to compare craft to expertise, or situated to disciplinary learning, as simply different types of knowledge. ACT case managers, however, experience the difference as a continual contest over how to represent and respond to clients’ needs.
FAULT LINES IN THE GROUNDWORK OF PRACTICE
The genealogy of an institution exposes its development through successive historical regimes, but without searching for underlying laws, hidden meanings, or progress along the way. From this angle, a social institution is an assemblage of different components that came together over time. They do not fit together seamlessly, and lining them up chronologically may not reveal a grand unfolding scheme. An institution—even a single workplace—carries the imprint of history, conceived as a series of moments and discrete practices that somehow left their mark on generations to come (see Lash 1984). This genealogy of Eastside Services is thus not a complete history of deinstitutionalization or of the professional field of psychiatric rehabilitation. The chapter ignores the development of many other institutions that impinge on the daily operation of Eastside Services, such as the hospital emergency room, homeless shelter, rooming house, meal site, the county jail, and the office of probation and parole. The more limited goal is to pose some basic questions about everyday ethics. What long-term structural contradictions underlie the problems that clinicians face in their routine work? Are the tools provided by the ACT model actually sufficient for the job? And when they fall short, does their failure provoke ethical reflection?
The landscape of practice at agencies like Eastside Services derives only partially from the formal blueprint for Assertive Community Treatment. The architects of ACT portray the model as a unified technology, designed to perform as planned in its defined tasks, given proper upkeep and well-trained operators. But as even the program's supporters admit, it is impossible to replicate the Madison model perfectly. With dissemination come infinite variations, driven by state finances, the shape of the regional mental health system (hospitals, foster homes, drug treatment facilities, etc.), the organizational climate of the agency where the ACT team operates, the training of its staff, and the shifting needs of clients (Mowbray 1997a and b, Lewin Group 2000). Most ACT teams do not, in fact, conform precisely to the original blueprint. They have drifted away as they assimilated to the surrounding ecology of services and funding.
At Eastside Services, the frontline staff practices with a bundle of inherited tools, each with a distinct lineage. Medications and the mechanism for compliance come from biopsyschiatry, and the technique of case management comes from broad developments in American human services since the 1970s (see Chapter Three). The paperwork technologies of assessment forms and treatment plans come from ACT manuals (see Chapter Four). The money to pay for services is cobbled together from federal entitlements and state and municipal programs—an amalgam reflecting 40 years of debate about public responsibility for dependent persons (Chapter Five). The directions for working with clients are inscribed in state law, itself the product of by both ACT advocates and civil libertarians who sharply narrowed commitment criteria (see Chapter Six). Today's ordinary tasks emerged from successive phases in the long development of community psychiatry services. Staff members and managers depend on this mixture of inherited ideas, regulations, and techniques in order to meet the demands of the day. Not surprisingly, people cannot make the ingredients mesh perfectly. The rest of the book follows the conflicts that erupt when the outlooks and routines of psychiatry, social work, law, and the public welfare system bump against each other.
These conflicts create difficult obstacles for the course of everyday work, and they can undermine its legitimacy even in the eyes of frontline staff. Clinicians get tangled up in several contradictory goals and expectations. The ACT manuals articulate a straightforward clinical goal: to lengthen the remission period of chronic psychiatric disease. The program's genealogy, however, shows why this simple goal is so hard to carry out. As the original CSP ideals got translated into programs on the ground, the case manager became responsible for funneling to clients the entire range of services (treatment, housing, food, counseling, social connections, and daily activities) that were once bundled in a single brick-and-mortar institution. The task, of course, is impossible. No single program can piece together again the full array of supports available in the old state hospitals. Nevertheless, today's case managers inherit the impossible mission of providing everything their clients need in the “community,” ambiguously defined as anywhere but the hospital, jail, or homeless shelter.
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