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
