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
