Everyday Ethics: Voices from the Front Line of Community Psychiatry

Everyday Ethics

Everyday Ethics

Voices from the Front Line of

Community Psychiatry

Paul Brodwin

UNIVERSITY OF CALIFORNIA PRESS

Berkeley·Los Angeles·London

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University of California Press

Berkeley and Los Angeles, California

University of California Press, Ltd.

London, England

© 2013 by The Regents of the University of California

Library of Congress Cataloging-in-Publication Data

Brodwin, Paul.

Everyday ethics : voices from the front line of community psychiatry / Paul Brodwin.

p. ; cm.

Includes bibliographical references.

ISBN 978-0-520-27478-5—ISBN 978-0-520-27479-2

eISBN 9780520954526

1. Title.

[DNLM: 1. Community Mental Health Services.

2. Community Psychiatry—ethics. WM 30.6]

362.19689-dc232012030149

Manufactured in the United States of America

22    21    20    19    18    17    16    15    14    13

10    9    8    7    6    5    4    3    2    1

In keeping with a commitment to support environmentally responsible and sustainable printing practices, UC Press has printed this book on Rolland Enviro100, a 100% post-consumer fiber paper that is FSC certified, deinked, processed chlorine-free, and manufactured with renewable biogas energy. It is acid-free and EcoLogo certified.

For the clients and staff at Eastside Services

The work of treating the chronically mentally ill in the community, often tedious, monotonous, apparently endless, and emotionally draining, represents a heavy load for any individual to manage alone.

—Mary Ann Test, Continuity of Care in Community Treatment (1979)

What matters is to give each person back the confidence that people can have in themselves, that they can lose in any social milieu, by some accident, by some event happening in your life. . . . Because I think that what is happening is people's heads is . . . they've come to the end . . . they're at the end . . . of nothing. You have to find a way out.

—Social worker quoted in Pierre Bourdieu et al., The Weight of the World: Social Suffering in Contemporary Society (1992)

Contents

Acknowledgments

Introduction: The Terrain of Everyday Ethics

PART ONE: BACKGROUND TO PRACTICE

1.Genealogy of the Treatment Model

2.Expert Knowledge and Encounters with Futility

PART TWO: TOOLS OF THE TRADE

3.Treatment Plans

Mandatory Narratives of Progress

4.Representative Payeeships

The Deep Logic of Dependency

5.Commitment Orders

The Practice of Consent and Constraint

PART THREE: FROM EVERYDAY TO FORMAL ETHICS

6.Coercion, Confidentiality, and the Moral Contours of Work

Bibliography

Index

Acknowledgments

This book is a collective project, and it would not exist without the longstanding generosity of colleagues and the support of friends. I owe my deepest debt to the staff and clients of the pseudonymous Eastside Services. Staff members allowed me to enter their tightly knit work group and share their frustrations and (rare) triumphs. They created a role for me—as friend, witness, and interested outsider—as they struggled to care for some of the most disenfranchised people in the United States. At the same time, individuals living with severe and disabling symptoms graciously accepted my intrusion into their lives. Their personal resilience and strategies for survival pushed me to rethink my personal and professional commitments. While writing this book, I have been honored to work alongside mental health advocates who self-identify as consumers, clinicians, activists, or all three. Their devotion to systemic reform is infectious, and I hope this book contributes to the changes that we all urgently need. In a book about the ethics of mental health care, I must scrupulously avoid identifying people even remotely connected to my research site. I thank them all, and I ask their forgiveness for any errors of fact or interpretation.

Long before beginning fieldwork, I benefitted from the guidance of many individuals. Robert (Skip) Nelson extended a warm mid-career welcome into bioethics. Carl Elliott, Tod Chambers, Ray DeVries, and Laurie Zoloth provided models of engagement and disciplinary self-awareness that helped me hone the fundamental questions about everyday ethics. Reaching further back, I owe my passion for this book to Arthur Kleinman, Byron Good, and Mary-Jo DelVecchio Good, the founders of the medical anthropology program at Harvard. Their mentorship and support over the years have been crucial to my professional growth. Steve Piker, now retired from Swarthmore College, laid the foundation for my career and provided my first model of humane anthropological scholarship.

Since completing fieldwork, my thinking has benefitted from a moveable conversation about anthropology, psychiatry, and social work. At the University of Chicago, Judy Farquhar and Summerson Carr have provided invaluable support, and they graciously invited me several times to present my work to their students. At the University of Paris, Livia Velpry and Anne Lovell shared their insights into the vexed worlds of consent, constraint, and community psychiatry, and I greatly appreciate their spirit of collaboration. Closer to home, my colleagues Kalman Applbaum and Michael Oldani invited me to join their research project on pharmaceutical compliance, and their ideas improved my analysis of this topic. Janelle Taylor, Erica Bornstein, and Richard Grinker offered useful suggestions and encouragement at various times during the long writing process. Sharon Kaufman's ideas and professional support also leave important traces on my own thinking.

The University of Wisconsin-Milwaukee provided a congenial atmosphere for research and writing, and I would like to thank all my colleagues in the Department of Anthropology. Department Chairs Robert Jeske, Patrick Gray, and Thomas Malaby, along with Deans Richard Meadows and Rodney Swain, helped create opportunities for serious intellectual work, and I am in their debt. The support of the university's Center for 21st Century Studies was crucial early in this project. At the Medical College of Wisconsin, the opportunities for dialogue among humanities, social sciences, and medical practice have improved this book, and I am grateful for the friendship and administrative skills of Art Derse, David Seal (now at Tulane), and Julia Uihlein.

I thank Reed Malcolm and Stacy Eisenstark at the University of California Press for seeing promise in my manuscript and expertly shepherding the book to completion. Thanks also to Rebecca Lester and an anonymous peer reviewer who helped me clarify my main argument and make the book more accessible. I also thank the National Science Foundation, which funded my research (BCS-0522263). Cherie Sixbey, director of the Assertive Community Treatment Association, invited me to address numerous audiences of social workers and psychiatrists. I also thank the editors and peer reviewers of the journals that published previous versions of this research. Portions of Chapter Two appeared in The Assemblage of Compliance in Psychiatric Case Management, Anthropology and Medicine (UK) 2010, 17(2):129-143, as well as Futility in the Practice of Community Psychiatry, Medical Anthropology Quarterly, 2011, 25(2):189-208. Portions of Chapter Six appeared in The Coproduction of Moral Discourse in U.S. Community Psychiatry, Medical Anthropology Quarterly 2008, 22(2):127-147.

Finally, the difficulties of research and writing have been tempered by a small local network—a source of challenge, support, and inspiration. The patience and persistent inquiries of Tom Reed, Richard Frank, and the pseudonymous Neil Hansen have all found their way into this book. Most importantly, my deepest thanks to Huong DangVu, whose life work illuminates the contours of care and its human core.

INTRODUCTION

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