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Everyday Ethics

Everyday Ethics: Voices from the Front Line of Community Psychiatry

Paul Brodwin
Copyright Date: 2013
Edition: 1
Pages: 248
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  • Book Info
    Everyday Ethics
    Book Description:

    This book explores the moral lives of mental health clinicians serving the most marginalized individuals in the US healthcare system. Drawing on years of fieldwork in a community psychiatry outreach team, Brodwin traces the ethical dilemmas and everyday struggles of front line providers. On the street, in staff room debates, or in private confessions, these psychiatrists and social workers confront ongoing challenges to their self-image as competent and compassionate advocates. At times they openly question the coercion and forced-dependency built into the current system of care. At other times they justify their use of extreme power in the face of loud opposition from clients. This in-depth study exposes the fault lines in today's community psychiatry. It shows how people working deep inside the system struggle to maintain their ideals and manage a chronic sense of futility. Their commentaries about the obligatory and the forbidden also suggest ways to bridge formal bioethics and the realities of mental health practice. The experiences of these clinicians pose a single overarching question: how should we bear responsibility for the most vulnerable among us?

    eISBN: 978-0-520-95452-6
    Subjects: Anthropology

Table of Contents

  1. Front Matter
    (pp. i-viii)
  2. Table of Contents
    (pp. ix-x)
  3. Acknowledgments
    (pp. xi-xiv)
  4. INTRODUCTION: The Terrain of Everyday Ethics
    (pp. 1-26)

    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...


    • CHAPTER 1 Genealogy of the Treatment Model
      (pp. 29-55)

      Everyday ethics emerges, by definition, against the background of ordinary practice. On a typical day, Eastside Services staff members make innumerable decisions about the right course of action for their clients. To do so, they must pose and then work through several questions. What does my client need, given what I know about his personality, his strengths and vulnerabilities, and the way he lives with his symptoms? Can I cobble together the resources to answer his need? Is there a standard, routine way to handle this sort of case, and can I conceivably follow it with the person standing in...

    • CHAPTER 2 Expert Knowledge and Encounters with Futility
      (pp. 56-86)

      In the published guidelines for setting up ACT teams, all the ingredients fit together into a coherent whole.¹ Training manuals specify the composition of the team (psychiatrist, psychologist, social worker, counselor and nurse), the proper lines of authority, and the paperwork to keep operations running smoothly. The guidelines lay out the precise duties and status of the case manager—a hybrid sociomedical worker—who is the linchpin of the work group. Eastside Services case managers rely on formal manuals, face-to-face instruction, and infinite improvisations in order to carry out their work. Combining disciplinary and situated knowledge in fluent, even unconscious...


    • CHAPTER 3 Treatment Plans Mandatory Narratives of Progress
      (pp. 89-117)

      Like clinicians everywhere, the staff at Eastside Services has a practical mastery of the tasks of care, and usually that is enough. Most case managers are relatively young, so they have no living memory of the problems of deinstitutionalization that ACT meant to solve. They spend most of their time immersed in daily routines, and they rarely need to articulate the program’s ethos. Caring for chronic illness, including psychiatric conditions, is a matter of daily action, of trying, adjusting and trying again in order to improve the patient’s life situation or keep it from deteriorating. Eastside staff continually search for...

    • CHAPTER 4 Representative Payeeships The Deep Logic of Dependency
      (pp. 118-144)

      Treatment plans are situated entirely inside the world of mental health services. The templates are printed in the Assertive Community Treatment training manuals, and each completed plan conforms to the norms of biopsychiatry and social work. Eastside Services staff members write the plan as a strategy to control clients’ medication and housing, and thereby to structure their own daily work. In the face of clients’ resistance, however, case managers must often reach outside their own professional field for more coercive tools located at the intersection of medicine, the social welfare system, and the law.

      Representative payeeships and commitment, the topics...

    • CHAPTER 5 Commitment Orders The Practice of Consent and Constraint
      (pp. 145-176)

      Emergency detention and commitment represent the most extreme types of control available at Eastside Services. These clinical gestures array the power of the police and the judicial system behind clinicians’ efforts to impose treatment. Staff members turn to them after other forms of persuasion have failed: when clients reject the case managers’ overtures, refuse medications, evade appointments, and exit thequid pro quoof the rep payee system. In the case of emergency detention, clinicians call the police to transport clients to the city’s only public psychiatric hospital, which can detain them for up to 72 hours. In the case...


    • CHAPTER 6 Coercion, Confidentiality, and the Moral Contours of Work
      (pp. 179-204)

      Can fieldwork in settings like Eastside Services advance the conversation between ethnography and clinical bioethics? Ethnography brings a deep respect for local knowledge and the hard-won skills of insiders. It shows what pushes clinicians to question the legitimacy and ultimate worth of encounters with the people they are supposed to help. Their ethical thinking does not begin from abstract ideals, and it does not follow an inherent logic. It begins instead where clinicians operate every day, that is, on the familiar landscape of practice. Their ethical sensibility is provoked by the obvious blockages in work: treatment tools that break down,...

  8. Bibliography
    (pp. 205-220)
  9. Index
    (pp. 221-233)