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?
|Publisher:||University of California Press|
|Edition description:||First Edition|
|Product dimensions:||6.00(w) x 9.10(h) x 0.80(d)|
About the Author
Paul Brodwin is Professor of Anthropology at the University of Wisconsin-Milwaukee and Adjunct Professor of Bioethics and Medical Humanities at the Medical College of Wisconsin. He is the editor of Biotechnology and Culture: Bodies, Anxieties, Ethics, author of Medicine and Morality in Haiti: The Contest for Healing Power, and coeditor of Pain as Human Experience: Anthropological Perspectives.
Read an Excerpt
Voices from the Front Line of Community Psychiatry
By Paul Brodwin
UNIVERSITY OF CALIFORNIA PRESSCopyright © 2013 The Regents of the University of California
All rights reserved.
Genealogy of the Treatment Model
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 front of me? But then they face the hard surfaces of the job: scarce resources, dilapidated housing, opaque bureaucracies, rigid agency policies, and indifference or disdain from other public service workers (police, probation officers, hospital staff, and welfare officials). These obstacles prevent the case manager from carrying out her preferred course of action. Everyday ethics is the label for commentaries that emerge at this stage about right and wrong, the obligatory and the forbidden, and the legitimacy of professional power. Frontline clinicians enter this collision zone between the desirable and the possible when they discover that their knowledge and training are not enough to carry out the right decision, given the background structures of their job.
Staff members do not know, because they do not need to know, that all these structures have a history. Clinician and client do not stand face-to-face on a featureless plain, as generic healer to sufferer. A particular institutional history has produced the way they come to meet, the balance of power between them, and the social worlds they jointly negotiate. As a result, when blockages in work provoke clinicians to talk about right and wrong, they do not speak as generic ethical agents. They speak instead from their partial perspective, traversing the permanent, if buried, features of this particular landscape of practice. In the end, everyday ethics is historically produced, but in ways largely invisible to clinicians themselves. To understand today's dilemmas requires tracing the tangled past of this mode of treatment. The shape of action for frontline providers is a layered domain where the outcome of prior policies and ideologies is woven in today's ordinary work routines (cf. Rhodes 1993). The relevant past includes the deinstitutionalization of psychiatric patients starting in the mid-twentieth century, the tragedies left in the wake of this broad social movement, the new models of community-based services that arose as a response, and the diffusion of these models across American mental health services. Each strand in this genealogy informs the everyday ethics that emerge at the clinical frontline.
DEINSTITUTIONALIZATION: ORIGINS AND AFTERMATH
Deinstitutionalization in the United States occurred at the confluence of several distinct trends. During the late nineteenth century, the number of patients at state mental hospitals gradually rose due to urbanization and immigration. The rising censuses pushed such institutions away from their founders' optimism and the humanistic goal of "moral treatment." By the first few decades of the twentieth century, most state hospital patients were confined for years, if not their entire lives, and received little more than custodial care. Outrage over the crowded and deteriorated conditions flared up during the 1940s in popular books, magazines, and films. These high-profile exposés made the mental hospital a symbol of hopelessness and neglect for the broad American public. At the same time, the professional commitment to hospital-based care also started to erode. Psychiatrists wanted to align themselves with the therapeutic revolutions sweeping through the rest of medicine and were eager to sever their long-standing exclusive association with custodial institutions. Psychiatrists' experience in World War II also fueled their enthusiasm to relocate patient care outside of hospitals. They discovered that the early diagnosis and treatment of soldiers' mental disorders near the battlefront and in soldiers' own social milieu often had better outcomes than the standard services delivered in remote hospitals. The experience of treatment soldiers in noninstitutional settings became an alluring model for psychiatry as a whole.
At the national level, vastly increased public investments in medical research also laid the groundwork for deinstitutionalization. During the immediate postwar period, the mental health system as a whole was reshaped by a new enthusiasm for federal health policy initiatives. With the establishment of the National Institute of Mental Health (NIMH) in 1949, policy makers and leaders of academic psychiatry began to conceive of mental illness as a public health problem, amenable to high-level systemic interventions. The architects of mental health policy aimed professional services at a broader population, including both inpatients and outpatients, with mild to severe symptoms. The public health perspective produced the paradigm of community mental health, which envisioned a dispersed, nationwide network of small outpatient clinics to replace the large, centralized state hospitals.
Other mid-century developments, both technological and ideological, made the large state mental hospital seem "antiquated, outmoded ... and obsolete," in the words of the 1958 presidential address of the American Psychiatric Association. In 1954, the first phenothiazine drugs were introduced into American hospital use. Chlorpromazine, marketed as Thorazine, had the dramatic effect of calming belligerent and loud patients and making it easier to discharge them without opposition from family members or neighbors. The expanding arsenal of antipsychotic medications (such as halperidol, introduced as Haldol in 1958) justified the goal of emptying the back wards and reintegrating long-term patients into society (see Gronfien 1985). Ideological shifts of the era also endorsed the vision of noninstitutional care. Sociologists criticized long-term psychiatric hospitalization as inherently humiliating and an assault on personal dignity (Goffman 1961, Belknap 1956). Within professional psychiatry, reformists shared in the early 1960s idealism about improving society through government programs. At a time of federal interventions to end segregation and combat poverty, a top-down recipe for refiguring mental health services was enormously attractive. The federal government seemed better equipped than the states to solve social problems, including the provision of mental health services. In 1961, an NIMH working group predicted that new community mental health programs, combined with public education to reduce the stigma of psychiatric illness, would make "the mental hospital as it is now known to disappear from the scene in 25 years" (quoted in Grob 1994: 253).
The cascade of public sentiment, professional interests, and pharmacological developments eventually produced an important shift in federal policy: the Community Mental Health Centers Act of 1963 (Title II of Public Law 88–164). The Act was the key driver of the planned replacement of custodial institutions with community-based treatment facilities. According to the dominant psychiatric opinion at that time, new medications meant that most of the mentally ill could be successfully treated in their own communities and returned to a useful place in society (see Rochefort 1997). The distance between such utopian rhetoric and the real-world results is widely documented. The legislation called for 2000 community mental health centers (CHMCs), but by 1980 only 754 had been built. The Act did not require planning to connect CHMCs to state hospitals. It did not specify the services needed by people after they were discharged. Indeed, contrary to reformers' expectations, state resources did not follow the ex-patients into the community. The savings from hospital closures essentially flowed back into state budgets, and local communities did not take over the financing of CHMCs when federal support declined. The populations of large state mental hospitals did decline, as intended by the 1963 legislation, but few ex-patients received services from the community mental health network.
The next phase of the deinstitutionalization process was driven by the expanding federal welfare state. Monies available through Medicare and Medicaid (federal health insurance programs established in 1965) did not pay for state mental health facilities, but they did reimburse other forms of long-term care. As a result, vast numbers of the elderly mentally ill were transinstitutionalized, that is, moved directly from state hospitals to nursing homes, which could capture federal payments. In the 1970s, Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) started to provide monthly living subsidies that enabled unemployed individuals with serious mental illness to live in room-and-board residences or independent apartments. Thanks to federal insurance and income maintenance programs, therefore, the states could realize substantial savings by closing or radically shrinking their large mental hospitals. These financial incentives sped up the deinstitutionalization process and essentially competed what earlier ideological, professional, and technological developments had begun.
Deinstitutionalization quickly and dramatically lowered the total number of psychiatric inpatients from the high point of 559,000 in 1955 to 193,000 in 1978, 110,00 in 1985, and 80,000 in 2002. Over the same period, the average inpatient stay also shortened considerably. Before 1965, people would often spend years, if not decades, in institutions. In 2006, the average length of stay in U.S. psychiatric hospitals was seven days (U.S. Dept. of Health and Human Services 2008), and that figure has remained constant ever since. However, a snapshot of before and after statistics hides the long-term effects of deinstitutionalization and hence the background of practice in today's community psychiatry. By the late 1960s, the rising cohort of young people with severe psychiatric disorders—which usually begin in people's late teens to early thirties—entered into a new array of treatment options. For the first time in nearly a century, people now experienced the onset of severe disorder while remaining outside of long-term institutional control. These young adults established a new pattern in their use of psychiatric services that continues until today: a "revolving door" of inpatient stays, stabilization via medication, discharge to the community, resumption of isolated and disorganized lives, and subsequent rehospitalization. Many members of this group live in marginal, often dangerous surroundings, and they depend on an uncoordinated and underfunded collection of outpatient medical and social services. The severity of the illness, the fragmentation of services, and the realities of urban poverty (including easy access to alcohol and street drugs) make it enormously difficult for people to recover fully or to establish independent lives outside the welfare, medical, and criminal justice systems.
What these young adults faced in the 1970s fundamentally drove the development of new forms of public mental health services. For the first half of the twentieth century, housing, food, daily occupations, medical and psychiatric treatment, and even social identity came bundled together for patients, who lived in self-contained state hospitals with populations as large as 11,000. As states scaled back these custodial institutions and shifted the costs to federal programs, the de facto responsibility for ex-patients fell onto a fragmented network of psychiatrists, police, judges, and social workers. In the current landscape, many different authorities target the needs of people with severe mental illness, but in an uncoordinated fashion. Separate agencies do not communicate well, and each has its own discrete mandate (housing, medications, employment training, addiction treatment, access to public subsidies, social rehabilitation, and criminal justice). They have little knowledge of each others' rules and operating procedures, and they enforce different expectations and eligibility criteria on clients. Although state and county mental hospitals continue to exist, they now offer short-term stabilization or serve as the last resort for the most treatment-resistant and difficult-to-place individuals. In stark contrast to the earlier era of total institutions, people with severe mental illness are scattered throughout society, and no single organization or profession accepts responsibility for their lives (Mechanic 1989, Grob 1994).
The failures of deinstitutionalization became clear by the mid-1970s. Broad public dismay was fueled by media reports about the homeless mentally ill and what was widely labeled the "dumping" of ex-patients into dilapidated single-room occupancy hotels. Expert opinion in psychiatry and health policy was just as scathing. A new consensus arose that "the rhetoric of deinstitutionalization seems to mask a brutal political and economic reality—the general abandonment of mentally disabled people" (Rose 1979: 440). In earlier decades, professional discourse had celebrated community care as a therapeutic revolution and an end to the dark ages of institutional confinement. During the 1970s, this discourse evaporated almost without a trace. Psychiatrists and social scientists instead characterized deinstitutionalization as programmatic chaos, a disaster, and a continual failure in which bureaucratic needs trumped patient care (the terms used by Scherl and Macht 1979, Talbott 1979, Brown 1985 and Talbott 1984).
The failure had many causes. Policy makers justified deinstitutionalization in undefined or generic terms—community, reintegration, and rehabilitation—that inevitably got used in contradictory ways. The terms gave the appearance of a progressive, coherent system that bore no resemblance to the reality on the ground. The forces arrayed in favor of depopulating state hospitals were unstoppable, but they lacked an overarching blueprint. The ultimate fragmentation and substandard care were thus the unintended consequences of a largely unplanned process (see Bachrach 1990, Mechanic 1989). In particular, reformers overlooked how housing, income support, and social connections affect the well-being of people with disabling symptoms. The stepwise process by which the state abandoned people with serious mental illness thus produced an entirely new cluster of clinical needs and social dilemmas.
For example, ex-patients and younger people who had never been hospitalized started to receive monthly federal subsidies, and they became a lucrative commodity for entrepreneurs operating nursing homes, group homes, board-and-care facilities, and single-room occupancy hotels. The economics of this business are simple: the less money spent per capita on tenants, the higher the profits. Consequently, people with serious mental illness began to spend part of their lives ghettoized in custodial settings that were smaller but just as untherapeutic as the old state hospitals. A similar logic operated in the private nonprofit agencies that specialized in community psychiatric services. Such agencies captured more federal reimbursements if they treated more individuals, and too often the result was higher caseloads, the hiring of under-qualified providers, and a declining quality of care (Mollica 1983). Because of economic contingencies, the isolation and neglect that characterized the early twentieth century asylum reemerged 70 years later as fundamental aspects of public sector mental health.
COMMUNITY SUPPORT PROGRAMS: ASSEMBLING THE NEW NORM
The undeniable neglect of people with severe mental illness and the reversion to custodial care led to a shift in the policy landscape of the late 1970s. The Community Support Program (CSP) was the major federal response. It rejected the naïve assumption that discharging hospital patients would naturally lead to "community integration" and that facilities like board-and-care homes actually rehabilitate their residents. The program instead began with a cold appraisal of the results of deinstitutionalization (Turner and TenHoor 1978). People with severe mental illness faced enormous obstacles in getting services from general hospitals, social welfare agencies, legal clinics, public housing bureaus, and employment training centers. These institutions simply had no experience with the mentally ill and no specific mandate to serve them. Their staff tried to avoid serving people with the most disabling and chronic symptoms. Federal programs were evaluated on the basis of their efficiency—that is, how cheaply and quickly they could find jobs and independent housing for their clients. As a result, providers preferred to cherry-pick the high-functioning individuals, and they left those with severe disabilities to fend for themselves (see Tessler and Goldman 1982).
Excerpted from Everyday Ethics by Paul Brodwin. Copyright © 2013 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
Introduction: The Terrain of Everyday Ethics Background to practice1. Genealogy of the Treatment Model 2. Expert knowledge and Encounters with Futility Tools of the trade3. Treatment Plans: Mandatory Narratives of Progress 4. Representative Payeeships: The Deep Logic of Dependency 5. Commitment Orders: The Practice of Consent and Constraint From Everyday to Formal Ethics6. Coercion, Confidentiality, and the Moral Contours of Work Bibliography