At the heart of this impressive ethnographic study of the pseudonymous ‘Eastside Service’ lies a simple question: what is – or might be – ‘everyday ethics’ for community mental health care? Anthropologist Paul Brodwin, never allows the question to slip out of sight, whilst never denying the elusiveness of a definitive answer.
Emphatically, ‘everyday ethics’ – the nexus of compromises, reflections, re-negotiations, fudges, ideals, ambitions, hard rules and soft cheats employed by a US Assertive Community Treatment (ACT) – is not formal bioethics. It ‘emerges, by definition, against the background of ordinary practice’ (p.29), though it both disrupts and makes possible this very practice. Neither is ‘everyday ethics’ bluntly antithetical to bioethics. Brodwin’s final chapter illustrates the interrelationship(s) between the formal, theoretical and high-order ethical debates and the practical, pragmatic manoeuvres of the community-based clinicians. ‘Everyday ethics’ and bioethics can sometimes form mutual co-productions, demonstrating ‘how scientific knowledge and particular social conditions emerge simultaneously and in mutual dependence’ (p.192), whilst on other occasions the ‘apparatus of formal bioethics’ and the ‘ethical sensibilities’ of the front line are in blunt and frustrating contradiction (p.198).
Brodwin’s thesis – grounded in long-standing sociological, bioethical and anthropological discourses – and his avowed intent of ‘[m]aking ethnography speak to bioethics’ (p.179), will be of especial interest to those involved in mental health policy, as clinicians or theoreticians, and those with an academic interest in bioethics. However, the book enjoys a considerably broader appeal. Brodwin provides an accessible account of the socio-historical context for the post-decarceration Community Service Program (CSP) for mental health care in the US, as well as a richly illustrative survey of the ACT model. Both in its opening contextual, two-chapter section ‘Background to Practice’ and each of the three cases studies of specific ACT powers and procedures comprising the second section, entitled ‘Tools of the Trade’, Everyday Ethics serves as a potted history of the politics, theory and practice of community psychiatric services. Though resolutely a work of academic bioethics, the text can be read easily by those new or entirely unrelated to the field.
Central to its readability are the well-drawn ‘cast’ of Eastside. There is Doctor Young, the realist psychiatrist, balancing medical rigour with offhand flourishes of Occam’s razor; of one patient’s ‘delusions’ he remarks ‘[m]aybe it’s because he’s a black man in Westbury’ (p.62). There is cynical supervisor Allison Esser, who dishes out ‘cover-your-ass’ (p.166) bon mots to the case managers and gallows humour to the ethnographer: ‘that’s the time to trample their rights’ (p.7). And then there are the various case managers, most notably the seasoned, critical ‘everyday ethicist’ Neil Hansen who – in a way that mirrors in microcosm the ethnography itself – provides an ‘immanent critique’ (p.83) of ACT (‘bullshit’ apparently p.172).
All this before turning to the ‘consumers’ of Eastside Services, who pepper the text as lightly sensational vignettes of varying sizes and tragedies. From dramatically discovered dead bodies, to bodies inflating to 240 pounds on a diet of antipsychotics and candy, from those bribed into swallowing ‘meds’ in a parked car like a parody of a street drug deal, to the genuine sofa-selling article badly concealing their crack smoking from the case manager knocking at the door. In this Dickensian spasm of characterisation, the ethnography (necessarily) echoes one of the key faults of the ACT care model: the ‘consumers’ only manifest as problems and crises, either receding into chronicity or cresting into an acute incident.
Undoubtedly, Brodwin makes the reality of the clinical ‘frontline’ – a military metaphor oddly left unchallenged – palpable, and occasionally visceral. There’s a ‘shaky cam’ aesthetic pleasure to be taken in these jerky interpolated narratives; the sassy quick-fire quasi-ethical debates in team meetings and corridor conferences, where the fates of service-users are ostensibly decided, feel like exchanges from an unwritten season of The Wire. There’s no reason to question their general authenticity yet Brodwin’s account of his methodology, only footnoted, explains that much of the material was captured in ‘field notes handwritten at the time’ (p.25 ft 4). Certainly, with several decades of anthropological fieldwork behind him, it’s probably safe to assume Brodwin has decent shorthand, but even so, these ‘quotations’ are only part ethnographic reportage, part fictional construct. As befits ethnography, Brodwin is overtly reflective of his practice, quoting Walter Benjamin on literary translations to frame the ethnographic language as one ‘powerfully affected by the foreign tongue’ (p.13). Consequently, it’s hard not to feel that it would have been interesting for Brodwin to reflect further on how these allegedly foreign tongues themselves are partially constructed by the ethnographer, and his cultural, social, historical and political orientation in time and space. An appendix on the fictionalising element inherent in ‘illness narratives’ or medical ethnographies would have been a fascinating added delight.
The text is strongest when focussing on one particular mechanism of practice, and pulling it apart, by deconstructing the ideological assumptions inherent in its construction and throwing into sometimes dazzling relief the perpetuation of those assumptions, and the inequalities of power and knowledge they simultaneously require and propagate. Brodwin’s taut analysis is never better than in Chapter Three’s quietly acerbic dismantling of the ‘paperwork technology’ of treatment plans, which reveals the ‘bureaucratic logic’ of their construction and the therapeutic consequences of that logic. A brief passage in which Brodwin demonstrates how the state rules dictating the narrative structure of a service-user’s progress and goals serve to actively derail treatment and ‘work against the team’s better clinical judgement’ (p.100) is jaw-dropping. Here, the author’s laconism is more affecting than any tub-thumping polemic.
There are some – perhaps strange – omissions from the debate(s) within the book. The baseline terminology of mental health grows increasingly troublesome daily, and Brodwin only obliquely engages with this issue, squirreling a brief clarification away in a footnote to the introduction. [Exhibiting the anthropologist’s painstaking deference to the voices of others, Brodwin introduces a critique of the terms ‘illness’, ‘diagnosis’ and ‘symptoms’ attributed to David Oaks, the director of ‘a human rights advocacy organization for people with experience of psychiatric hospitalization’; this language gives sufficient indication of Oaks’ ideological position towards the bio-psychiatric discourse (p.25 ft 3).]
What goes wholly unremarked throughout Everyday Ethics is how the ACT ‘consumers’ are framed by references to poverty, substance abuse and familial problems, and never conceived in terms of neurochemistry, psychodynamics, or epidemiology. As a consequence, Brodwin’s claim that ‘[b]iopsychiatry pervades ordinary work at Eastside Services’ (p.61) seems only partially true. It is a loose biopsychiatry that trades in general references to disconnected symptoms, and vague, bureaucratic ‘compliance’ ‘stips’ and ‘meds’. Though Brodwin conceives of this as a bi-product of the case mangers being unable to ‘control the most highly valued knowledge’ or to ‘deliver the verbal performance’ (p.48) of biopsychiatry, it feels that the economically motivated displacement of the bulk of mental health care onto those with little or no medical training has played some role in the steadily increasing dissemination of non-biopsychiatric frameworks for understanding the experiences of these service-users. Though the ‘situated’ knowledge of the case managers may be – in any power hierarchy – ‘marginal to the official knowledge of professional psychiatry’ (p.49), the deep-situating of healthcare must contribute to the on-going grassroots reappraisal of the dominant biopsychiatric models, and some analysis of the influence of community healthcare on the changing epidemiological landscape of the psychoses would have been welcomed.
Similarly, the ‘consumer’ role – constructed through the various paperwork technologies and bureaucracies of policies and procedures quoted – is never fully interrogated. Perhaps the ethical assumptions underpinning a ‘marketisation’ of healthcare provision had necessarily to remain outside the scope of this ethnography, along with the relationship between the well-documented ‘fault lines’ in the community care model and the unaddressed ‘fault lines’ in the encompassing community of late capitalism. In societies of atomised consumers loosely bound by individual transactions, the old joke that care in the community was in truth don’t-care in the community can be topped; now, it’s don’t-care in the no-community.
Everyday Ethics accidentally throws up some interesting questions for those with experience of the UK mental healthcare system. Evidently, clinicians in the UK experience a paucity of coercive tools compared to those working at Eastside. Brodwin devotes a chapter to representative payeeships, a formal instrument of coercion in the US whereby the ACT receives the service-user’s welfare directly, and then helps them organise their finances. As Brodwin observes, the official purpose of the payeeships is to ensure the smooth payment of rent, utilities and food bills. The reality is that control of the service-user’s purse strings inevitably becomes leveraged as a method of treatment coercion and behaviour modification. Even when not so leveraged, the mechanism serves as both a reflection of supposed biomedical dependency (the service-user is neurochemically incapable) and a mechanism of socio-economic dependency (the service-user plays impoverished beneficiary to the wealthy paternal patron that is the ACT). No such formal equivalent exists in the UK, where residual welfarism guarantees an ever-diminishing minimum of financial sovereignty, though comparable mechanisms of leverage are on the rise according to a recent paper (Canvin et al 2013), with the possible outcome of weakening therapeutic effectiveness (Rugkasa et al 2014). If the US ACT model of coercion and dependency represents – to use the managerial speak increasingly applied to healthcare – the ‘direction of travel’ for UK community services, the lessons of Everyday Ethics could not be more timely or more necessary.
Reviewed by Michael Flexer, who is in the third year of his PhD on the semiotics of schizophrenia, at the Centre for Medical Humanities; University of Leeds. Outside academia, he works as a semiotician and freelance playwright.
Canvin, Krysia, Jorun Rugkasa, Julia Sinclair and Tom Burns. “Leverage and other informal pressures in community psychiatry in England.” International Journal of Law and Psychiatry 36 (2013): 100-106.
Rugkasa, Jorun, Krysia Canvin, Julia Sinclair, Anna Sulman and Tom Burns. “Trust, deals and authority: community mental health professionals’ experiences of influencing reluctant patients.” Community Mental Health Journal Available at < http://link.springer.com/article/10.1007%2Fs10597-014-9720-0> [Accessed 16 June 2014]