Abstract
This article investigates the ambivalence of front-line mental health clinicians toward their power to impose treatment against people’s will. Ambivalence denotes both inward uncertainty and a collective process that emerges in the midst of everyday work. In their commentaries about ambivalence, providers struggle with the distance separating their preferred professional self-image as caring from the routine practices of constraint. A detailed case study, drawn from 2 years of qualitative research in a U.S. community psychiatry agency, traces providers’ response to the major tools of constraint common in such settings: outpatient commitment and collusion between the mental health and criminal justice systems. The case features a near-breakdown of clinical work caused by sharp disagreements over the ethical legitimacy of constraint. The ethnography depicts clinicians’ experience of ambivalence as the complex product of their professional socialization, their relationships with clients, and on-going workplace debates about allowable and forbidden uses of power. As people articulate their ethical sensibility toward constraint, they stumble over the enduring fault lines of community psychiatry, and they also develop an ethos of care tailored to the immediate circumstances, the implicit ideologies, and the broad social contexts of their work.
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Notes
The comparison between biopsychiatry and psychoanalysis trainees—the heart of Luhrmann’s book—yields a striking paradox. The former group exerts much more power over patients (via commitment orders, restraints and seclusion room) than do psychotherapists. Yet young biopsychiatrists view their patients as potentially harmful, and on that basis fear or resent them, while the therapists worry about how they can harm their patients (Luhrmann 2000, pp. 84–118).
The second question reflects the specific conditions of emergency room psychiatry, where the extremely short length of stay and the mandate simply to stabilize patients and then make a quick disposition prevents staff from learning much about their personal style, standard ways of reacting to stress, level of insight, etc.
I have slightly rearranged the order of these passages, but have not altered any words, phrases or sentences.
The arrest rates for this population are remarkably high. In a recent study from Florida, 31 % of Medicaid enrollees with schizophrenia or bipolar disorder were arrested within 7 years after hospital discharge (Van Dorn et al. 2013).
Participant observation research took place for two years at an intensive case management program for people with severe mental illness. Although based on the principles of Assertive Community Treatment, “Eastside Services” does not meet the formal fidelity standards for ACT currently used by certain states to authorize, evaluate and fund community psychiatric services (see Teague et al. 1998). The author attended 120 staff meetings and accompanied six case managers, for approximately four months each, on their daily visits to clients’ homes and meetings with psychiatrists, lawyers and family members. The author observed ten sessions of counseling and medication management between the consulting psychiatrist and clients. Other sources of data include 30 semi-structured interviews: 20 with case managers, five with the program director, and five with the psychiatrist. Fieldwork involved documenting both the on-going moral commentaries made by clinicians in the midst of seeing clients and the use of more abstract ethical language during staff meetings and research interviews. The author also attended training sessions for new case managers run by the state Department of Mental Health, as well as four regional continued education seminars for social workers about ethics and boundaries. Transcribed interviews and field notes were coded with Nvivo 2.0. Institutional Review Board approval from the University of Wisconsin-Milwaukee was obtained before beginning research. Study participants did not receive compensation. All names and identifying details have been changed.
Monahan includes other common practices in community psychiatry under the category of mandated treatment, especially the use of money and housing as leverage. In public sector settings, many clients of community agencies depend on disability payments from the Social Security Administration. The agency can petition the government to become a “representative payee” and directly receive clients’ disability monies. Providers can make acceptance of treatment a condition for access to disability monies or for help finding subsidized housing. These types of leverage fall on the same continuum as directly constraining tactics like commitment (Redlich and Monahan 2006).
Technically, they have a record of “stipulations to treatment,” a legal hold that is easier to obtain in mental health court but lasts for a shorter period of time than a full commitment. As a tactic to leverage adherence to community-based services, stipulations are the functional equivalent to commitment.
I omit the citation in order to ensure the anonymity of the research setting.
Commenting on a conference presentation of this case, Dr. Raj Bhatla, a Canadian ACT psychiatrist, pointed out the distinctively American approach to settling the impasse. Ending the controversy via majority rule left a significant number of clinicians angry and dissatisfied, thereby harming team morale and cooperation (Bhatla, personal communication). His comment emphasizes the need for more international and comparative research into the everyday ethics of community psychiatry. Since its invention in Madison, Wisconsin in the late 1970s, the ACT model has spread globally in the Canada, the UK, Australia, Japan, and several European countries, where the implicit modes of governance and resolution of ethical debates are potentially quite different (see Burns et al. 2001).
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Acknowledgments
The author thank the National Science Foundation for funding this study and the clients and staff of the pseudonymous Eastside Services for their generosity. The author is also grateful for the perceptive comments of the peer reviewers as well as Janelle Taylor, Michele Rivkin-Fish, and their colleagues at the University of Washington-Seattle and the University of North Carolina-Chapel Hill where he presented early versions of this paper.
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Appendix
Appendix
Excerpt from Narrative Progress Note, Eastside Services:
Client: Nicole Watkins… I had a meeting with supervisor Linda Martell. We developed a treatment plan to present to the court in an effort to provide Nicole with a realistic treatment program in the community that could keep her from becoming a repeat offender and can be presented to the court in order to avoid her doing some significant time in prison. We came up with the following guidelines which will be put forth in a letter to Attorney Dan Schmidt.
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She is to be enrolled in the mental health unit of the Office of Probation and Parole and will be expected to comply with all probation officer’s visits.
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Upon release from jail, she will be placed in a residential treatment program for prisoners with drug and alcohol problems.
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After completion of the residential treatment program, she will spend 1 year in a room and board facility that has a focus on serving prisoners with drug and alcohol problems. She must indeed reside at this facility which includes spending her nights there.
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4.
She is to comply with psychiatric services provided by Eastside Services. These services are to include medication monitoring 7 days a week, 3 of these visits will occurring the Eastside Services office and 4 of them will be home visits by Eastside Services staff. She is to take psychiatric medications as prescribed. She is to be available at the designated appointment times whether it is in the Eastside Services Office or a home visit. She is to allow for money management with dispensation of discretionary income at the Eastside Services’s discretion.
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She is to comply with random urine screens.
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She is to refrain from any alcohol or illicit substance use.
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7.
She is to refrain from illegal activities.
James Young, MD [signature]
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Brodwin, P. The Ethics of Ambivalence and the Practice of Constraint in US Psychiatry. Cult Med Psychiatry 38, 527–549 (2014). https://doi.org/10.1007/s11013-014-9401-z
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DOI: https://doi.org/10.1007/s11013-014-9401-z