The ethics of ambivalence and the practice of constraint in US psychiatry.

Cult Med Psychiatry (2014) 38:527-549 DOI 10.1007/s11013-014-9401-z ORIGINAL PAPER

The Ethics of Ambivalence and the Practice of Constraint in US Psychiatry Paul Brodwin

Published online: 16 September 2014 Springer Science+Business Media New York 2014

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. Keywords

Psychiatry Ethics Coercion Constraint Ambivalence Care

Introduction This article explores the ethical sensibilities of front line providers in U.S. psychiatry. It asks how they come to terms with their disproportionate power over P. Brodwin (&) Department of Anthropology, University of Wisconsin-Milwaukee, PO Box 413, Milwaukee, WI 53201, USA e-mail: [email protected]

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Cult Med Psychiatry (2014) 38:527–549

people with in severe psychiatric distress. The article focuses on clinicians’ ambivalence toward common tools for work—physical restraints in hospitals and legal tactics to impose treatment in community settings—that have a built-in power inequality. Ambivalence, in the original sense of the word, is a psychological dynamic: the coexistence in one person of contradictory emotions or attitudes (such as love and hate) toward a given object. It is an interior state, and therefore intrinsically resistant to ethnography. Ambivalence can nevertheless motivate people to speak openly about their discomfort and actively to contest local norms and clinical routines. To order someone tied in four-point restraints or to deliver outpatient treatment under the threat of imprisonment can stir up contradictory attitudes, difficult for one person to contain. When clinicians express their ambivalence to each other, it can undercut the tacit justifications for psychiatric power. Expressions of ambivalence are a brand of everyday ethics, which I have defined elsewhere as the spontaneous expressions about right and wrong, the obligatory and the forbidden and the legitimacy of medical power made by clinicians immersed in ordinary work routines (Brodwin 2013, p. 10ff). Most of the time, of course, mental health staff who impose treatment against people’s will do not pause to evaluate the ethical legitimacy of their action. The demands of the day crowd out any moment of moral contemplation. In some settings, the entire rationale and apparatus of treatment can make coercive techniques seem inevitable and indispensable (illustrated by mental health services in prisons, see Rhodes 2004; Waldram 2012). To explore why some clinicians nevertheless do step back from the on-rush of work and articulate their ambivalence about psychiatric power provides an acute case study in everyday ethics. People discover that their own evolving self-regard as competent and compassionate somehow conflicts with the tools they must use or the decisions they are expected to make for individuals in psychiatric crisis. This sort of emergent conflict can motivate people to question if their usual work routines are justified or morally repugnant. The dictionary definition of ambivalence focuses narrowly on individual psychology: the subjective combination of love and hate or attraction and repulsion. As a classic psychoanalytic concept, it denotes a tendency to be pulled in opposite directions as well as the capacity to see multiple sides of an issue and to perceive interpersonal relations as having more than one value (English 1958, p. 25). Some authors sharply distinguish between ‘‘ambivalence’’ (a matter of deep subjectivity) and simple ‘‘mixed feelings’’ (a realistic assessment of objective conditions) (Rycroft 1973, p. 6). To examine ambivalence through the lens of everyday ethics, however, demands a broader definition. First of all, the interior state bleeds into face-to-face relations and can impede collective action. Holding contradictory attitudes can impair one’s ability to resolve a problem affecting interpersonal or group life. Even defined strictly as an interior state, ambivalence can disrupt social action, especially in settings marked by recurrent crises that demand a coordinated response. At the supra-individual level, ambivalence can also refer to the contradictory attitudes held by different people in the same group. When people try to harmonize their diverse orientations in order to launch a unified response to external events, ambivalence manifests as a collective state and a painful social

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tension. The disjunctive and sometimes incommensurable values held by different people are suddenly exposed. These are prime conditions for people to articulate their usually implicit value commitments, precisely because their own values are contradicted by others in a situation that demands that some triumph and others lose out. The hospitals and intensive case management programs described below show the operation of both personal and collective ambivalence. In these settings, clinicians must make quick judgments about treatment and the overall management of other people’s lives. To handle a psychiatric crisis, staff must act aggressively; they must do something in the next few minutes or hours (see Lupton 1995). The open expression of ambivalence can set staff members against each other and obstruct pressing clinical decisions. In the most practical terms, ambivalence can block the prime imperative to act; to articulate ambivalence and try to resolve it thus become pressing matters for the entire work group. When people engage in discussion and vigorous debate, personal and collective ambivalence becomes ethnographically visible. From the standpoint of front-line staff, the goal is simply to restore the smooth flow of clinical work. In the longer run, however, efforts to resolve ambivalence have another important effect. Such collective debates force into awareness of the occupational moralities and idealized self-images that usually hover in the background, and these are the fertile grounds of everyday ethics. The ethnography of ambivalence can shed new light on the contemporary culture of psychiatry and the ways clinicians articulate their expertise and the shifting values underlying their work. The article traces clinicians’ ambivalence toward tactics of constraint as it emerges in the midst of everyday routines. The original data come from ethnographic research in a single U.S. community psychiatry agency (the setting and theoretical goals of fieldwork are described in Brodwin 2008, 2010, 2011, 2013). In order to frame the data, the following section reviews prior discussions of ambivalence by anthropologists of psychiatry as well as psychiatrists themselves in their first-person narratives about clinical training. These writings highlight clinicians’ preferred self-image as compassionate and caring advocates and the problems this self-image creates during professional socialization. Because ethnography and autobiography differ as literary genres, each highlights distinctive aspects of people’s ambivalence about tactics of constraint. But both types of accounts reveal how self-doubt occasionally breaks through the surface of clinical work and the ways psychiatrists try to resolve it.

Ambivalence Toward Constraint: The Disposition of Front-Line Clinicians A growing tradition of research into the culture of US psychiatry explores how clinicians come to terms with the power imbalance in their workplace. In the accounts summarized below, psychiatrists’ must negotiate between their preferred self-image as fundamentally good and the mandate to distance themselves from patients and occasionally impose involuntary treatment. Especially during their years as medical student or resident, these clinicians struggle with a dual perception

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of people with severe psychiatric symptoms as persons but also as patients: two optics that sometimes coincide but more often rule each other out. Hospital-based residency training in biological psychiatry involves learning not only pharmacology and medical models of mental illness, but also ways to handle psychiatric emergencies, including the use of restraints and procedures for commitment (Luhrmann 2000, p. 27). Medical school and internship help set the stage for how residents eventually become comfortable with such techniques of constraint. Socialization as a physician teaches stoicism and emotional detachment as well as the assumption that patients are the source of physical exhaustion and danger. The antagonism toward patients only increases during psychiatric residency. People hospitalized against their will may curse, assault or threaten to sue their doctor. In-patients rarely stay long enough to become better and express their appreciation of good care (ibid.: 96 ff). In the end, the conditions of residency lead the young psychiatrist to become wary and even fearful of patients and the potential harm they cause.1 At the same time, residency training helps to fashion the moral instincts of young psychiatrists, that is, how they frame their ambitions and expertise as ‘‘fundamentally right and good’’ (ibid.: 23). On the one hand, residents know that their diagnostic judgments and clinical predictions have enormous consequences for patients’ lives. These forms of authoritative knowledge not only drive involuntary treatment but also create an image of the patient as irresponsible, incompetent and dependent. On the other hand, there is no gold standard for such judgments, and ambiguity often remains about the accuracy of a given diagnosis. Getting it wrong could undercut the psychiatrist’s good intentions by, for example, coercing someone who is actually responsible and rational. Psychiatrists manage that ambiguity by drawing a bright line between the patient’s person and the patient’s illness (ibid.: 139). They regard the illness as radically different from the person as a sovereign decision-maker. Guided by this notion, the psychiatrist responds to out-of-control or self-destructive behavior by taking the patient’s intention out of the equation (ibid.: 274). Seen in this light, for example, the action of somebody attempting suicide becomes simply a bodily dysfunction treatable by medication and whatever else is necessary to deliver that medication. To extrapolate from Luhrmann’s study, the notion that illness is fundamentally disconnected from the person ethically sanitizes the practice of involuntary treatment. At the moment when a psychiatrist actually signs the order for restraints, for example, she has the option of viewing the patient’s person as temporarily displaced by the illness. Even more, she can frame the intervention as recuperating the person; that is, creating the conditions so the person (as a responsible moral agent) will later re-emerge. The psychiatrist can thus accept the imbalance of power in the workplace but not continuously worry that it is unjust or usurps patients’ rights. In that sense, the biopsychiatric model coupled with the 1

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).

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powerful socialization of residency shields psychiatrists from ambivalence about involuntary treatment. Clinicians in psychiatric hospital emergency rooms largely accept the necessity to control patients and intervene against their will when their behavior becomes intolerable (Rhodes 1991, p. 37). Ambivalence nevertheless creeps closer to the surface for these workers compared to psychiatric residents described above. The ER staff remain aware of the moral murkiness of their situation. Psychiatrists in a supervisory role say they have learned to be comfortable in this setting where it is impossible to be good and that challenges broad social norms against direct coercion (ibid.:158, 38). Becoming comfortable is not an easy or quick process, however, and Rhodes explores how trainees come to terms with their power. One medical student expressed ambivalence after his court testimony helped send someone with homicidal thoughts to the locked ward. He wondered if his action served the best interest of the patient or instead of the system that demands quick turnover of new admits. Echoing the same ambiguity described by Luhrmann, he worried that the patient’s homicidal talk simply expressed poor judgment and not a disease (bipolar disorder, in this case) amenable to treatment. Ambivalence over psychiatric power here grows from two unresolved (and perhaps unresolvable) dilemmas. What is my obligation to the patient’s own interests and to the medical system, and what to do if these obligations conflict? How can I make high stakes decisions despite the questionable accuracy of predictions about future behavior?2 To push trainees through such impasses and turn them into effective workers, long-time staff counsel them not to take the patients’ point of view. For example, some students are shocked at the use of seclusion rooms, and they share the rage and frustration of patients locked inside. Their reaction contains an incipient critique of this standard ER practice as an abuse of power, even though students never develop it that far. In any case, they are told to reframe their automatic empathy with patients via the injunction, ‘‘Remember, you are not the patient’’ (ibid.: 142). Senior psychiatrists instruct the student to regard the patient as objectively sick and not a fit subject for identification. Students thereby get inducted into the clinical gaze: a ‘‘soft power’’ performed through diagnosis and other rituals of treatment that instantiate and legitimate the clinicians’ unilateral decisions (compare Martin 2007, pp. 98–133). In Rhodes’s account, however, power does not operate in a top-down fashion (from senior psychiatrist over students over patients). She adopts the Foucauldian model of fluid capillary power that gets exercised at different nodes throughout the mental health system and that people deploy in different ways. Perhaps Rhodes’s chosen theoretical framework allows her to detect persistent ambivalence even among senior psychiatrists and to trace the cracks in the justification for constraint that continually reappear among front-line staff. Autobiographic narratives by US psychiatrists shed another light on the moral pedagogy of residency training. In some of their first-person accounts, the author easily justifies the imbalance of power and perceives little conflict with the standard 2

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.

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ethos of care. Early in his book, Paul Linde describes the mission in the Psychiatric Emergency Service of San Francisco General Hospital (SFGH) as helping society’s most disenfranchised and hopeless (Linde 2010). He then reports two scenes from his training of people careening out of control: screaming, lunging at staff members, banging on the door of their seclusion room, and agitating other patients. In each case, the staff quickly puts the person in four-point restraints (that is, they tie the arms and legs to the corners of a steel bed bolted to the floor) and inject antipsychotic and tranquilizing medications. The confrontations end well in these narratives. The patients fall asleep for a few hours and after a nurse unties the restraints, they wake up less irritable and more able to manage social relations with staff and peers. Linde’s commentary on the cases is brief and confident. Doctors use the apparatus of constraint not out of an arrogant need for control, but because it helps improve people’s lives. It is ‘‘a necessary and therapeutic step in patients’ treatment. Giving truly ill patients sedatives and anti-psychotic medications allows them a chance to regain a piece of sanity—to tamp down anxiety, hallucinations and paranoia’’ (ibid.: 6–7). Linde endorses the procedure on both clinical and ethical grounds; in fact, his explanation effectively combines the two rationales. Relieving suffering, he writes, is the core of ‘‘the practice of ethical medicine’’ (ibid.: 180), and this goal legitimates the imposition of pharmaceutical treatment by all the usual means (restraints, seclusion rooms, and when necessary, the additional manpower of the SFGH security force). Although Linde does report some ambivalence about these scenarios, it does not extend very far. After overseeing the restraint and medication of a hostile woman, he reflects, ‘‘It’s weird. I feel bad that I had to order the shot at all, and I feel bad that I didn’t give it sooner’’ (ibid.: 11, emphasis in the original). After testifying in support of patients’ commitment at the mental health court, he says ‘‘I often felt like a jailer, sometimes justifiably so, sometimes not….in fact, I came to relish the challenge of trying to outduel the public defender….’’ (ibid.: 100). Throughout his memoir, Linde’s ambivalence is muted. It never affects his clinical decisions or makes him question the legitimacy of his role. Linde’s ethical sensibility recalls the way that residents in Luhrmann’s study manage their ambivalence. He subscribes to a therapeutic pragmatism in which the clinically beneficial consequences of his actions makes them ipso facto acceptable. The ambivalence cuts deeper in Tomer Levin’s account of his training at Eitanim Mental Health Center in Israel (Levin 2001). In his first month of residency, a patient punched Levin in the face, and he narrates the aftermath with a mixture of self-disclosure and empathy. He felt angry, helpless, and suddenly filled with doubt about his chosen profession. A few days later, the same women upturned a table and the nurses put her in four-point restraints. Levin describes his response: When I arrived at the restraint room, the [patient]…was crying uncontrollably. Between sobs she explained that she couldn’t take it anymore. There was no room to breathe in the department. She was the only one who did not smoke. No-one paid any attention to her. She wanted to go into the exercise yard to get some air and bit of peace and quiet.

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It was not hard to empathize with her. What she was saying was in no way psychotic… I tried to remind myself that physical restraint is a therapeutic intervention, calming the disturbed psychotic patient and facilitating a forced rest. The patient’s emotion-laden memory, however, was of physical restraint as a nontherapeutic event…. It is unavoidable that the other patients will look on, horrified. There is an element of humiliation and degradation, even if it is not intentional… … For me, there is no symbol of loneliness more tragic than a patient tied to a cast-iron bed in a whitewashed room, regardless of whether it is a necessary measure or not (Levin 2001, pp. 541, 542).3 Levin’s account of ambivalence proceeds in several steps. First, he is uncertain about the continuing therapeutic need for four-point restraint. Once tied to the bed, was the woman indeed still psychotic? Second, he feels/imagines his way into the experience of people at the receiving end of massive psychiatric power. Levin grants validity to patients’ experience, and on this basis, he interprets the practice of constraint as both an effective treatment and an act of humiliation and degradation. Significantly, the first interpretation does not rule out the second. Levin’s account recalls the ethos of care described by the clinicians in Good et al. (2011). He maintains a vision of the woman in restraints as both a patient (requiring treatment, even against her will) and a person (requiring dignity and understanding). Even when constraint is clinically appropriate for the patient, it can gravely harm the person. Levin’s double perspective explains the lingering ambivalence in his written self-portrait. First-person accounts by psychiatrists are complex literary products, involving elements of the confessional, the bioethics case (Chambers 1999), and the professional training tale (Pollock 1996). Like all physician autobiographers, Linde and Levin draw authority from their eye-witness and experience-near perspective. At the same time, their works are meant for public consumption, so they portray medical practice in a particular light (Pollock 2000). Despite their differences, both Linde and Levin depict themselves (and by extension, other psychiatrists) as upright ethical actors. The stories show them reflecting on the stakes of work, becoming aware of their own ambivalence, and trying to strike the right balance between compassion and coercion. In both cases, the stories function as a private conscience on public display. As textual performances of personal conscience, the narratives contain built-in assumptions and limitations that call for ethnography as a corrective. The first assumption, intrinsic to the genre of autobiography, concerns the location of ethical sensibility. In these narratives, it rests entirely inside the individual, who either personally endorses (Linde) or partially resists (Levin) the customary practices that surround him. The stories recount the sentimental education of young psychiatrists who develop their own moral compass in trial-by-fire fashion. The authorprotagonists shape themselves as moral agents by observing the situation around them and assessing particular acts of constraint on empirical as well as empathetic 3

I have slightly rearranged the order of these passages, but have not altered any words, phrases or sentences.

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grounds (Do medications help the patient? Do four-point restraints humiliate the person?) Providers’ ethical sensibility, as portrayed in these stories, is a matter of individual discernment. Clinicians arrive at their values privately, and not through conversation, debate or persuasion. The ambivalence they write about is an interior mental state. The narratives are nested in, and implicitly refer to, the dominant model of selfhood in American medicine. One of the tenacious assumptions of Western medicine (Gordon 1988) is the moral autonomy of the individual, uncontaminated by social roles and local practices. The same commitment to individual ethical choice, developed in the modern liberal tradition of Western moral philosophy, colors both the literary self-consciousness of these physician authors as well as the formal bioethics discourse of rights and legitimate paternalism that regulates the practice of constraint in the workplace (Wolpe 1998). The psychiatrists’ autobiographical voice in these narratives strikes us as moral precisely because it conforms to a model of the autonomous individual who crafts a distinctive position toward social routines and consensual norms. The second assumption concerns occupational sovereignty. The stories told by Linde and Levin report on the first few months on the job and the first year of residency, respectively. Similar to other medical training tales (Pollock 1996), the authors acknowledge their dependence on the greater clinical experience of nurses and their conflicts with the entrenched hospital bureaucracy. Both authors and readers, however, know that such rites of passage are temporary. Even these newly credentialed psychiatrists have the sole authority to sign the medication order and treatment plan and in other ways make decisions that lower-ranked professionals will carry out. Sooner rather than later, they will occupy a secure and powerful position in the medical hierarchy. Without stating it outright, the authors assume that their ethical reflections matter, because their decisions bear most strongly on patients’ lives.

Varieties of Ambivalent Experience The following case study from Eastside Services draws on many of the ideas presented above. It privileges the local, short-term logic and partial understanding of mental health staff, in the manner of Rhodes (1991). It explores the competing images of personhood and patienthood that clinicians apply to people receiving mental health treatment. Many of the staff members in this case management agency invoke a therapeutic pragmatism comparable to Linde’s in order to justify their unilateral power. Others experience a crisis of conscience similar to Levin’s, and they criticize tactics of constraint as untherapeutic at best and morally reprehensible at worst. The case study departs, however, from certain assumptions in the autobiographical narratives. The published first-person accounts present ethical sensibility in its fully developed form that the author applies retrospectively to cases long since finished. The case below, by contrast, depicts providers immersed in front line work who build up their position step-by-step in an iterative process. Each twist and turn in the case demands from people a new articulation of

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the ethical stakes and new opportunities to persuade others or push against the growing consensus. Autobiographical narratives portray ambivalence as a conflict with the individual. Yet ambivalence is also a collective problem that produces friction between people on the same treatment team. Open debates and shared clinical labors enter deeply into peoples’ judgments about the legitimacy of constraint. Finally, the case from Eastside Services does not focus on the socialization of clinicians, but on people who have long since finished their training and hence face different contingencies for their everyday decision-making. The ethnography explicitly connects people’s ambivalence to their place at the scene of work. The case study does not substitute a crude sociological determinism (where social role and rank dictate one’s values) for a purely individualist notion of moral agency. Providers’ experience of ambivalence is nevertheless connected to their training, typical duties, their memories of past conflicts, and the politics of the workplace. Particularly in this community treatment settings, staff members of all ranks run into difficult quandaries about the legitimacy of constraint and the justifiable scope of their power. In mental health services located outside the hospital, formal authority does not map cleanly onto people’s felt obligation for clients’ well-being. Case managers often have great independence and make many decisions about care on their own. The occupational sovereignty of psychiatry has definite limits in these settings, and lines of authority become tangled, because lower-ranked social workers have by far the most contact with service users. Ethnography must therefore attend to the ethical experience of all ranks of clinician, from the young case manager with only a bachelor’s degree to the seasoned psychiatrist. The way people talk about the line separating care from constraint, and legitimate from illegitimate constraint, depends on the immediate context of work and the template of the treatment program. The case documented below unfolds within a clinical team practicing ‘‘intensive case management,’’ a common model in US community psychiatry (for more details about the setting, see Brodwin 2013; similar programs are described by Estroff 1981; Floersch 2002). The outpatient location of this work establishes the broadest conditions for people’s experience of ambivalence. In a hospital, the contest of wills between clinician and patient has a fairly swift and pre-determined outcome. Outside the hospital, the time-line for tactics of constraint grows longer and people can find more strategies to resist treatment orders. Some people living in poverty and with symptoms of schizophrenia or bipolar disorder get immersed in the criminal justice system.4 As a consequence, community-based providers find that the distinction between police power and psychiatric power is blurred. Linde expresses his ambivalence about in-patient commitment with the metaphorical question: Am I jailor, and if so, is it justified? When community providers cooperate with criminal courts, the metaphor becomes real and the stakes considerably higher. In the case below, clinicians reached

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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).

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diametrically opposed positions about cooperation with the criminal justice system, and the impasse threatened a total breakdown in clinical work.

Tactics of Constraint in U.S. Community Psychiatry This ethnography draws from 2 years of fieldwork with an intensive case management team, founded on the principles of Assertive Community Treatment, in a mid-sized city in the American Midwest.5 The pseudonymous Eastside Services operates within a large behavioral health clinic serving a poor inner-city neighborhood, and it strives 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. They risk becoming more psychiatrically unstable, homeless, re- hospitalized, or incarcerated (typically for non-violent offenses such as loitering, disorderly conduct, and drug charges). Eastside case managers are primarily social workers (with a BA or MSW) who travel to clients’ homes and deliver medications, watch clients take them, and assess their symptoms. In line with the ACT mandate, 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 police, probation officers and landlords, testify at commitment hearings, and do whatever else is necessary to help them succeed in community living. Clinicians at Eastside Services rely on the two main types of constraint typical in US community psychiatry (see Monahan 2011).6 The most common is outpatient 5

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.

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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).

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commitment: a legal order to adhere to treatment while residing outside the hospital. This tactic of constraint emerged in the 1970s in the wake of deinstitutionalization and civil rights reforms in mental health law (Hiday 1996). Under this scheme, people with severe mental illness who meet certain medico-legal criteria (dangerousness and major deficits in self-care) are allowed to live freely in the community but must accept mental health services. If they refuse (that is, if they miss appointments or reject medications), they can be forcibly hospitalized. When a client relapses, Eastside staff discuss whether to ‘‘call in the commitment,’’ that is, request the county sheriff to drive to a clients’ apartment and transport them, sometimes in handcuffs, to the emergency room of the public psychiatric hospital. At Eastside Services, the vast majority of clients have a history of outpatient commitment.7 Even when it expires after a few months, the staff do not necessarily inform the person. One case manager told me that outpatient commitments are the ‘‘gluing agent’’ that makes possible the whole constellation of services: home visits, medication, and control over housing. Almost all the clinicians on this team accept the need for civil commitment. They acknowledge that most clients do not want to take their medications or to allow case managers into their apartments. They believe that only the additional (but usually veiled) possibility of forced re-hospitalization convinces people to accept their medications and keep appointments. Clinicians here follow the familiar logic of therapeutic pragmatism. For them, the manifest effectiveness of outpatient commitment removes any grounds for objection to it as contrary to the ethos of care. Outpatient commitments issue from a civil court, sometimes a dedicated mental health court, and more specifically from negotiations between an individual’s lawyer (arguing to protect civil liberties) and the mental health department’s lawyer (arguing for mandated treatment). Entirely a matter of civil law, they nevertheless resemble probation in the criminal justice system: a person avoids confinement as long he or she complies with certain conditions. Community psychiatry has another tool of constraint, however, that engages more directly with the criminal law. Individuals facing incarceration (for non-violent offenses) can win probation from a judge in criminal court by agreeing to accept mental health treatment in the community. Again, if they cannot or refuse to comply, they must return to confinement, but now in an actual jail in order to serve out their original sentence. In one multi-site study in the US, between 12 and 20 % of persons with mental illness experienced either outpatient commitment or legal probation conditional upon accepting treatment (Swartz et al. 2006).

The Ethnography of Ambivalence The case below shows how clinicians figure the legitimacy of these two types of constraint: outpatient commitment from a civil court and cooperation with the office of probation and parole in the criminal justice system. Eastside clinicians accepted 7

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.

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the first without hesitation, but some staff members vociferously opposed the second. Tracing the roots of their opposition and its expression in the give-and-take of daily work builds up an ethnographic portrait of ambivalence as a collective reality. As portrayed here, ambivalence is not only an interior or psychological dilemma, but also a feature of the shared discourse and the pressing decisions that the local work group must make. Nicole Watkins, a single middle-aged woman, had been an Eastside Services client for over a decade at the time of the crisis described below. Her many years with the agency are not unusual. By design, the ACT model provides services for as long as necessary, so many people remain as clients for decades until they transfer to other public treatment funding streams at age 65. In the opinion of the clinical staff, however, Nicole had only recently started to show some progress. The psychiatrist James Young recalled his early years of working with her: She was very unstable for the first few years. She never really engaged with treatment for large blocks of that time. She was un-medicated, she continued to have a lot of trouble with cocaine use and prostitution and evictions. Housing was always a huge problem. She just never thought she was ill, and she always kind of ran on the hypomanic side. Occasionally she would get manic and psychotic, but usually was more hypomanic, belligerent and loud. She ended up developing diabetes, which was a real nightmare… And she wasn’t controlling that well, and then she got tuberculosis. So here we have a cocaine-abusing diabetic with TB, and she wasn’t taking meds. Following the ACT blueprint, Eastside clinicians tried to stay in close contact with Nicole and to provide or to broker for all her needed services. The nurse taught her how to inject insulin, and the case managers delivered the syringe and vials each week, but Nicole never learned how to manage the diabetes successfully. The disease eventually provided an opening for outpatient commitment orders. Dangerousness due to mental illness is the chief criterion for involuntary commitment in the state Mental Health Act that ultimately governs the operation of Eastside Services. The Act provides exhaustive and highly detailed definitions of dangerousness, including behavior that makes people ‘‘unable to satisfy basic needs for nourishment, medical care, shelter or safety without prompt and adequate treatment.’’8 If, in the opinion of a judge, death or serious disease will result without treatment, the state can impose treatment (either inpatient or outpatient, depending on symptoms, severity, and availability of community services). James Young provided testimony at the mental health court, and he considers it the first turning point in Nicole’s case: We finally ended up getting a commitment on her, due to her diabetes. She was running blood sugars in the 600 s. It was out of control. So we kind of used that medical piece to finally get a court order to some medication. And

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I omit the citation in order to ensure the anonymity of the research setting.

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she went on just a drop of Risperdal [an atypical antipsychotic medication], and it just cleared her. She’s responded so well, she’s like a different person. Slowly, since she’s been medicated, which is a year or two, she’s got more insight. She’s got more engaged, she’s been able to look a little bit at the fact that she has an illness and that she’s better on meds. She talks about Nicole with a capital N, that’s her manic Nicole, so she’s really come a long way just to be able to say that. For six years, her sessions were 90 seconds blips where she would, within two minutes, escalate and scream and storm out of the room. And now to have half-hour talks with her about her struggle and her wanting to stay clean…. The psychiatrist never mentioned any ambivalence about this commitment, nor did any other staff member. To the contrary, people framed it as a success story and an ingenious way to guarantee that Nicole receives both life-saving medical treatment and life-changing psychopharmaceuticals. In fact, commitments based on a dangerous physical disease are exceedingly difficult to obtain in this jurisdiction, due to a powerful public defender’s office zealous to protect civil liberties. Eastside staff considered the episode a rare victory. They reversed the course of Nicole’s diabetes, and like ACT clinicians everywhere, they believe in what they do because they see its positive effects (Diamond and Wikler 1985). Open conflicts did eventually erupt about the legitimacy of the team’s power over Nicole, but from another direction entirely. Over the years, Nicole had amassed numerous drug convictions and jail sentences. Her typical pattern after release from jail involved returning to her boyfriend, carrying drugs and stealing for him, engaging in commercial sex work, and then re-arrest after a few months. Her legal troubles finally caught up with her in a stormy and complicated course of events. Nine months after her most recent release on parole, she was charged with new counts of prostitution and intent to manufacture and deliver cocaine. Already on parole from one drug felony and now charged with another, Nicole was immediately incarcerated to await trial and almost certainly a three-year prison sentence. The psychiatrist and the social work supervisor did not want to see Nicole in prison; they knew the notoriously poor mental health care would undo all her progress. Some Eastside clients rotate through the corrections system, and the supervisor Linda Martell can recall only one case where incarceration did not severely worsen their illness. Incarceration, she believes, is just not appropriate for Eastside clients with their usual non-violent misdemeanors and felony drug charges. ‘‘These are not sophisticated criminals,’’ she told me. ‘‘They’re un-medicated, they re-offend and re-offend, break into cars, that kind of stuff.’’ Linda actively sought out a sympathetic lawyer from the Public Defender’s office assigned to Nicole’s case. Both she and the lawyer wanted Nicole to avoid prison, so upon the lawyer’s urging, Linda and the psychiatrist wrote out a list of clinical goals they wanted Nicole to meet. James Young describes this de facto contract that quickly acquired the force of law: I put together a wish-list treatment plan of what would maximize her ability not to break the law again, and also maximize her being psychiatrically stable. Because it’s all connected, you know.

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We made this thing extremely specific. It said she’ll get out of jail, she’ll go to a residential AODA [alcohol and other drug abuse] treatment program for six months. Then she’ll go to a room and board facility, and she’ll stay there for a year. And while she’s there, she’ll be in a drug treatment program here at Eastside Services, and we’ll do daily medications on her…. It’s a step-wise thing, where she has to keep her appointments and come into the office. I wrote this up, and it got taken to the court, and the judge looked at it. And he goes, ‘This is great! This is it!’ He just took the whole thing and said that if she does this, then she gets to be on probation and doesn’t go to jail. [See Appendix] For the first time the psychiatrist’s memory, two systems that usually work at cross-purposes (the mental health and criminal justice systems) cooperated for the client’s benefit. James Young could not imagine a better outcome than the judge turning is ‘‘wish list’’ into treatment recommendations and legal conditions for probation. He considers criminal probation orders and civil commitment simply as alternative and equally feasible means toward the same end of imposing treatment. Once again, the pragmatic and ethical stakes of work became braided together: ‘‘Whichever system works better,’’ he told me, ‘‘we try to utilize.’’ In this instance, he grabbed the first opportunity he saw to protect Nicole from the harm of a long incarceration with substandard mental health treatment. Other clinicians, however, reacted to the arrangement in a radically different way. They found it unrealistic, unworkable, and a direct threat to their self-image as caring advocates. To begin with, many case managers told me that the resources called for in the treatment/probation agreement just do not exist. They based their evaluation on long experience with the fragmented and underfunded world of public sector psychiatry. Indeed, as Nicole’s release date came nearer, the frustrations began to pile up. The team will need several weeks to restart her benefits (Medicaid and Social Security disability) after she leaves jail, and no-one knows where she will live in the interim. Only one residential alcohol treatment center in the city accepts Medicaid recipients, and it has a 3 month waiting list. Even when the disability money becomes available, Nicole will probably not have enough to pay for this residential treatment. She will instead move directly to a less expensive, less structured and less therapeutic room-and-board facility, thereby defeating the logic of step-down services. The problem is systematic, as one case manager explained to me: ‘‘There are plenty of drug offenders in jail who could use residential rehabilitation to stay clean. And that’s not available. It [Nicole’s the treatment/ probation agreement] is inherently flawed, because the resources aren’t there to support it.’’ Most case managers regarded the trajectory of step-down services as a fantasy that immediately broke down in the real world of public sector services. Case managers also criticized the agreement because Nicole could not possibility meet its conditions. They argued that the psychiatrist and judge had set her up to fail. Carl Heiser, the case manager with the most experience with addiction treatment, was assigned to Nicole, and he bluntly dismissed the agreement: ‘‘She’s never been able to do any piece of that. She misses visits, she uses drugs, she stops taking her medication.’’ Carl spoke not only from his knowledge of Nicole’s history,

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but also the general notion shared by Eastside staff that people with severe mental illness have poor insight into their condition (Amador 2000) Staff members believe that clients’ lack of insight explains most refusals of prescribed treatments. In Nicole’s case, people also believed that her drinking and drug use further impair her judgments and her ability to meet the treatment plan/probation conditions. Carl thought that skipping the strict residential treatment would mean certain relapse within weeks. All the case managers felt enormous pressure once the agreement started to govern their work with Nicole. They thought it laid out a difficult and rigid set of conditions that made the pay an extremely high cost for failure. If she never had been able to meet such conditions in the past, why expect anything different now? Case managers’ objections to the treatment/probation agreement and the psychiatrist’s strong endorsement reflects their particular positions in the workplace. James Young has the sole expertise and authority to oversee the bundle of services for clients, and his daily work mostly consists of office-based 20-min medication checks. He interacts with the other systems impinging on clients’ lives—the hospital, the courts and police, and the welfare bureaucracy—on the formal level of signed documents and prepared testimony. The ordinary case managers, by contrast, have less authority but more frequent and more intimate face-to-face engagements with clients in their own living spaces. Case managers depend on situated knowledge to apply the formal ideals spelled out in treatment plans to the exigencies of clients’ lives (Floersch 2002). Their craft-like skills grow from trial-and-error experience that slowly sediments into clinical habit and intuition (Rice 2010). If they cannot find a way to translate the treatment plan successfully—if the client evades their surveillance and refuses treatment—case managers themselves have no authority to alter the approach. The contrast between the credentialed expertise of the psychiatrist and practical wisdom of the case managers, which parallels their sovereign and subordinate roles in the agency, helps explain their antithetical positions toward the agreement with Nicole. The psychiatrist celebrates it as the most promising institutional maneuver to keep her out of prison and engaged in treatment. It strikes case managers as logistically and clinically impossible given the details on the ground. Disagreements over the feasibility of the plan lay the groundwork for a specifically ethical response from case managers. The psychiatrist, as described already, regarded the agreement as good in both a clinical and ethical sense, the first type of goodness guaranteeing the second. Merging the mental health and probation systems posed no challenge to his general ethos of care; that is, his commitment to improving people’s health or at least protecting them from harm. The case managers faced a different problem as they carried out their usual task of translating the treatment/probation agreement into detailed recipes for action. The scheme of services set up for Nicole involved all the standard gestures of work: visiting her on a weekly schedule, handing her the prescribed pharmaceuticals, and recording when she missed appointments or refused medications. But the plan said nothing about a crucial point: how to interact with her probation officer (PO). In a bewildered tone, the case manager Marie Hines listed all the unanswered questions that dogged the team one week before Nicole’s release from jail:

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When do we report a missed medication? A relapse in using cocaine? How much do we tell the PO? We don’t have to tell him anything, I suppose. But then, disclosing everything, is that the right thing? What is our job, ethically? The question ‘‘What is our job, ethically?’’ signals a ripple of conscience that breaks through the routines and busyness of ordinary clinical work. She poses the question because she has entered a new and unfamiliar zone of action. She cannot find her way forward by learning new facts about the case or by relying on the usual calculus of effective and hence acceptable forms of constraint. Nicole’s primary case manager Carl Heiser explained that he’s now forced to adopt an entirely different approach to his daily work. If he sees a crack pipe in the apartment of any other client, he can simply ignore it: ‘‘We’re there to give them their meds and money, if they choose to use crack, [that’s] fine.’’ He may mention it in his progress notes, but the evidence would stay inside the clinical team. If other clients on probation are mandated to complete AODA treatment, Carl provides the service. But he would have no responsibility to report back to Office of Probation and Parole about the person’s continued drug use. In fact, he believes that with every client besides Nicole, rules of confidentiality bar him from communicating anything to the PO. The agreement with Nicole runs contrary to case managers’ habitual practice and also to their conception of the obligation to care for and protect clients. The agreement forces them into an unwanted collusion with police power, and it feels like a betrayal. In addition to the step-down trajectory of services, the agreement binds Nicole to very specific conditions. She must ‘‘take psychiatric medications as prescribed… comply with random drug screens… refrain from any alcohol or illicit substance abuse… [and] refrain from illegal activities’’ (see Appendix). Recall that the case managers fully expected Nicole to fail these conditions, given her history with the agency thus far. If they follow standard procedure and document her med refusals and drug or alcohol use, the information will probably end up in the criminal justice system. Their progress notes could even help send her to prison, because the agreement transforms the notes into an official document of probation violations. Most case managers found this situation repugnant. Even worse, they asked themselves if hiding her behavior and misleading the probation officer would be tantamount to breaking the law. No-one really knew, and the ambiguity points out the impossible choices facing them. Following the agreement means renouncing their commitment to care about clients. Evading the agreement might actually make them guilty of obstructing a court order. The ambiguity produced by the treatment/probation agreement ramified from the concrete details of work (how to write daily progress notes) to the core subject position of front-line staff (as carers or punishers). Such contradictions motivated the expressions of personal ethical ambivalence among individual clinicians. Carl said that he is ‘‘on both sides of the fence’’ about his responsibilities toward Nicole; that is, whether he should do everything to keep her out of prison or let her deal with the consequences of her actions. The supervisor reflected, ‘‘We’re in the position of doing [the Department of] Corrections’s job, but we’re a voluntary treatment program. So, it’s very weird.’’ A few case managers managed to resolve their

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ambivalence, albeit in different ways. One social worker rejected any collusion with the probation system, saying ‘‘Commitment is, get them in the hospital and some meds in them, and then maybe they’ll come out a little better. That’s for their own good. I don’t think a jail stay is for anybody’s good, from a treatment perspective.’’ Reaching the opposite conclusion, another case manager concluded that it had been a mistake to oppose prison time. He thought that Eastside Services should simply let Nicole serve her sentence and then coordinate services once she gets out (to support his position, he repeated the saying, ‘‘If you do the crime, you do the time’’). At the individual level, therefore, clinicians expressed ambivalence in different registers and resolved it in different directions. Ambivalence also emerged at the collective level in a polarized staff room debate on the very day of Nicole’s release. At Eastside, every client receives services from case managers in addition to the psychiatrist and nurse. Case managers often cover for each other, and clients routinely are shifted to new case managers as the caseload and staff composition changes. The entire team, therefore, must know and follow a single schedule that orchestrates home visits, medications, appointments, communication with family members, etc. In Nicole’s case, the need for everyone to harmonize their approach extended to the details of her new treatment/probation conditions. During the morning staff meeting, all ten members of Eastside Services sat around the conference-room table and struggled to decide the right way to enact this apparatus of constraint. In a tense and angry discussion, people argued about how to report her failures to follow the plan. Should they wait for the Probation Officer to request information? Should they proactively call the PO every week? How should they even define medication refusals: a single missed dose or 50 % missed medications over the month? The group had to resolve all these ambiguities by the day’s end in order to communicate with each other effectively, organize Nicole’s services and start the paperwork flowing. The sticking point, and the only issue people could not resolve through hard compromise, concerned step five of the agreement, ‘‘She is to comply with random urine drug screens.’’ The possibility of Eastside Services conducting the urine screens divided the group into two opposing camps. Those who already categorically opposed jail sentences for clients’ non-violent offenses totally rejected this new form of surveillance. They held fast to their self-definition as a treatment team that has no business enforcing rules from criminal justice. Other case managers, however, approved of the agreement because they saw it as a last-ditch effort to keep Nicole out of prison. They saw no special harm in administering the drug screens, since Nicole has to submit to them in any case, whether from her probation officer or case manager. In the staff meeting debate—a stark example of collective ambivalence—the psychiatrist defended the treatment/probation agreement as a fait accompli. He pointed out to his opponents that, whatever their personal opinion, they have to uphold it as legally binding. He held it in the air and said, ‘‘This is not a get-out-ofjail-free card! This says that you are still in jail, but are allowed to stay in the community if you do points 1, 2, 3, 4…’’ The opponents remained unconvinced, and they countered with a different argument. Several Eastside clients are already ‘‘on paper’’ (that is, under supervision by the Office of Probation and Parole), so case

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managers already know how the system operates. They are bothered especially by probation officers’ inconsistent and seemingly illogical response to ‘‘dirty’’ (positive) urine screens. One client comes up dirty every week, and the PO does nothing. Another client stayed clean for several years, but then received no leniency after his next arrest. The procedure is not even random; the clients receive a card announcing that a screen will take place within 5 weeks. If the Eastside team took responsibility for urine screens, whose rules should they follow? Truly random screens with prompt reporting would actually make incarceration more likely for Nicole compared to similar clients. Being more punitive than the probation system struck the opponents as the ultimate betrayal of both Nicole and their own identity as caring and compassionate. The team had reached an absolute impasse. Would conducting the urine screens make them the punitive enemy of their client, the exact opposite of a caring advocate? Or is cooperation with the probation system best chance for Nicole best to avoid prison? Between these two positions, consensus and compromise simply became impossible. But the social work supervisor, exhausted and at her wit’s end, still needed to set the minimal shared guidelines to deliver services. So she called for a simple vote by written ballot. ‘‘This is a one-time deal,’’ she half-apologized and half-explained as the votes were tallied. In the end, the opponents won, and the supervisor turned to Carl, ‘‘Tell the PO that she’s doing the UA. It’s all on her.’’9 With that instruction, the high drama was finished. Over the next few days, the team started to manage Nicole’s case in the standard fashion, with every clinician agreeing to a single set of rules. Commenting on the whole affair several weeks later, people who had taken different positions seemed to make peace with the outcome. One of the plan’s opponents told me, ‘‘We have done good care. We tried to set up something that would work for her. If it doesn’t work out, we won’t have any regrets.’’ Nicole’s case manager Carl, who truly remained on the fence from start to finish, related that she was doing well at her room-and-board: Nicole’s at a weird place in her life now. She spent so much time un-medicated and drugged out before. Now she’s clean, not prostituting. But she doesn’t know what to focus on…. I’m afraid that people will see how well Nicole is doing, and then use that to say we should do the same with future clients.

Conclusion This ethnography situates people’s complex reaction to tactics of constraint in the on-going flow of clinical work. It portrays ambivalence in the context of people’s 9

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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engagements with particular clients, other providers, and the norms and routines of their workplace, as they manage crises with the tools at hand, including bureaucratic instruments such as civil commitment orders and agreements with the criminal court. The case illustrates the operation of ambivalence at both the personal level (the individual’s uncertainty about the legitimacy of her action) and the collective level (the teams’ debates and eventual impasse about the right way forward). The personal level of ambivalence is relatively easy to understand, for the Eastside staff members endorse an ethos of care widely shared in contemporary US mental health services. According to the multi-site study by Good et al. (2011), most clinicians readily endorse humanistic ideals of trust and individualized relationships. They list the criteria of a successful therapeutic engagement as respect, consistency, and finding something of worth in each person they treat. They champion a universalist vision of the good clinician, focused on personal qualities like curiosity and thoughtfulness. Providers endorse the mission to recognize the uniqueness of individuals seeking help, to listen to their voices, and bear their silences (Carpenter-Song 2011). All ranks subscribe to this occupational morality, from MA-level counselors at neighborhood clinics to academic psychiatrists at prestigious teaching hospitals, whatever their therapeutic approaches (psychodynamic, pharmacological, cognitive, etc.). They nevertheless acknowledge a fundamental conflict in their orientation to work. In the words of one psychologist, I have been trained in the empathetic exploration of intensely personal experiences and emotions with people who are destabilized and vulnerable. I have also been trained in noninjurious methods of taking down and restraining a violent patient within the context of (frequently coerced) inpatient treatment. Psychiatric treatment is thus a combination of compassion and coercion (Calabrese 2011). The above case from Eastside Services exemplifies this tension between the ideal of empathy and the necessity to carry out coercive treatments. It documents clinicians negotiating between their preferred self-image—competent, helpful, therapeutic—and tactics of constraint that involve physical force and the overpowering of people’s wills and bodies. The collective level of ambivalence raises another set of issues. Clinicians navigate the tension in different ways, depending on their training, rank, and the type of workplace. Impasses or conflicts will surely emerge when people working in the same setting adopt contradictory approaches to the use of constraint. Some people at Eastside Services, inspired by a therapeutic pragmatism, retained confidence in their own good intentions, no matter how much power they wield over the users of mental health services. Other people, carrying out the same clinical maneuver with the same person, got caught in a conflict between their idealized selfimage and the likely consequences of unilateral action. Even those who wrestled with the legitimacy of one form of constraint passed over another form in silence. Everyone agreed that civil commitment was justified; in fact, they regarded this sort of legal power over clients as necessary to get their job done. A majority rejected

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taking on the probation officer’s role because it was ethically repugnant, while the psychiatrist thought it was absolutely the best way forward. To explain the uneven and idiosyncratic patterns of ambivalence demands close attention to people’s training, their rank, the sources of their authority, and their precise relationships with clients. Such relationships are the medium in which clinicians try to realize the ethos of care or perceive threats to this humanistic ideal. Conscience, understood as the individual’s private possession, is not the only or even the best starting point for fieldwork about ambivalence. The ethnography of ethics in health care must begin with another question: why do people ferret out one particular issue, but not another one, as raising ethical stakes? Why do they puzzle over the rightness or wrongness of this particular clinical maneuver, but regard that maneuver as unproblematic (see Brodwin 2013)? These are empirical questions about the shape of collective ethical debate, and an exclusively private and interior model of conscience cannot fully answer them. In particular, the interior model cannot explain the following paradox. Certain tactics of constraint, once they get woven into the order of work, become unquestionable on clinical or ethical grounds; no-one at Eastside Services, for example, suffers from a bad conscience because of outpatient commitments. But novel tactics of constraint like the probation/treatment agreement, require fresh scrutiny and discussion. They threaten to disturb the equilibrium between people’s self-image as caring and their manifestly unequal power, and for that reason, they can become objectionable (that is, people find the ability to articulate their objections and thereby influence the course of treatment). To understand the paradox, fieldwork should focus especially on the moments when people’s sense of unease erupts into collective life. Such moments demonstrate the ways that people’s specific social position can provoke their ambivalence or shield them from it. Eastside clinicians perceived the treatment/ probation agreement differently because of their different social locations (mental health provider and not corrections officer, social worker or psychiatrist, with low or high rank, etc.). They approached the agreement with confidence, anxiety, or mixture of the two depending on whether they felt secure or instead pushed out of their preferred roles and moralized orientations. Ambivalence signals that they can no longer rely on their usual disposition, that is, the cognitive and evaluative structures built up from long experience on the job. That realization motivates them to measure the distance between the real and the ideal: between their actual place in the system and the one they prefer to occupy. In the end, ambivalence reveals itself as a truly multi-scalar phenomenon: an interior uncertainty about how to realize one’s moral commitment, a collective work blockage, and an unfolding social commentary about the roles one is forced to enact. 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 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. 1. 2. 3.

4.

5. 6. 7.

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. Upon release from jail, she will be placed in a residential treatment program for prisoners with drug and alcohol problems. 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. 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. She is to comply with random urine screens. She is to refrain from any alcohol or illicit substance use. She is to refrain from illegal activities. James Young, MD [signature]

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