Everyday Ethics: Voices From the Front Line of Community Psychiatry by Paul Brodwin (review)

Brodwin’s well-researched book is a must-read for anyone interested in the anthropology of psychiatry, social work, health care, or everyday moral decision-making. His aim is to show “what happens in the backstage of medical settings,” which he does well (199). Brodwin’s book embeds us in the social work teams of Eastside Services in a Midwestern city to reveal the extreme social conditions and ethical uncertainty in the lives of people with serious psychiatric disabilities and the people struggling to provide them with care.

At Eastside, teams of low-paid, “bottom of the ladder” clinical social workers offered Assertive Community Treatment (ACT) model care to clients with serious psychiatric disabilities, such as schizophrenia, bipolar disorder, and major depression. Many Eastside clients also seemed to struggle with addictions, which is true for about 50 percent of people diagnosed with serious mental illnesses in the public mental health system (Drake et al. 2006). ACT clients, according to Brodwin (and the original model developed in Wisconsin [Stein and Test 1980]) were often deemed to be in need of hands-on care in order to reduce rehospitalizations and enhance their participation in the community. At times, they were recipients of outpatient commitment orders, which are often considered to be a controversial imposition of the state on individual liberties.

The ACT model of case management has been well-researched, and at least two good ethnographies of case management for people with serious psychiatric disabilities have been published, including Sue Estroff’s (1981) classic, Making It Crazy: An Ethnography of Psychiatric Clients in an American Community, and Jerry Floersch’s (2002) Meds, Money, and Manners. These books offer intimate perspectives on case management models from the perspectives of service users (Estroff) and from the perspective of front line staff (Floersch).

Brodwin’s book builds on the findings of these previous studies and makes an important contribution to the literature because he targets very important issues in care and caregiving, and relentlessly questions the ethical uncertainty of mental health care. He asks: how are decisions made about the care of people with serious psychiatric disabilities, why, by whom, and to what end?

The book moves us toward understanding the complex answers to these questions. To help guide his understandings of clinical decisionmaking, Brodwin employs the term “everyday ethics,” which he has borrowed from Donna Haraway (2013). He describes “everyday ethics” as a “species of situated knowledge” that is a partial perspective based on one’s own way of organizing the world according to one’s own local worldview (173). Interspersed in his ethical vignettes are informative discussions of the ways the mental health care system as-is emerged on a policy level, and the ethics of everyday decision-making that the mental health system forces care providers to manage.

The work offers a very humanizing perspective of frontline community psychiatry care providers and their efforts to make incredibly important, challenging, and often demoralizing decisions for their clients with psychiatric disabilities. They do so with a very local perspective, Brodwin argues. Brodwin is most interested in moments of “rupture” when ethical comments do emerge unexpectedly and people take a moment to reflect upon the “social game” they are playing (202).

It seems there are two kinds of frontline care providers playing the game in this book. The seemingly well-educated, all-powerful psychiatrist Dr. Young, who operates on his own set of biomedical logics that a person has a medical disease, needs treatment, and cannot be counted on to take care of themselves until they have proven themselves capable of doing so in a very specific, step-by-step way. “He can decide what counts or does not count as ethically relevant” because he is privileged with biomedical information and the power that comes from it (129). Dr. Young’s ethics are based on a narrative of progress, which guides his decisions (e.g., medication changes, representative payeeship decisions). He must continually...