Genealogy of the Treatment Model
Everyday ethics emerges, by definition, against the background of ordinary practice. On a typical day, Eastside Services staff members make innumerable decisions about the right course of action for their clients. To do so, they must pose and then work through several questions. What does my client need, given what I know about his personality, his strengths and vulnerabilities, and the way he lives with his symptoms? Can I cobble together the resources to answer his need? Is there a standard, routine way to handle this sort of case, and can I conceivably follow it with the person standing in front of me? But then they face the hard surfaces of the job: scarce resources, dilapidated housing, opaque bureaucracies, rigid agency policies, and indifference or disdain from other public service workers (police, probation officers, hospital staff, and welfare officials). These obstacles prevent the case manager from carrying out her preferred course of action. Everyday ethics is the label for commentaries that emerge at this stage about right and wrong, the obligatory and the forbidden, and the legitimacy of professional power. Front-line clinicians enter this collision zone between the desirable and the possible when they discover that their knowledge and training are not enough to carry out the right decision, given the background structures of their job.
Staff members do not know, because they do not need to know, that all these structures have a history. Clinician and client do not stand face to face on a featureless plain, as generic healer to sufferer. A particular institutional history has produced the way they come to meet, the balance of power between them, and the social worlds they jointly negotiate. As a result, when blockages in work provoke clinicians to talk about right and wrong, they do not speak as generic ethical agents. They speak instead from their partial perspective, traversing the permanent, if buried, features of this particular landscape of practice. In the end, everyday ethics is historically produced, but in ways largely invisible to clinicians themselves. To understand today's dilemmas requires tracing the tangled past of this mode of treatment. The shape of action for front-line providers is a layered domain where the outcome of prior policies and ideologies is woven in today's ordinary work routines (cf. Rhodes 1993). The relevant past includes the deinstitutionalization of psychiatric patients starting in the mid-20th Century, the tragedies left in the wake of this broad social movement, the new models of community-based services that arose as a response, and the diffusion of these models across American mental health services. Each strand in this genealogy informs the everyday ethics that emerge at the clinical front line.
Deinstitutionalization: Origins and Aftermath
Deinstitutionalization in the United States occurred at the confluence of several distinct trends1. During the late 19th Century, the number of patients at state mental hospitals graduate rose due to urbanization and immigration. The rising censuses pushed such institutions away from their founders' optimism and the humanistic goal of "moral treatment." By the first few decades of the 20th Century, most state hospital patients were confined for years, if not their entire lives, and received little more than custodial care. Outrage over the crowded and deteriorated conditions flared up during the 1940s in popular books, magazines and films. These high-profile exposes made the mental hospital a symbol of hopelessness and neglect for the broad American public. At the same time, the professional commitment to hospital-based care also started to erode. Psychiatrists wanted to align themselves with the therapeutic revolutions sweeping through the rest of medicine and were eager to sever their long-standing exclusive association with custodial institutions. Psychiatrists' experience in World War II also fueled their enthusiasm to relocate patient care outside of hospitals. They discovered that the early diagnosis and treatment of soldiers' mental disorders near the battle-front and in soldiers' own social milieu often had better outcomes than the standard services delivered in remote hospitals. The experience of treatment soldiers in non-institutional settings became an alluring model for psychiatry as a whole.
At the national level, vastly increased public investments in medical research also laid the groundwork for deinstitutionalization. During the immediate post-war period, the mental health system as a whole was reshaped by a new enthusiasm for federal health policy initiatives. With the establishment of the National Institute of Mental Health in 1949, policy makers and leaders of academic psychiatry began to conceive of mental illness as a public health problem, amenable to high-level systemic interventions. The architects of mental health policy aimed professional services at a broader population, including both in-patients and out-patients and with mild to severe symptoms. The public health perspective produced the paradigm of community mental health, which envisioned a dispersed, nation-wide network of small out-patient clinics to replace the large, centralized state hospitals.
Other mid-century developments, both technological and ideological, made the large state mental hospital seem "antiquated, outmoded... and obsolete," in the words of the 1958 presidential address of the American Psychiatric Association. In 1954, the first phenothiazine drugs were introduced into American hospital use. Chlorpromazine, marketed as Thorazine, had the dramatic effect of calming belligerent and loud patients and making it easier to discharge them without opposition from family members or neighbors. The expanding arsenal of antipsychotic medications (such as Halperidol, introduced as Haldol in 1958) justified the goal of emptying the back wards and re-integrating long-term patients into society (see Gronfien 1985). Ideological shifts of the era also endorsed the vision of non-institutional care. Sociologists criticized long-term psychiatric hospitalization as inherently humiliating and an assault on personal dignity (Goffman 1961, Belknap 1956). Within professional psychiatry, reformists shared in the early 1960s idealism about improving society through government programs. At a time of federal interventions to end segregation and combat poverty, a top-down recipe for re-figuring mental health services was enormously attractive. The federal government seemed better equipped than the states to solve social problems, including the provision of mental health services. In 1961, an NIMH working group predicted that new community mental health programs, combined with public education to reduce the stigma of psychiatric illness, would make "the mental hospital as it is now known to disappear from the scene in 25 years" (quoted in Grob 1994: 253).
The cascade of public sentiment, professional interests, and pharmacological developments eventually produced an important shift in federal policy: the Community Mental Health Centers Act of 1963 (Title II of Public Law 88-164). The Act was the key driver of the planned replacement of custodial institutions with community-based treatment facilities. According to the dominant psychiatric opinion at that time, new medications meant that most of the mentally ill could be successfully treated in their own communities and returned to a useful place in society (see Rochefort 1997). The distance between such utopian rhetoric and the real-world results are widely documented. The legislation called for 2000 community mental health centers (CHMCs), but by 1980 only 754 were built. The Act did not require planning to connect CHMCs to state hospitals. It did not specify the services needed by people after they were discharged. Indeed, contrary to reformers' expectations, state resources did not follow the ex-patients into the community. The savings from hospital closures essentially flowed back into state budgets, and local communities did not take over the financing of CHMCs when federal support declined. The populations of large state mental hospitals did decline, as intended by the 1963 legislation, but few ex-patients received services from the community mental health network.
The next phase of the deinstitutionalization process was driven by the expanding federal welfare state. Monies available through Medicare and Medicaid (federal health insurance programs established in 1965) did not pay for state mental health facilities, but they did reimburse other forms of long-term care. As a result, vast numbers of the elderly mentally ill were transinstitutionalized, that is, moved directly from state hospitals to nursing homes, which could capture federal payments. In the 1970s, Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) started to provide monthly living subsidies that enabled unemployed individuals with serious mental illness to live in room-and-board residences or independent apartments. Thanks to federal insurance and income maintenance programs, therefore, the states could realize substantial savings by closing or radically shrinking their large mental hospitals. These financial incentives sped up the deinstitutionalization process and essentially competed what earlier ideological, professional, and technological developments had begun.
Deinstitutionalization quickly and dramatically lowered the total number of psychiatric in-patients from the high point of 559,000 in 1955 to 193,000 in 1978, 110,00 in 1985, and 80,000 in 2002.2 Over the same period, the average in-patient stay also shortened considerably. Before 1965, people would often spend years if not decades in institutions. In 2006, the average length of stay in US psychiatric hospitals was seven days (US Dept. of Health and Human Services 2008), and that figure has remained constant ever since. However, a snapshot of before and after statistics hides the long-term effects of deinstitutionalization, and hence the background of practice in today's community psychiatry. By the late 1960s, the rising cohort of young people with severe psychiatric disorders - which usually begin in people's late teens to early thirties - entered into a new array of treatment options. For the first time in nearly a century, people now experienced the onset of severe disorder while remaining outside of long-term institutional control. These young adults established a new pattern in their use of psychiatric services that continues until today: a "revolving door" of in-patient stays, stabilization via medication, discharge to the community, resumption of isolated and disorganized lives, and subsequent rehospitalization. Many members of this group live in marginal, often dangerous surroundings and they depend on an uncoordinated and underfunded collection of out-patient medical and social services. The severity of the illness, the fragmentation of services, and the realities of urban poverty (including easy access to alcohol and street drugs) make it enormously difficult for people to recover fully or to establish independent lives outside the welfare, medical, and criminal justice systems3.
What these young adults faced in the 1970s fundamentally drove the development of new forms of public mental health services. For the first half of the twentieth century, housing, food, daily occupations, medical and psychiatric treatment, and even social identity came bundled together for patients, who lived in self-contained state hospitals with populations as large as 11,000. As states scaled back these custodial institutions and shifted the costs to federal programs, the de facto responsibility for ex-patients fell onto a fragmented network of psychiatrists, police, judges, and social workers. In the current landscape, many different authorities target the needs of people with severe mental illness, but in an uncoordinated fashion. Separate agencies do not communicate well, and each has its own discrete mandate (housing, medications, employment training, addiction treatment, access to public subsidies, social rehabilitation, and criminal justice). They have little knowledge of each others' rules and operating procedures, and they enforce different expectations and eligibility criteria on clients. Although state and county mental hospitals continue to exist, they now offer short-term stabilization or serve as the last resort for the most treatment-resistant and difficult-to-place individuals. In stark contrast to the earlier era of total institutions, people with severe mental illness are scattered throughout society, and no single organization or profession accepts responsibility for their lives (Mechanic 1989, Grob 1994).
The failures of deinstitutionalization became clear by the mid 1970s. Broad public dismay was fueled by media reports about the homeless mentally ill and what was widely labeled the "dumping" of ex-patients into dilapidated single room occupancy hotels. Expert opinion in psychiatry and health policy was just as scathing. A new consensus arose that "the rhetoric of deinstitutionalization seems to mask a brutal political and economic reality - the general abandonment of mentally disabled people" (Rose 1979: 440). In earlier decades, professional discourse had celebrated community care as a therapeutic revolution and an end to the dark ages of institutional confinement. During the 1970s, this discourse evaporated almost without a trace. Psychiatrists and social scientists instead characterized deinstitutionalization as programmatic chaos, a disaster, and a continual failure in which bureaucratic needs trumped patient care (the terms used by Scherl and Macht 1979, Talbott 1979, Brown 1985 and Talbott 1984).
The failure had many causes. Policy makers justified deinstitutionalization in undefined or generic terms - community, re-integration, and rehabilitation - that inevitably got used in contradictory ways. The terms gave the appearance of a progressive, coherent system that bore no resemblance to the reality on the ground. The forces arrayed in favor of depopulating state hospitals were unstoppable, but they lacked an overarching blueprint. The ultimate fragmentation and substandard care were thus the unintended consequences of a largely unplanned process (see Bachrach 1990, Mechanic 1989). In particular, reformers overlooked how housing, income support, and social connections affect the well-being of people with disabling symptoms. The step-wise process by which the state abandoned people with serious mental illness thus produced an entirely new cluster of clinical needs and social dilemmas.
For example, ex-patients and younger people who had never been hospitalized started to receive monthly federal subsidies, and they became a lucrative commodity for entrepreneurs operating nursing homes, group homes, board-and-care facilities, and single room occupancy hotels. The economics of this business are simple: the less money spent per capita on tenants, the higher the profits. Consequently, people with serious mental illness began to spend part of their lives ghettoized in custodial settings that were smaller but just as untherapeutic as the old state hospitals. A similar logic operated in the private non-profit agencies that specialized in community psychiatric services. Such agencies captured more federal reimbursements if they treated more individuals, and too often the result was higher caseloads, the hiring of underqualified providers, and a declining quality of care (Mollica 1983). Because of economic contingencies, the isolation and neglect that characterized the early 20th Century asylum re-emerged seventy years later as fundamental aspects of public sector mental health.
Community Support Programs: Assembling the New Norm
The undeniable neglect of people with severe mental illness and the reversion to custodial care led to a shift in the policy landscape of the late 1970s. The Community Support Program (CSP) was the major federal response. It rejected the naÔve assumption that discharging hospital patients would naturally lead to "community integration" and that facilities like board-and-care homes actually rehabilitate their residents. The program instead began with a cold appraisal of the results of deinstitutionalization (Turner and TenHoor 1978). People with severe mental illness faced enormous obstacles in getting services from general hospitals, social welfare agencies, legal clinics, public housing bureaus, and employment training centers. These institutions simply had no experience with the mentally ill and no specific mandate to serve them. Their staff tried to avoid serving people with the most disabling and chronic symptoms. Federal programs were evaluated on the basis of their efficiency - that is, how cheaply and quickly they could find jobs and independent housing for their clients. As a result, providers preferred to cherry-pick the high functioning individuals, and they left those with severe disabilities to fend for themselves (see Tessler and Goldman 1982).
The CSP was an ambitious, top-down effort at systemic reform aimed precisely at such problems. It grew out of a series of working conferences at the National Institute of Mental Health held from 1975 to 1977 that conceptualized the ideal "community support system" needed by mentally disabled adults (see Turner and TenHoor 1978). Participants debated which elements of the current system to keep, the base-line responsibility of the government for individual welfare, and the legitimacy of demands that the mentally ill be productive and independent. Without reaching consensus on any of these issues, the assembled experts nonetheless identified ten essential functions for community services (Turner 1977):
1. Identification of and outreach to mentally disabled adults, whether in hospitals or the community
2. Assistance in applying for public entitlements
3. Crisis stabilization services in the least restrictive setting possible
4. Psychosocial rehabilitation, including evaluation of strengths and weaknesses, in vivo training in community living skills, and improving employability
5. Supportive services of indefinite duration, including living arrangements and daytime and evening activities
6. Medical and mental health care
7. Backup support to families, friends and community members
8. Involvement of community members in planning services
9. Protection of client rights through grievance procedures
10. Case management: a single person or team responsible for remaining in touch with clients on a continuing basis.
With this list, the architects of the Community Support Program made a clean break from previous decades of policy. They did not even mention prevention or cure, but focused instead on rehabilitation and ongoing support. Their list thereby acknowledged people's broad needs for simple survival in the post-asylum era. Often poor, unemployed, and marginalized, this group faced not only the fragmented mental health system, but also the dispersal (or non-existence) of all the other services that once came bundled together in the state hospital. Planners also endorsed the notion that severe mental illness is truly chronic, and that some people may need comprehensive assistance for life.
The Community Support Program was the first comprehensive plan to re-organize services after deinstitutionalization. As a distinct program, it was cut short by the fiscal austerity of President Ronald Reagan, which effectively ended the era of national mental health planning that Kennedy began almost 20 years before. The program's basic orientation, however, continued to drive the development of services at the state and local level, despite the ideology of limited government and the on-going privatization of health care. In the 1980s, states devised programs that mixed and matched ingredients from the original CSP list of 10 essential functions. Vermont, for example, established regional "community rehabilitation and treatment" agencies that provided vocational training, social support, case management, emergency care, and education for family members (Wilson 1989). Columbus, Ohio established "community treatment teams" that kept up with clients through all their moves about the city, brokered for services from different agencies, and placed clients in supported housing (Fleming and York 1989).
The Invention and Diffusion of Model Programs
Building up the apparatus of community-based treatment demanded an enormous amount of improvisation. The problems left in the wake of deinstitutionalization overflowed the bounds of any single mental health specialty (psychiatry, psychology, social work or nursing). To reconstruct a decent support system for people living in poverty and isolation required gathering resources from different institutions and experimenting with new organizational logics. This open-ended moment of invention, however, soon gave way an era of precise blueprints and bureaucratic regulation. As new models of treatment were scaled up and woven into state mental health codes, the front-line provider had considerably less room to maneuver. Her tasks became spelled out in minute detail, routinized, and audited from above. This tension between the need for improvisation in community services and the strict definition and regulation of clinical roles still pervades daily work in agencies like Eastside Services.
The development of services on the ground demanded the translation of CSP rhetoric into recipes for action with clients. The task often fell to social workers, who by necessity relied on their pragmatic and highly local knowledge to organize programs. The development of "Community Support Services" in the pseudonymous High County, Kansas, illustrates the translation from policy ideals to the operation of a single local agency (Floersch 2002). In the mid-1970s, administrators of an already-existing mental health center looked to re-vamp their services for recently discharged patients. They linked up with the Community Support and Rehabilitation branch of NIMH, and a full-time director arrived in 1982 to turn rehabilitation principles into a workable operation.
The director was a social worker trained in traditional office-based assessment and psychodynamic therapy. She soon decided that her training was simply irrelevant for serious mental illness, so she pushed her staff to newer types of interventions, such as driving clients to appointments, helping them find housing, and negotiating on their behalf with employees, landlords and roommates. At this early stage, no professional guidelines existed for the director to follow. She built her program through trial and error as she gradually discovered the best tactics to keep clients out of the hospital. Pragmatic innovation - in the absence of disciplinary knowledge or detailed instructions from above - created a new type of mental health service on the ground. Staff members followed individuals as they moved through their own spaces and rhythms of life, instead of demanding that they conform to the norms of office-based or hospital care.
CSP services after deinstitutionalization developed via a complex traffic between policy mandates, professional expertise and practical knowledge. At the start, federal policy makers established some broad conceptual outlines and a top-down plan for systemic reform. The scene then shifted to local programs around the country (such as High County, Kansas) where clinicians improvised ways to keep clients out of the hospital. Attracted by the programs' evident success, established professionals in social work, psychology, and psychiatry scrutinized fledgling programs and scaled them up. Charles Rapp, a professor at the University of Kansas School of Social Welfare, accepted a contract to provide case management services at the High County agency. Rapp and his social work students evaluated his new approach (Rapp and Champerlain 1985), replicated it in other agencies, and in 1983, articulated it in a training manual. He received a series of NIMH grants for further refinement and testing of what he now labeled "strengths-based" case management. His influence soon spread to higher levels in the public sector mental health system. In 1986, the Kansas Department of Mental Health contracted with him to provide technical assistance to programs throughout the state, and his research helped shape the Kansas Mental Health Reform Act of 1990 (Floersch 2002).
Rapp formalized the approach in his book The Strengths Model: Case Management with People Suffering from Severe and Persistent Mental Illness (Rapp 1998). The text lays out his core argument: individuals with severe mental illness can achieve a higher quality of life if enabling niches are available in their immediate environment. Opportunities for work, education and social involvement strengthen people's intrinsic abilities and facilitate their recovery, even if their symptoms remain. Rapp contrasts his "strengths" model to the "deficit" model typical of psychiatry, which he criticizes for focusing on pathology and increasing people's dependency. Rapp develops his argument with an mix of human ecology, the psychology of resilience, and empirical studies of positive long-term outcomes for people with serious mental illness. His book features numerous flow charts and lists of formal therapeutic principles that recast his pragmatic innovations into explicit and disciplinary correct form. He provides detailed instructions to set up a working program, including templates for key paperwork technologies such as assessment forms, treatment plans, and organizational charts that map the proper relations between agency director, middle management, supervisors, front-line workers, and clients.
Rapp's textbook formalizes the conceptual rationale of a single experiment, standardizes the treatment model, and then supplies a blueprint for implanting it anew in different settings. The text thus exemplifies the transformation in CSP services from the 1970s to the 1990s. At the NIMH, a panel of experts developed an ideal vision of community services to redress the worst results of deinstitutionalization. Their mandate then diffused downwards to the level of particular mental health agencies, where front-line workers translated ideals into workable programs on the ground. Individual clinicians used real-time, trial-and-error learning to figure out how to keep clients stable outside the hospital. In the third step, the results of their experimentation were scaled up, inserted into disciplinary discourses and re-packaged as manuals and templates generalizable to other settings. Over the following years, the standardized and transposable model for community services was legitimized by academic research, and it had broad effects in mental health policy and state law.
The same trajectory marks the history of Assertive Community Treatment (ACT), the most influential model for CSP-style services and the template for Eastside Services. The program dates from the earliest period of deinstitutionalization at Mendota Mental Health Institute in Madison, Wisconsin, a traditional state psychiatric hospital. In the 1960s, a small research team experimented with behaviorist techniques to produce neater personal appearance, better work habits, and more cooperative behavior among patients (Ludwig 1968). The goal was to prepare them for discharge and community residence, but to the researchers' surprise, what people learned in the hospital did not generalize to success outside. Those who improved with in-patient treatments often ended up back at the hospital in a few weeks or months, disheveled and psychotic. By contrast, those discharged with substantial symptoms often managed quite well with community living.
In a set of recollections published on the website of the Assertive Communty Treatment Association (the model's national professional organization), Mary Ann Test -a professor of social work on the research team - describes how staff members' frustration led to the birth of Assertive Community Treatment. During a ward meeting in April 1970, staff complained that their efforts were in vain, and they protested to Test and her psychiatrist colleague Arnold Marx,
"We don't want to do another one of these programs where we try to get patients ready for life in the community. Even though they appear 'ready' when we discharge them, they come right back. What good are we doing?"
We directed the discussion toward what kinds of interventions might be more helpful to our patients. Eventually, one of the paraprofessionals commented, "You know, the patients that Barb Lontz works with intensively don't come back. Maybe we should all go out and do what Barb does." Barb Lontz was an innovative and spirited social worker on the ward that, among other things, helped clients with discharge planning. Indeed, when time allowed her, Barb did far more than plan discharge. She drove patients to their new residence in the community and then spent countless hours and days providing them "hands on" support and assistance to help them live in the community. Barb helped clients move in and get sheets on the bed and a telephone installed; she taught clients how to use the local Laundromat by doing laundry with them again and again. She instructed them to ride the bus to the mental health center to get medications by going side by side with them as many times as was needed. ....
As we listed the clients with whom Barb had worked intensively and continuously in this fashion, it was indeed apparent that almost none of them had come back to the hospital! We talked about why these methods seemed to be effective and someone said, "You know, I think the community, not the hospital, is where our patients need the most help.... Other staff nodded in agreement and gradually voices got louder and suggestions more extreme. Finally, the room filled with excitement when a staff member proclaimed, "We ought to close down B-2 [the research ward at Mendota Mental Health Institute] and all go out into the community like Barb and help our clients out there, where they really need support and where it will do the most good!"
The meeting ended in a spirit of incredibly high morale. Rather remarkably, in a four-hour meeting we and our staff together had decided to change radically our own (and the existing) philosophy of care for persons with severe and persistent mental illness!4
It is an appealing origin story, whether or not every detail is correct. It omits, of course, the context of deinstitutionalization that drove similar efforts at community treatment across the country (see Test and Stein 1978). Nonetheless, the story suggests that Assertive Community Treatment began with the pragmatic trial-and-error efforts of front-line clinicians, in the same manner as Rapp's strengths model.5 The next phase of scaling-up began almost immediately, given that the team at Mendota State all held faculty posts at the University of Wisconsin-Madison. They assembled a 12-month pilot program of community-based training in basic coping skills, and compared it to a control group (of in-patients as well as patients discharged to usual aftercare services). After five months, the experimental group had spent less time in the hospital and had better living and employment situations (although with no change in symptom level) (Marx 1973). Published evidence, following the disciplinary norm of randomized controlled clinical trials, had legitimized the intuition of social workers in the field.
The momentum continued as the researchers obtained NIMH funds to develop the "Training in Community Living" model, based on the same strategy of individualized supports provided in the community. The goal, however, had shifted because of the quickening pace of deinstitutionalization and the need for states reduce the costs of in-patient care. The program now aimed at prevention of hospitalization instead of preparation for discharge. In 1972, the entire staff of a hospital ward was retrained and transferred to a rented house in Madison. Staff members met as a group twice a day to share information about clients and plan treatment. The rest of the time they visited clients at their homes, neighborhood gathering spots, or workplaces. Staff members consulted widely with family members and employers, and they provided clients with a full schedule of daily activities. They supplied medication, taught basic skills (shopping, cooking, grooming, budgeting, etc.), helped clients find housing and employment, and prodded them to get involved with recreational and social groups. The researchers evaluated the program and confirmed the earlier study: clients spent less time hospitalized, more time employed, and even showed symptom improvement. The program produced savings of $800 per patient per year with no increased burden on family members (see Stein and Test 1980 and Test and Stein 1980. Sue Estroff's classic study  describes this project from the clients' point of view)6.
These articles had an enormous influence on the emerging field of psychiatric rehabilitation. The authors described their program in common-sense terms that responded perfectly to the CSP vision (not surprisingly, since Leonard Stein and Mary Ann Test attended the original CSP conference at the National Institute of Health). To succeed in the community, people with serious mental illness need not only medical treatment, but also material resources such as food, shelter, and clothing. They need to learn basic coping skills in real world contexts. They need on-going social support, and their families, landlords and employers also need education about mental illness. The model program described by Stein and Test supplied precisely the range of services that people lost because of the phasing down of state mental hospitals.
Moreover, the authors' methods and approach dovetailed with the contemporary neo-Kraepelinian revolution in American psychiatry as a whole: the renewed emphasis on the taxonomy of psychiatric disorders and the search for organic causes. The articles were published in 1980, the same year as the DSM-III, the Diagnostic and Statistical Manual of Mental Disorders (3rd edition). During late 1970s, American psychiatry began to move towards explicit, research-tested, discrete criteria for disorder - the template for medical psychiatry laid down by Emil Kraepelin almost a century before. The DSM-III aimed to rationalize psychiatric research as a scientific enterprise by providing stable and mutually exclusive categories for disease. With these stable categories in hand, all researchers could be confident they meant the same thing by "schizophrenia" or "depression." The Madison group applied the same logic to mental health services. They measured outcomes in a way that invited further refinement and testing with validated and reliable instruments that quantified community adjustment, self-esteem, family burden, etc.. With these outcome measures in hand, researchers across the country could replicate the program and test it against other modes of treatment. Assertive Community Treatment (ACT) eventually became the most thoroughly studied intervention in American community mental health services.7
In 1998, after almost 30 years of development, several long-time ACT clinicians published comprehensive manuals that provide a conceptual rationale and detailed instructions for running programs (Stein and Santos 1998, Allness and Knoedler 2003 )8. Taken together, the books fulfill the same functions as Rapp's text, but from a different angle. Whereas Rapp criticizes the medical focus on deficits, Leonard Stein and Alberto Santos are both psychiatrists, and they explicitly frame mental illness as a chronic disease parallel to diabetes, hypertension or arthritis. They present the orthodox medical view of chronic conditions as alternating between acute episodes and periods of stability accompanied by long-term impairments. The out-of-control and the stable phase each requires distinctive treatments. For certain serious mental illnesses (the authors single out schizophrenia, schizoaffective and bipolar disorders), the acute phase involves psychosis and disorganized or bizarre behavior. Hospitalization and medication are the appropriate treatment. The stable phase involves several key impairments: vulnerability to stress, deficient life skills, difficult interpersonal relationships, and inability to generalize skills learned in one setting (such as the hospital) to another (the community). Stein and Santos devised ACT to target precisely these impairments via continuous support and the teaching of life skills in the immediate contexts of patients' lives. It also delivers pharmaceutic treatment directly to people's homes in order to prevent relapse.
Stein and Santos endorse the now dominant paradigm of contemporary American psychiatry. Mental illnesses are brain diseases: discrete, organic malfunctions, each with its characteristic signs, symptoms, course, disabilities and appropriate medications (see Luhrmann 2000 and Lakoff 2005). They write their ACT handbook as clinicians first and foremost, not critics of deinstitutionalization. The revolving door pattern is simply bad medical practice that treats the acute episode but neglects the stable phase of a chronic but manageable disease. Treatment during the remission phase it critical, because what happens between episodes affects the severity and frequency of relapse. This rationale anchors their entire vision of Assertive Community Treatment. To help clients with community living, ACT teams must be multidisciplinary, comprising social workers, nurses, psychologists, psychiatrists, vocational specialists, and experts in drug and alcohol treatment. To prevent relapse and hospitalization, they must be ready to intervene around the clock and seven days a week. They must take ultimate responsibility for providing what clients need, when and where they need it, and not force them into 9 to 5 schedules and office appointments. In practice, this means that ACT staff members themselves deliver as many services as possible. When forced to broker services with outsiders, they must monitor and coordinate the relevant agencies. The 10-person ACT team is the fixed point of responsibility that ensures clients receive all necessary services from the fragmented non-system of public mental health.
The instructions for everyday work and the organization of ACT teams embody the biopsychiatric view of severe mental illness. Because predictors of relapse are subtle and unique to each person, clinicians must continually scrutinize clients' lives to discern the symptoms, stressors or lifestyle changes that precede psychotic breaks or disorganization. Because the needs of clients can change quickly, everyone on the team must know every client: case managers share details of their own caseload with the entire group during morning staff meetings. Because of their poor transfer of learning among people with severe mental illness, clinicians must deliver services in the real contexts of clients' lives: shelters, meal-sites, clients' apartments and workplaces. Borrowing a metaphor from laboratory science, the ACT literature champions in vivo as opposed to in vitro services. Because of clients' disorganization, anxiety and poor coping skills, clinicians must act assertively to help clients benefit from treatment. If a client does not answer the phone, staff members drive out to his apartment. If he is not at home, they comb the neighborhood to find him. Clinicians continue to seek out clients even they refuse contact for months on end. Finally, this model assumes that serious mental illness is chronic disease with life-long impairments. Allness and Knoedler (2003: 397) provide sample discharge criteria, but they warn that clients should not be discharged for "traditional reasons" like needing less care or because their problems are too complex.
Assertive Community Treatment is the single most well-known model of mental health services that appeared after deinstitutionalization. A cadre of researchers continue to refine the approach, apply it to new populations, identify its core ingredients, and measure whether ACT teams on the ground adhere to the model's standards9. Even as a pilot program, it won the Gold Achievement Award from the American Psychiatric Association in 1974 (Dixon 2000). In 1996, the National Alliance for the Mentally Ill - the leading mental health lobby in the US - officially endorsed ACT and began to pressure federal and local officials to make it available nationwide (Allness and Knoedler 2003: xi). In a coordinated effort, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) proclaimed ACT one of six approved evidence-based treatments for severe mental illness and devised an implementation toolkit for clinicians and patients . It has won recommendation from the US Surgeon General's Report on Mental Health; it has its own professional association in the US, and it currently influences clinical practice internationally (Burns et al. 2001). 10
The diffusion of ACT illustrates a key tension in community psychiatry: between the need for improvisation and practical knowledge, on the one hand, and the influence of formal models and regulation on the other. ACT began as an experimental response to the failures of deinstitutionalization. It was nurtured by psychiatrists and social workers with relatively elite academic standing. The treatment norms they devised were operationalized, published in manuals, and passed on to lower-status front-line workers. The model was implanted across the United States in settings with fewer resources and dramatically different social problems than a Midwestern college town. The on-going implementation of ACT, of course, transforms daily practice despite attempts to ensure fidelity to the original principles, on the part of program evaluators and mental health policy makers. In the end, the infinite adaptations of the model and the top-down attempts to standardize and control clinical work place significant strains upon front line staff.
Some of the adaptations took place at the organizational level. By 1995, several states had reformed their public mental health services in line with the ACT model (Deci et al. 1995). Local mental health administrators received consultation and training from the ACT founders, demonstrated cost-savings, and persuaded state legislators and mental health departments to scale up services. Newly organized teams inevitably differed from the ideal model program. After all, they were not constructed de novo, but instead by retraining people already employed in the mental health system. To build up new teams, the ACT consultants enlisted outreach workers and alcohol counselors who actually knew very little about chronic psychiatric illness or the community support model. ACT planners took staff from the shrinking state hospitals or from traditional case management programs where clinicians had caseloads of up to 60 clients (instead of the ACT recommendation of ten). The earliest ACT teams easily drifted away from the original standards; clinicians continued to see the majority of clients in their offices during normal business hours or simply did not try to engage with people who refused contact. In response, ACT planners encouraged work teams to distance themselves from the daily operation of the surrounding agency. Teams started to have separate staff meetings and record-keeping systems, to develop their own network of housing options, and generally to develop their own organizational identity.11
The sheer expense of ACT also influenced how treatment ideals got translated into workable programs on the ground. Like so many community medical services established in the US since World War II, ACT programs faced a crisis at the end of the demonstration period (cf. Starr 1982: 370). State mental health authorities turned immediately to Medicaid as the new source of funding, and their strategy had important long-term effects. First of all, Medicaid reimbursements cannot actually pay the entire cost of a fully-fledged ACT program. Under Medicaid's lower funding, a bottleneck appeared in the public mental health system with doctors and social workers pleading for the few open spots In 1992, therefore, step-down programs - less intensive, with fewer services and higher caseloads - were created for high-functioning clients. At the same time, administrators tightened admission criteria to reserve ACT slots for the most severely disabled and most often hospitalized people. The shift to Medicaid essentially re-tooled ACT programs to admit the most difficult clients and to encourage the healthier ones to leave sooner. Clinicians found their caseloads filling up with sicker and more disabled individuals.
Secondly, the ACT model fits poorly with the basic Medicaid categories for reimbursement, because it combines health and social services in a single delivery technology (Lewin Group 2000). For example, delivering in vivo treatment may involve several trips until a case manager finds her client, but most of this travel cannot be reimbursed. Teaching people how to shop or write a household budget falls entirely outside Medicaid's definition of medical treatment. The recently implanted ACT teams came under pressure to tailor their services to the balky logic of Medicaid. This problem was solved in a way that profoundly influenced the conditions of work for front-line staff. ACT advocates made alliances with the highest level of state mental health authorities, and in the state where Eastside Services is located, they managed to get program services inserted directly into state law. By working closely with the state mental health division, the advocates planners ensured that community support programs are mandated in each county and spelled out in precise detail.
Eastside staff members, like all ACT teams in this state, must conform to the current administrative code: a triumph of bureaucratic control over everyday clinical work. The state code establishes the make-up of each local work group and the required training for each member. It establishes the maximum client/staff ratio. It sets exact criteria for admission, including diagnosis and levels of impairment. The code dictates the order of work with newly admitted clients (assessment, treatment planning, services, record-keeping, and discharge) and defines each phase of work in minute detail, enumerated by headings, sub-headings, and sub-sub-headings. The legalistic language reaches deeply into program operations and explicitly prescribes case managers' tasks. It lays out the precise steps to help clients find a job (make wake-up calls, counsel them about grooming, and help them buy clothes). It delineates the specific living skills they must teach clients: housecleaning, cooking, shopping, laundry, and money management.
The daily activities of case managers, therefore, is governed by a bureaucratic as well as clinical logic. They operate with a split identity as both clinicians and public employees (cf. Friedson 2001). Even as they deal face-to-face with a client in his own living area, case managers must obey explicit definitions of their duties devised by a remote cadre of mental health administrators. Front line staff never escape the control and surveillance of officials located higher up in the system.12 Case managers at Eastside Services often lack the prerogative to determine their tasks or how best to carry them out. They do not control the criteria by which their work is judged. To a remarkable degree among health care workers, their labor is specified in advance and in writing. The state code standardizes and rationalizes their tasks, and (on paper, at least) leaves them little room to resolve ambiguities and contingencies on their own.
Weaving ACT services into Medicaid financing demanded especially tight surveillance of programs on the ground. To qualify for Medicaid, programs must meet the state certification standards. ACT planners support such audits, since they provide a reliable measure of the fidelity of individual teams to the original principles13. At Eastside Services, the state evaluator arrives every year to comb through clients' charts and billing records. Pushed by this scrutiny from above, the supervisors in turn create structures of surveillance over the case managers. Supervisors continually revise and correct treatment plans, and in both staff meetings and face-to-face reviews, they instruct and discipline the case managers in other details of paperwork (see chapter four). These types of surveillance immerse front-line clinicians more deeply in the bureaucratic mode of control.
Case managers must wrestle with yet another aspect of the micropolitics of work. Their structural weakness is produced by not only distant bureaucratic control, but also their position vis-‡-vis the psychiatrist on the team. As a medico-social intervention, Assertive Community Treatment rests on an inherently complex division of labor. The program's architects acknowledge the tension between case managers and higher status psychiatrists, who are accustomed to directing non-medical staff members. In order to mitigate the friction, Stein and Santos (1998: 60ff) advise psychiatrists to be "helpful and collegial, rather than dictatorial and demeaning," to teach case managers about medications and side effects, to accept calls after hours, and to come in occasionally on weekends. According to this ACT textbook, careful attention to social relationships will foster a well-functioning team, despite the inevitable hierarchy.
At first glance, the psychiatrist on the team is indeed the topmost authority, with the highest credentials and surest control of the jargon and practices at the core of the ACT model. But the relationship between case managers and psychiatrists involves more than their rank order in the hierarchy. The two clinicians rely on different warrants for knowledge. The psychiatrist draws on in-hospital training with people in acute crisis as well as long experience with pharmaceutics. On this basis, she devises recipes for action and deputizes other staff members to carry them out. In such interactions, the psychiatrist acts as expert, and the case managers (mostly social workers) as a less knowledgeable lay audience. The case managers draw on substantially longer interactions with particular clients and much deeper knowledge of clients' life world - their roommates, neighborhoods, usual moods, pastimes, hopes, social connections and family histories. Case managers become proficient in particular perceptual skills, such as noticing small changes in a client's appearance or words. They learn key political skills, such as navigating other public sector services, anticipating future blockages, and finding scarce resources.
A more sophisticated reading of expertise will illuminate the exact relationship between psychiatrists and case managers as well as the trouble it causes for the latter group. From an anthropological perspective, expertise is something that people do, rather than something they possess (Carr 2010). It is an enactment - a performative claim made in the midst of social life - not a cache of individual knowledge. Through verbal and non-verbal communication, people project an authoritative framing of cultural objects, and try to convince others to follow their lead. Success, however, depends not only upon their individual charisma or fluent command of dominant codes. It also depends upon institutional supports: the roles people occupy and the accompanying status. In the context of Eastside Services, the psychiatrist is supported by the ideology woven into the program template and the more general hierarchy of multidisciplinary health care. Indeed, the following chapters illustrate how this psychiatrist inhabits his prescribed role and verbally enacts his expertise during staff meetings. In many cases, the case managers accept (or are forced to accept) that they are less aware, less knowing, and less knowledgeable than the psychiatrist (see Carr 2010: 22).
Case managers obviously do not control the most highly valued knowledge within ACT - that is, biopsychiatry. They also cannot deliver the verbal performance often demanded by psychiatrists. In a private interview, one psychiatrist who devoted his career to ACT expressed his continual frustration with case managers. During a busy staff meeting, he will ask for particular details about clients' symptoms. He wants a quick reply, summarizing the information most relevant for medication management - just the sort of reply that medical students and residents are trained to provide. But the case managers instead respond with long rambling stories about the person's social problems and minute details about her appearance and preoccupations. The psychiatrist must take a deep breath and patiently extract the two or three facts that he actually needs. Case managers simply do not have the training, institutional support, or performative skills to qualify as experts on ACT teams.
The team functions smoothly so long as all parties conform to a few rules of engagement. The case managers are expected to accept the psychiatrist's rendering of clients' conditions and needs. When asked, they should offer their rich knowledge of clients' living conditions, habitus, and immediate social environment, so the psychiatrist knows what to expect in that day's appointments or how to deal with an emerging crisis. In the ACT model, the highest ranking professional routinely depends on lower-ranking staff. That very dependence, however, gives case managers an opening to present authoritative readings of clients' inner mental states. After all, the two types of clinicians have different ways of knowing and different kinds of knowledge. Case managers therefore have traction to push back against the psychiatrist's interpretation and recommended actions. The low-ranking staff can advance alternative interpretations of clients' inner states, their potential for recovery and the sources of their suffering. The conflict of interpretation between case manager and psychiatrist often drives staff room debates, and can sow deep divisions in the team.
To some extent, such conflicts reflect the differences between situated and disciplinary knowledge (see Floersch 2002). Case managers develop their knowledge through the infinite improvisations demanded by ordinary work: the slow accumulation of practical experience with particular clients as well as the core ACT tools (the treatment plans, schemes for money management, and paperwork for commitment examined in the rest of this book). Such knowledge is parallel but marginal to the official knowledge of professional psychiatry (or professional social work, for that matter). The psychiatrist, by contrast, sees clients primarily in his office and usually for medication management. The conditions of his work better fit his disciplinary training, compared to the situation faced by case managers. But the categories of situated vs. disciplinary knowledge eventually break down. Psychiatrists too must cultivate something beyond formally coherent textbook knowledge to do the job well. Their connoisseurship of pharmaceutics is intuitive and based on decades of experience At Eastside Services, to choose another example, the psychiatrist must have an intuitive grasp of the agency's positions within the local ecology of mental health services. Only then can he judge when a commitment order will likely succeed or fail, and which addiction treatment center will accept a particular client.
The conflict of interpretations between psychiatrist and case manager reflects fundamentally the difference between expertise and craft (see Rice 2010). People learn the skills of case management almost at an unconscious level and in specific circumstances. Such learning does not depend on an explicit articulation of categories, basic principles or algorithms. People instead learn through trial and error as well as guidance about particular cases from more seasoned colleagues. Day by day, they learn how to attach salience to the details of clients' apartments, appearance, and expressions. At Eastside Services, the craft-like quality of their skills becomes clear in the way they work through crises, such as treatment refusal, worsening symptoms, and the disruptions caused by eviction or arrest. Case managers rarely compare a given case to a previous crisis, or try to fit the manifold details into a more abstract conceptual scheme (such as checklist of risk factors for suicide, or the precise line between persuasion and coercion). To figure out how to handle a crisis, people simply expand the range of relevant details. Their conversation circles more and more widely, taking in more of the person's life-world and social connections, until a provisional solution somehow appeared.
The craft of case management involves assembling and re-assembling components of their clients' lives. Case managers start anew with each new crisis; although guided by intuition and experience, they never articulate such guidance in its own terms. They cannot separate the body of knowledge authorizing their interpretation from the details of the case at hand. Their knowledge is actually better termed "know-how", and it exceeds any professional jargon or classificatory system. (In any case, most Eastside case managers actually have very little course work in severe mental illness from their social work or counseling training.) People's skill in the craft of case management depends on the tools that they use. Their clinical disposition gets animated only when engaged in the details of work.
Because of their craft-like approach, case managers have a different angle of vision compared to the psychiatrist. The differences often pushes them to contest the psychiatrist's interpretation of clients' problems, but they enter this contest with several disadvantages. Of course, they lack the signs and habits of expertise, as authorized within the ACT model. In some ways, moreover, the psychiatrist cannot even fully take in all that the case managers know. Their ways of making and transmitting knowledge are simply too different (see Marchand 2010). The result is typically miscomprehension and bewilderment - a breakdown in team work that the psychiatrist often resolves simply by fiat. Discord, instead of dialogue, usually marks staff room debates. The division of labor on ACT teams, so clear and complementary in the program manuals, becomes a permanent faultline on the landscape of practice. Anthropologists may wish to compare craft to expertise, or situated to disciplinary learning, as simply different types of knowledge. ACT case managers, however, experience the difference as a continual contest over how to represent and respond to clients' needs.
Fault Lines in the Groundwork of Practice
The genealogy of an institution exposes its development through successive historical regimes, but without searching for underlying laws, hidden meanings, or progress along the way. From this angle, a social institution is an assemblage of different components that came together over time. They do not fit together seamlessly, and lining them up chronologically may not reveal a grand unfolding scheme. An institution - even a single workplace - carries the imprint of history, conceived as a series of moments and discrete practices that somehow left their mark on generations to come (see Lash 1984). This genealogy of Eastside Services is thus not a complete history of deinstitutionalization or of the professional field of psychiatric rehabilitation. The chapter ignores the development of many other institutions that impinge on the daily operation of Eastside Services, such as the hospital emergency room, homeless shelter, rooming house, meal site, the county jail and the office of probation and parole. The more limited goal is to pose some basic questions about everyday ethics. What long-term structural contradictions underlie the problems that clinicians face in their routine work? Are the tools provided by the ACT model actually sufficient for the job? And when they fall short, does their failure provoke ethical reflection?
The landscape of practice at agencies like Eastside Services derives only partially from the formal blueprint for Assertive Community Treatment. The architects of ACT portray the model as a unified technology, designed to perform as planned in its defined tasks, given proper upkeep and well-trained operators. But as even the program's supporters admit, it is impossible to replicate the Madison model perfectly. With dissemination come infinite variations, driven by state finances, the shape of the regional mental health system (hospitals, foster homes, drug treatment facilities, etc.), the organizational climate of the agency where the ACT team operates, the training of its staff, and the shifting needs of clients (Mowbray 1997a and b, Lewin Group 2000). Most ACT teams do not, in fact, conform precisely to the original blueprint. They have drifted away as they assimilated to the surrounding ecology of services and funding.
At Eastside Services, the front-line staff practices with a bundle of inherited tools, each with a distinct lineage. Medications and the mechanism for compliance come from biopsyschiatry, and he technique of case management comes from broad developments in American human services since the 1970s (see chapter three). The paperwork technologies of assessment forms and treatment plans come from ACT manuals (see chapter four). The money to pay for services is cobbled together from federal entitlements and state and municipal programs: an amalgam reflecting 40 years of debate about public responsibility for dependent persons (chapter five). The directions for working with clients are inscribed in state law, itself the product of by both ACT advocates and civil libertarians who sharply narrowed commitment criteria (see chapter six). Today's ordinary tasks emerged from successive phases in the long development of community psychiatry services. Staff members managers depend on this mixture of inherited ideas, regulations and techniques in order to meet the demands of the day. Not surprisingly, people cannot make the ingredients mesh perfectly. The rest of the book follow the conflicts that erupt when the outlooks and routines of psychiatry, social work, law, and the public welfare system bump against each other.
These conflicts create difficult obstacles for the course of everday work, and they can undermine its legitimacy even in the eyes of front-line staff. Clinicians get tangled up in several contradictory goals and expectations. The ACT manuals articulate a straightforward clinical goal: to lengthen the remission period of chronic psychiatric disease. The program's genealogy, however, shows why this simple goal is so hard to carry out. As the original CSP ideals got translated into programs on the ground, the case manager became responsible for funneling to clients the entire range of services (treatment, housing, food, counseling, social connections, and daily activities) that were once bundled in a single brick-and-mortar institution. The task, of course, is impossible. No single program can piece together again the full array of supports available in the old state hospitals. Nevertheless, today's case managers inherit the impossible mission of providing everything their clients need in the "community," ambiguously defined as anywhere but the hospital, jail, or homeless shelter.
The genealogy of ACT also shapes how they carry out their job. By all accounts, the forerunners of today's case manager were remarkably creative in helping recently discharged patients stay stable, fed, and housed. They simply improvised in the near absence of role models, professional norms, or guidance from above. Thirty years later, the situation faced by case managers requires the same flexibility and pragmatism. Their room for improvisation, however, has shrunk significantly. When mental health service researchers from psychiatry and social work scaled up the nascent programs, they standardized and rationalized the roles of all clinical personnel. Case managers were inserted into a particular slot on the ACT team. The ACT manuals and (especially) state codes meticulously define case managers' activities in line with bureaucratic needs for surveillance. The guidelines substitute algorithms and explicit lists in place of judgments based on accumulated clinical experience.
In the first decade of ACT, a psychiatrist who trained with its founders wrote that good case managers are pragmatists; they believe in what they do because they see its positive effects (see Diamond and Wikler 1985). Today's case managers have inherited a task that intrinsically demands constant improvisation. Clients' needs and the available resources shift rapidly, and case managers typically must push through a plan of action on their own - in the immediate term, on the street or in people's apartments - with no immediate supervision. Over the years, however, their job has become hedged in by organizational and technocratic restrictions. Their work demands a tactical, situated knowledge, but their formal role blocks them from acting on this hard-earned knowledge. By design, they have the most exposure to and closest relation with clients, but the least authority over decisions about diagnosis, medication, and hospitalization.
The swerves and successive phases in the development of CSP-style services all converge at the clinical front line. Eastside Services - like similar work teams in the US and around the world - is not a seamless, unified apparatus with a singular goal. The mission of the work team is filled with long-standing contradictions. The role of case manager is deeply ambiguous, mixing elements of social worker, nurse, physician extender, counselor, friend, advocate, gatekeeper, enforcer of agency and municipal rules, and representative of formal state power (see Aviram 1990). Case managers have inherited ultimate and limitless responsibility for clients. They are arguably the last people left standing alongside their clients - seven days a week, for years on end - after the dismantling of state hospitals, the retrenchment of public welfare, and the decline of urban neighborhoods. At the same time, case managers have the least credentials, the lowest rank, and the least control over their conditions of work among all providers in the public sector mental health system. How they survive, and how they talk about their survival, is the topic of the following chapters. Their everyday ethics emerge from the way they negotiate the deep fault lines on this landscape of practice.
1 The literature about deinstitutionalization is huge and contentious. This overview draws from the works of clinicians, historians, and sociologists: Bassuk and Gerson 1978, Breakey 1996, Cohen 1990, Dear and Wolch 1987, Grob 1994, Gruenberg and Archer 1979, Jones 1979, Mechanic 1987, Mechanic and Rochefort 1990, Pilgrim and Rogers 1993, Rochefort 1989, and Scull 1981. 2 The figures come from Bassuk and Gerson (1978), Mechanic and Rochefort (1990), and Council of State Governments (2002). 3 The poor clinical outcomes of public sector services among people with severe mental illness and multiple social disabilities have been described in the same terms over the past few decades; see Schwartz and Goldfinger (1981), Pepper and Ryglewicz (1984), McLaughlin and Pepper (1990), Bachrach (1990), Human Rights Watch (2003) 4 See www.actassociation.org/origins, accessed 30 June, 2011. The brief citation provided by ACTA is The Journal 9(1), 1998. I have been unable to locate the original source. 5 Scattered reports suggest that many individual front-line clinicians were innovating during this period to address the problems of deinstitutionalization. In rural Vernon County, Wisconsin, for example, mental health center staff were already providing community support and enlisting the help of the family and friends of people with mental illness, before the ACT program trainers arrived on the scene (Diamond and Van Dyke 1985). 6 Estroff's book is a landmark in the anthropology of psychiatry in the United States. Many of the fault lines in the ACT model that she uncovered in the late 1970s still characterize the treatment model today. An enormous level of surveillance and control now takes place outside of hospital walls, and many clients become emotionally and materially dependent on upon their case managers. The present study, focusing on the ethical dilemmas faced by ACT clinicians, thus complements Estroff's study of the double binds faced by clients. Like her book, however, the present work is not an attempted evaluation of the ACT program in general or the significantly modified form that I observed firsthand at Eastside Services. 7 See Marshall (1998), Stein and Santos (1998: 30-39), Allness and Knoedler (2003: 4-7), and the bibliography maintained by the ACT Center of Indiana (psych.iupui.edu/ ACTCenter/Biblio.htm, accessed June 2, 2011). 8 A similar manual for implanting and operating ACT teams in the United Kingdom was published a few years later (see Burns and Firn 2002). 9 Important replication and fidelity studies of ACT include Phillips (2001), Lewin Group (2000), McGrew et al. (1995), and Bond (2001). 10 Over the past twenty years, ACT services have been introduced to Australia, England, several European countries, and Japan. Not surprisingly, the reception to ACT varies considerably due to divergent cultural contexts and national health care policies. The model has rapidly disseminated in certain settings. In 1999, mental health policy in England mandated the provision of "assertive outreach teams," and five years later there were 263 such programs (Killaspy et al. 2006). Introduced to the Netherlands in 2001, at least 55 teams were soon in operation (Van Dijk et al. 2007). Other settings have seen a mixed or even hostile reception (Burns et al. 2001). The rate of deinstitutionalization, and hence the very development of community psychiatry, differs across national borders. The fragmentation between social welfare and health care services also varies, so the notion of a single point of services does not offer the same marginal value in all countries. Finally, the ideology of psychiatry and the expertise claimed by social workers is culturally specific, and ACT can appear as an elitist American import (ibid.). 11 Contemporary accounts illustrate the pragmatic and opportunistic process of implanting new ACT teams; see Diamond and Van Dyke (1985), Essock and Kontos (1995), McDonel (1997), and Mowbray (1997b). 12 Although ACT case managers often work for a private non-profit agencies, the agencies themselves depend on public funds, and the funds get disbursed according to state and federal regulations. 13 Concerns about the slippage between the textbook ACT model and operation of actual work teams run throughout the professional literature, and health service researchers can now choose among four fidelity models to evaluate and compare individual programs (Lewin Group 2000).