Between Two Worlds: Care and Decline in a Closing Psychiatric Emergency Department

This dissertation examines how organizational decline became visible and consequential in the everyday work of a public psychiatric safety net. It draws on an ethnographic case study of the Mental Health Service (MHS), a county-run psychiatric emergency department in a racially segregated Midwestern city during its final six months of operation. Across more than two years of engagement with the local behavioral health ecosystem, participant observation at MHS, interviews with staff and administrators, and organizational document review, I analyze how contraction impacted patient trajectories, frontline practice, and everyday organizational life as public psychiatric infrastructure gave way to privatized and fragmented alternatives. The three papers trace this process across linked dimensions of care. The first paper examines the production of the “county patient,” a position generated through the accumulated exclusion and avoidance practices of the broader behavioral health system. It shows how private hospitals, law enforcement, caregivers, inpatient facilities, and MHS, itself, participated in sorting certain patients into the public psychiatric safety net and concentrating vulnerability there, and how MHS remained indispensable to that arrangement without gaining leverage from it. The second paper examines humor and shows how humor moved resistant patients through intake, held together a demoralized workforce, and made structural dysfunction speakable as formal supports eroded. Humor became a load-bearing element of the organization’s cultural toolkit, taking on relational, coordinative, and affective work that formal systems could no longer perform reliably and enabling staff not only to grieve the institution but to keep working inside it as it closed. The third paper examines the production and accumulative nature of restraint. It shows that restraint was organized by a recurring misalignment where the formal authority to order restraint was separated from the practical labor, situational knowledge, physical risk, and moral weight through which it was carried out. Restraint took shape in the gaps this opened, as staff positioned differently within the clinical hierarchy read the same encounter differently, while patients communicated distress and trauma that staff did not always recognize as relevant. This process was also accumulative: staff carried prior histories, judgments, and expectations into encounters, and restraint and near-restraint encounters could leave behind residue that shaped later ones. Together, these papers show that decline does more than reduce capacity. It intensifies who gets concentrated in emergency psychiatric care, shapes how restraint interventions become possible, and heightens the weight of informal practices that sustain continuity as organizations die. The dissertation contributes to scholarship on psychiatric emergency care, organizational decline, restraints, and public safety nets by showing how the burdens of contraction are redistributed onto frontline workers and the patients least able to contest the terms of their care.