UNIVERITY OF CALIFORNIA, IRVINE Slumcare and the Fail-State DISSERTATION Submitted in partial satisfaction of the requirements for the degree of DOCTOR OF PHILOSOPHY in Criminology, Law and Society by Kenneth Alexander Cruz Dissertation Committee: Professor Elliott P. Currie, Chair Professor Valerie Jenness Arizona Regents’ Professor Raymond Michalowski Assistant Professor Sora Han 2016 © 2016 Kenneth A. Cruz TABLE OF CONTENTS Page ACKNOWLEDGMENTS iii CURRICULUM VITAE iv ABSTRACT OF THE DISSERTATION v INTRODUCTION 1 CHAPTER 1: Organized Chaos: Tales of Unsustainable Care 37 CHAPTER 2: The Therapeutic Void 93 CHAPTER 3: Systemic Endangerment 129 CHAPTER 4: Slumcare and the Fail-State 173 CHAPTER 5: Conclusion 217 REFERENCES 244 ii ACKNOWLEDGMENTS I would like to thank my committee chair, Professor Elliott Currie, for his extraordinary mentorship and guidance. His integrity, intellectual gravitas, and wizardry with the written word will continue to inspire me for years to come. I am profoundly grateful for his example. I would also like to thank my committee members, Professor Valerie Jenness, Professor Sora Han and Professor Raymond Michalowski, whose critical scholarship have served as beacons for my intellectual home. In addition, I would like to thank Professor Geoff Ward, Professor Justin Richland, Professor Rebecca Maniglia and Professor Neil Websdale who supported and guided me along the way. iii CURRICULUM VITAE Kenneth Alexander Cruz PhD. 2016 University of California, Irvine Criminology, Law and Society M.S. 2009 Northern Arizona University Applied Criminology (with distinction) Thesis: Surface Versus Substance: How Medicalizing the Behavioral Problems of Abused and Neglected Youth Individualizes Maltreatment J.D. 2002 University of Connecticut Law B.A. 1997 Southern Connecticut State University Psychology (magna cum laude) iv ABSTRACT OF THE DISSERTATION Slumcare and the Fail-State By Kenneth Alexander Cruz Doctor of Philosophy in Criminology, Law and Society University of California, Irvine, 2016 Professor Elliott P. Currie, Chair In this empirical study of an evidence-based intervention with aggressive and violent adolescent males, I show how the state repeatedly fails Native American youth, their families and their communities. Using grounded theory methods with a critical realist lens, I demonstrate how the provision of substandard care to the poor—what I call, slumcare—was enabled, justified and allowed to continue. In particular, I reveal how slumcare is the result of the state’s repeated failure to achieve its mandate of balancing quality care with other priorities. In this account of how poor quality care persists, I show how a form of governing I call the fail-state enables slumcare to emerge and linger. In addition, this study demonstrates that practitioners of evidence-based ‘conformist’ interventions can be a surprising resource for discovering ‘transformative’ solutions. v Introduction “There can be no keener revelation of a society’s soul than the way in which it treats its children.” Nelson Mandela When I put in my two-weeks notice at Mountain View,1 I wrote in my research journal: “I feel like I am trying to stop an avalanche . It no longer feels like a group-home where staff run the house” (Journal Notes). In my last few entries—written after I had collected my interviews for this study—I reveal how emotionally painful it was to see chaos become the norm at the group-home I worked at for more than a year and how most of the new staff simply didn’t have what it takes to work with troubled youth. In my final entry, I wrote “[n]ow, the kids run the house, don’t follow the rules, and don’t listen to staff. It feels like chaos.” Although my shifts were generally run without a single crisis, our staff-log revealed that crises became the norm with our new staff. Tina—the regional manager—went out of her way to tell me she missed me and that “supervision of the kids has gone down since I left” my fulltime position to work one shift a week. Despite Tina’s wish that she could “clone” me, I felt “powerless.” No matter how hard I tried, I couldn’t prevent the collapse of what I helped to maintain for the better part of a year. 1 To protect the anonymity of my participants, I have created fictitious names for my participants, the company I worked for, the group-home where I worked, the location of the group-home and the Native American tribes that have been affected by the findings of this study. 1 During those last few months, Luna—the group-home manager—was fired and three of our strongest direct-care workers left the job as a result. The core group of staff I worked with for almost a year had all left at the same time and were replaced by new staff who generally couldn’t run a shift without something going seriously wrong. Although Luna was reportedly fired for “insubordination” (Journal Notes), it was well known that she—along with a core of strong staff—held Mountain View together and prevented it from imploding. In my final entry, I reflect on how different things were just a few months before: “[w]hen I was working fulltime and we still had a core of strong staff, we ran a program that was structured. Not only were rules followed, the kids were proud of letting us know they were following the rules. Consistency across shifts was never fully attained, but the odd shift dominated by weak staff was the exception to the rule” (Journal Notes). Further, when Luna and I were colleagues, it was evident that the kids gravitated towards her and clearly benefitted from their connection with her. Indeed, she was commonly recognized as a natural in this line of work. In fact, as she tells it, it was her advocacy for the kids that ultimately got her fired. Regardless of why she was terminated, after Luna and the core of Mountain View’s staff left, chaos took a hold of the program on most days of the week and I couldn’t bear to be associated with it any longer. So, I left as well and—to this day—I still carry the guilt of having abandoned the kids at Mountain View.2 Although it may not assuage my guilt, I feel a tremendous responsibility to share the stories I collected of what it was like to work there and why even a core of strong staff couldn’t prevent substandard care from occurring. As this empirical study will show, the layers of dysfunction in this evidence-based program were too great and the sources of that dysfunction too far removed for us to control. 2 Two weeks before I put in my notice, I wrote: “It pains me to see the house in chaos and to see the look of abandonment in the kids’ eyes” (Journal Notes). 2 Even the CEO of Adolescent Behavioral Care (ABC)—the for-profit company that owned and operated Mountain View—was often powerless. Despite good intentions, even he couldn’t prevent the provision of substandard care to the poor: what I call, slumcare. As manifestations of poor quality care, the slumcare practices detailed in this study— such as the facilitation of chaos and systemic endangerment—were not only substandard, they were also linked to harmful interventions. Because the harms produced by these practices are both widespread and destructive, it is urgent that we understand how they are produced and how they are enabled to persist. What this study will show is that it is the state that is ultimately responsible for the provision of slumcare. In particular, it is what I call the fail-state—a form of governing that repeatedly fails to achieve its mandate—that is heavily responsible for the substandard care detailed throughout this empirical analysis.3 Although Mountain View is a single case of poor quality care, the insights derived from this study indicate that slumcare is enabled by the structure of Medicaid managed-care in this state: a structure that happens to be quite ubiquitous. It is my hope that this study will contribute to the structural harm literature by identifying how slumcare is enabled to persist. The Structural Harm Literature In the last few decades, a growing body of interdisciplinary research has begun to examine how the structuring of society leads to a variety of social harms (Alexander, 2010; Beckett & Sasson, 2004; Biehl, 2005; Bourgois & Schonberg, 2009; Currie, 2004; Farmer, 2004; 3 Rothman (1980) argues that substandard interventions are the result of institutional conveniences and that “when conscience and convenience met, convenience won” (1980: 10). This study, however, reveals that substandard care often occurred in spite of institutional conscience. In fact, many of my colleagues were deeply committed to the services they were providing for troubled youth. Nevertheless, they were often constrained by structures beyond the control of the institution. Further, although implementation failures were connected to some slumcare practices, others were the direct result of fidelity to the state-supported interventions they were providing. That is, conscience—at the state-level—was often implicated in slumcare. 3 Galtung, 1969; Price, 2012; Richie, 2012; Roberts, 2002; Scheper-Hughes, 2004; Waquant, 2009). While the academic disciplines that house these works are as varied as the theories and methods they use, their central findings are substantively similar and disturbingly clear: the structuring of society can lead to dire consequences for some groups more than others. Indeed, the startling revelation of this body of work is that some of our valued—and taken-for-granted— policies, institutions and practices are routinely harming women (Price, 2012; Richie, 2012), children (Currie, 2004; Scheper-Hughes, 2004), and the forsaken (Alexander, 2010; Biehl, 2005; Beckett & Sasson, 2004; Bourgois & Schonberg, 2009; Farmer, 2004; Roberts, 2002; Waquant, 2009).