UC Berkeley

This dissertation examines how public mental health care systems in France and the United States treat similar diseases while producing very different kinds of mentally ill subjects. Through ethnographic observations of clinics, welfare offices, and courts, three hundred interviews with professionals and policymakers, and government archives, I document the seemingly chaotic and disordered trajectory of severely mentally-ill persons in the post-asylum era. The fragmentation and conflict in each country is consistent with literatures in medical sociology on mental health systems organization and with the sociology of professions.

I argue, however, that there is nonetheless an underlying order to these trajectories in each country. Medical actors and bureaucrats—such as judges, psychiatrists, and social workers—use shared, culturally-specific categories to divide between normality and pathology, disability and functionality, and dangerousness and deviance. In France, a common vision treats the mentally ill as a distinct class of persons with a deep-seated, troubled subjectivity that molds their entire life. This reproduces a system based on specialized, segregated services. In the United States, a perception of mental illness as primarily a behavioral problem—in the same vein as drug use or general delinquency—underpins a shared jurisdiction between different institutions of poverty governance. In place of typologies, the United States locates individuals on a simultaneously moral and medical continuum between failure and redemption, fluctuating based on personal discipline and medication compliance. The result is profoundly different distributions of the severely mentally ill between institutions of care and control.

These results suggest that the literatures on medical classification, professions, and bureaucratic decision-making need to better account for broader differences in state structure, national culture, and conceptions of the self which set the terrain of professional and bureaucratic conflict and underpin medical diagnoses.