UCLA

This dissertation investigates inequality in community-based mental health services by comparing public safety net and elite private treatment in Los Angeles. Drawing on more than four years of ethnographic fieldwork, interviews, and historical research, the dissertation analyzes the way social class shapes the care, control, and empowerment of people diagnosed with serious psychiatric disabilities. A substantial literature has investigated the consequences of deinstitutionalization, such as the crisis of criminalization and homelessness for poor psychiatric services users, yet far less is known about the experience of those with more social and economic resources. Comparing clinics for the poor and rich, I show how the very meaning of treatment shifts by class context. In a public safety net setting oriented to urban poverty governance, staff members work to secure their clientele access to survival resources. With few therapeutic interventions beyond psychiatric medication, care is oriented to housing and basic stability. Providers engage in what I call a “tolerant containment” approach that accepts a surprising amount of seemingly problematic behavior, like drug use and “non-compliance,” with intervention focused on harm reduction and creative solutions for keeping people off the streets. In the elite private settings, on the other hand, providers have access to a broad array of therapeutic interventions and a goal of transformative care. Far from letting people choose to be “deviant,” I find providers heavily invest therapeutic resources to both cultivate and control privileged patients. Building on sociological theories of privileged childrearing, I term this form of family-driven governance “concerted constraint.” Holding these cases as mirrors to one another, I argue that the clinics are not simply treating mental illness, but also attempting to create different kinds of people for their respective classed milieus.