Literature Review



Bounding and Scaling:Principles of Classification in Psychiatric Care in the United States and FranceAlex V. BarnardDepartment of SociologyNew York UniversityAcknowledgements: The author gratefully acknowledges the assistance of Lili Dao, Linsey Edwards, Neil Fligstein, Marion Fourcade, Bonnie Ip, Nahoko Kameo, Carly Knight, Armando Lara-Millán, Nick Rekenthaler, Mary Shi, and Iddo Tavory, as well as the Genial and Ephemeral Meetings in Sociology at the University of California, Berkeley, the NYU Ethnography Workshop, and the UC Santa Barbara Culture Workshop. Versions of this paper were presented at the 2020 Eastern Sociological Society, 2020 American Sociological Association, and 2018 Council for European Studies Annual Meetings. The Georges Lurcy and Chateaubriand Fellowships provided funding for this research.Word Count: Front Matter:Tables: 761Bounding and Scaling:Principles of Classification in Psychiatric Care in the United States and FranceAbstract:Modern mental health systems face simultaneous pressures to expand treatment to new populations through “medicalization” and to constrain care and control costs through “rationalization.” This paper compares how these trends shape who receives treatment in the public mental health system in France and the United States, drawing on ethnographic observations of a clinic in Paris and California, over three-hundred-fifty qualitative interviews, and archival materials. In France, clinicians resist medicalization and rationalization, defending a professional prerogative to use broad typologies to draw boundaries around a small group of mentally ill persons. In the U.S., they embrace both medicalization and rationalization and identify pathology through classifying behaviors across a wide continuum of the population through rankings and counts. I argue that this “bounding” and “scaling” represent two different “classificatory principles”—a set of shared understandings about what the system is actually treating and what kinds of categories can be used to evaluate it. Analyzing these meta-level assumptions helps us understand cross-national differences in how actors resist or embrace common external pressures, like those for medicalization and rationalization, and how they shape classificatory decision-making in practice. Key words:Medicalization, Principles of Classification, Rationalization, Mental Health, FieldsModern mental health systems face two competing pressures. On one hand, clinicians seeking to expand their jurisdiction, politicians looking to contain disruptive behaviors, and a population demanding treatment has pushed the frontiers of “mental illness” outward through a process of “medicalization” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1vdhs8cnd3","properties":{"formattedCitation":"(Conrad 2007; Horwitz 2001; Jutel 2011)","plainCitation":"(Conrad 2007; Horwitz 2001; Jutel 2011)","noteIndex":0},"citationItems":[{"id":2977,"uris":[""],"uri":[""],"itemData":{"id":2977,"type":"book","abstract":"Over the past half-century, the social terrain of health and illness has been transformed. What were once considered normal human events and common human problems—birth, aging, menopause, alcoholism, and obesity—are now viewed as medical conditions. For better or worse, medicine increasingly permeates aspects of daily life.Building on more than three decades of research, Peter Conrad explores the changing forces behind this trend with case studies of short stature, social anxiety, \"male menopause,\" erectile dysfunction, adult ADHD, and sexual orientation. He examines the emergence of and changes in medicalization, the consequences of the expanding medical domain, and the implications for health and society. He finds in recent developments—such as the growing number of possible diagnoses and biomedical enhancements—the future direction of medicalization. Conrad contends that the impact of medical professionals on medicalization has diminished. Instead, the pharmaceutical and biotechnical industries, insurance companies and HMOs, and the patient as consumer have become the major forces promoting medicalization. This thought-provoking study offers valuable insight into not only how medicalization got to this point but also how it may continue to evolve.","event-place":"Baltimore, MD","ISBN":"978-0-8018-8585-3","language":"English","number-of-pages":"224","publisher":"Johns Hopkins University Press","publisher-place":"Baltimore, MD","source":"Amazon","title":"The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders","title-short":"The Medicalization of Society","author":[{"family":"Conrad","given":"Peter"}],"issued":{"date-parts":[["2007"]]}}},{"id":2251,"uris":[""],"uri":[""],"itemData":{"id":2251,"type":"book","abstract":"In this surprising book, Allan V. Horwitz argues that our current conceptions of mental illness as a disease fit only a small number of serious psychological conditions and that most conditions currently regarded as mental illness are cultural constructions, normal reactions to stressful social circumstances, or simply forms of deviant behavior. \n\n\"Thought-provoking and important. . .Drawing on and consolidating the ideas of a range of authors, Horwitz challenges the existing use of the term mental illness and the psychiatric ideas and practices on which this usage is based. . . . Horwitz enters this controversial territory with confidence, conviction, and clarity.\"—Joan Busfield, \n\n\"Horwitz properly identifies the financial incentives that urge therapists and drug companies to proliferate psychiatric diagnostic categories. He correctly identifies the stranglehold that psychiatric diagnosis has on research funding in mental health. Above all, he provides a sorely needed counterpoint to the most strident advocates of disease-model psychiatry.\"—Mark Sullivan,Journal of the American Medical Association\n\n\"Horwitz makes at least two major contributions to our understanding of mental disorders. First, he eloquently draws on evidence from the biological and social sciences to create a balanced, integrative approach to the study of mental disorders. Second, in accomplishing the first contribution, he provides a fascinating history of the study and treatment of mental disorders. . . from early asylum work to the rise of modern biological psychiatry.\"—Debra Umberson, Quarterly Review of Biology","event-place":"Chicago, IL","publisher":"University of Chicago Press","publisher-place":"Chicago, IL","source":"press.uchicago.edu","title":"Creating Mental Illness","author":[{"family":"Horwitz","given":"Allan?V."}],"issued":{"date-parts":[["2001"]]}}},{"id":2371,"uris":[""],"uri":[""],"itemData":{"id":2371,"type":"book","abstract":"Over a decade after medical sociologist Phil Brown called for a sociology of diagnosis, Putting a Name to It provides the first book-length, comprehensive framework for this emerging subdiscipline of medical sociology.Diagnosis is central to medicine. It creates social order, explains illness, identifies treatments, and predicts outcomes. Using concepts of medical sociology, Annemarie Goldstein Jutel sheds light on current knowledge about the components of diagnosis to outline how a sociology of diagnosis would function. She situates it within the broader discipline, lays out the directions it should explore, and discusses how the classification of illness and framing of diagnosis relate to social status and order. Jutel explains why this matters not just to doctor-patient relationships but also to the entire medical system. As a result, she argues, the sociological realm of diagnosis encompasses not only the ongoing controversy surrounding revisions to the Diagnostic and Statistical Manual of Mental Disorders in psychiatry but also hot-button issues such as genetic screening and pharmaceutical industry disease mongering.Both a challenge and a call to arms, Putting a Name to It is a lucid, persuasive argument for formalizing, professionalizing, and advancing longstanding practice. Jutel’s innovative, open approach and engaging arguments will find support among medical sociologists and practitioners and across much of the medical system.","event-place":"Baltimore, MD","ISBN":"978-1-4214-0067-9","language":"English","number-of-pages":"200","publisher":"Johns Hopkins University Press","publisher-place":"Baltimore, MD","source":"","title":"Putting a Name to It: Diagnosis in Contemporary Society","title-short":"Putting a Name to It","author":[{"family":"Jutel","given":"Annemarie Goldstein"}],"issued":{"date-parts":[["2011"]]}}}],"schema":""} (Conrad 2007; Horwitz 2001; Jutel 2011). These same systems face an imperative to “rationalize” services through cost controls and protocols for limiting treatment ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a5h14jml4v","properties":{"formattedCitation":"(Livne 2019; Luhrmann 2000; Scheid 2004)","plainCitation":"(Livne 2019; Luhrmann 2000; Scheid 2004)","noteIndex":0},"citationItems":[{"id":3626,"uris":[""],"uri":[""],"itemData":{"id":3626,"type":"book","event-place":"Cambridge, MA","publisher":"Harvard University Press","publisher-place":"Cambridge, MA","title":"Values at the End of Life","author":[{"family":"Livne","given":"Roi"}],"issued":{"date-parts":[["2019"]]}}},{"id":3613,"uris":[""],"uri":[""],"itemData":{"id":3613,"type":"book","abstract":"With sharp and soulful insight, T. R. Luhrmann examines the world of psychiatry, a profession which today is facing some of its greatest challenges from within and without, as it continues to offer hope to many. At a time when mood-altering drugs have revolutionized the treatment of the mentally ill and HMO’s are forcing caregivers to take the pharmocological route over the talking cure, Luhrmann places us at the heart of the matter and allows us to see exactly what is at stake. Based on extensive interviews with patients and doctors, as well as investigative fieldwork in residence programs, private psychiatric hospitals, and state hospitals, Luhrmann’s groundbreaking book shows us how psychiatrists develop and how the enormous ambiguities in the field affect its practitioners and patients.","event-place":"New York","ISBN":"978-0-679-74493-1","language":"English","number-of-pages":"352","publisher":"Alfred A. Knopf","publisher-place":"New York","source":"","title":"Of Two Minds: The Growing Disorder in American Psychiatry","title-short":"Of Two Minds","author":[{"family":"Luhrmann","given":"T. M."}],"issued":{"date-parts":[["2000"]]}}},{"id":3587,"uris":[""],"uri":[""],"itemData":{"id":3587,"type":"book","abstract":"Tie a Knot and Hang On is an analysis of mental health care work that crosses the borders of diverse sociological traditions. The work seeks to understand the theoretical and empirical linkages between environmental pressures and activities and how these intersect with organizations and individuals. The work draws upon a research tradition that sees the issue of mental health care in terms of institutional pressures and normative values. The author provides a description and a sociological analysis of mental health care work, emphasizing the interaction of professionally generated norms that guide the &quot;emotional labor&quot; of mental health care workers, and the organizational contexts within which mental health care is provided. She concludes with a discussion of emerging institutional forces that will shape the mental health care system in the future. These forces are having greater impact than ever before as managed care comes to have a huge fiscal as well as institutional impact on the work of mental health professionals. Scheid&#39;s book is a brilliant, nuanced effort to explain the institutional demands for efficiency and cost containment with the professional ethics that emphasize quality care for the individual. The book is essential reading for those interested in mental health care organizations and the providers responding to these seemingly larger, abstract demands. The work offers a rich mixture not just of the problems faced by mental health care personnel, but the equilibrium currently in place ?? an equilibrium that shapes the theory of the field, no less than the activities of its practitioners. Teresa L. Scheid is associate professor of sociology, at the University of North Carolina at Charlotte. She has published widely in the area, including major essays in Sociology of Health and Illness, Sociological Quarterly, Perspectives on Social Problems, and The Journal of Applied Behavioral Science.","event-place":"Hawthorne, NY","ISBN":"978-1-4128-4003-3","language":"en","number-of-pages":"212","publisher":"Transaction Publishers","publisher-place":"Hawthorne, NY","source":"Google Books","title":"Tie a Knot and Hang On: Providing Mental Health Care in a Turbulent Environment","title-short":"Tie a Knot and Hang On","author":[{"family":"Scheid","given":"Teresa L."}],"issued":{"date-parts":[["2004"]]}}}],"schema":""} (Livne 2019; Luhrmann 2000; Scheid 2004). Because of the lack of definitive diagnostic criteria or a consensus about the goals of treatment, both the boundaries of the mental health system and the allocation of care within it are contentious ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a3a8n6ot93","properties":{"formattedCitation":"(Mechanic, McAlpine, and Rochefort 2014; Rosenberg 2006; Schnittker 2017)","plainCitation":"(Mechanic, McAlpine, and Rochefort 2014; Rosenberg 2006; Schnittker 2017)","noteIndex":0},"citationItems":[{"id":3589,"uris":[""],"uri":[""],"itemData":{"id":3589,"type":"book","edition":"6th","event-place":"Boston, MA","ISBN":"978-0-205-54593-3","language":"en","number-of-pages":"340","publisher":"Pearson","publisher-place":"Boston, MA","source":"Google Books","title":"Mental Health and Social Policy: Beyond Managed Care","title-short":"Mental Health and Social Policy","author":[{"family":"Mechanic","given":"David"},{"family":"McAlpine","given":"Donna"},{"family":"Rochefort","given":"David"}],"issued":{"date-parts":[["2014"]],"season":"1969"}}},{"id":2366,"uris":[""],"uri":[""],"itemData":{"id":2366,"type":"article-journal","container-title":"Perspectives in Biology and Medicine","DOI":"10.1353/pbm.2006.0046","ISSN":"1529-8795","issue":"3","note":"<p>Volume 49, Number 3, Summer 2006</p>","page":"407-424","source":"Project MUSE","title":"Contested Boundaries: Psychiatry, Disease, and Diagnosis","title-short":"Contested Boundaries","volume":"49","author":[{"family":"Rosenberg","given":"Charles E."}],"issued":{"date-parts":[["2006"]]}}},{"id":3184,"uris":[""],"uri":[""],"itemData":{"id":3184,"type":"book","abstract":"Mental illness is many things at once: It is a natural phenomenon that is also shaped by society and culture. It is biological but also behavioral and social. Mental illness is a problem of both the brain and the mind, and this ambiguity presents a challenge for those who seek to accurately classify psychiatric disorders. The leading resource we have for doing so is the American Psychiatric Association’s Diagnostic and Statistical Manual, but no edition of the manual has provided a decisive solution, and all have created controversy. In The Diagnostic System, the sociologist Jason Schnittker looks at the multiple actors involved in crafting the DSM and the many interests that the manual hopes to serve. Is the DSM the best tool for defining mental illness? Can we insure against a misleading approach?Schnittker shows that the classification of psychiatric disorders is best understood within the context of a system that involves diverse parties with differing interests. The public wants a better understanding of personal suffering. Mental-health professionals seek reliable and treatable diagnostic categories. Scientists want definitions that correspond as closely as possible to nature. And all parties seek definitive insight into what they regard as the right target. Yet even the best classification system cannot satisfy all of these interests simultaneously. Progress toward an ideal is difficult, and revisions to diagnostic criteria often serve the interests of one group at the expense of another. Schnittker urges us to become comfortable with the socially constructed nature of categorization and accept that a perfect taxonomy of mental-health disorders will remain elusive. Decision making based on evolving though fluid understandings is not a weakness but an adaptive strength of the mental-health profession, even if it is not a solid foundation for scientific discovery or a reassuring framework for patients.","event-place":"New York, NY","ISBN":"978-0-231-54459-7","publisher":"Columbia University Press","publisher-place":"New York, NY","source":"Columbia University Press","title":"The Diagnostic System: Why the Classification of Psychiatric Disorders Is Necessary, Difficult, and Never Settled","title-short":"The Diagnostic System","author":[{"family":"Schnittker","given":"Jason"}],"issued":{"date-parts":[["2017"]]}}}],"schema":""} (Mechanic, McAlpine, and Rochefort 2014; Rosenberg 2006; Schnittker 2017).This paper analyzes why similar pressures to rationalize and medicalize lead to distinctive populations receiving care in the public mental health system of France and the United States, with a focus on Paris and an urban area in California. In both places, public mental health services have traditionally served people with severe illnesses while leaving milder cases to a large, developed private sector. In each, this repartition has become less stable as the public sector faces intensifying demands to deliver care to more people, despite constrained budgets. The relationship between these pressures and the people that ultimately get care is not straightforward. French clinicians have resisted medicalization and rationalization. Yet they now serve 3.4% of the adult population, twice what they did in the 1980s. They divide strictly between a small set of individuals receiving intensive interventions and a much larger group receiving minimal treatment. In the U.S., the public mental health field has simultaneously embraced medicalization and reconciled it with a mandate to economize care. The system serves a relatively constant 2.3% of adults, but this aggregate is composed of individuals who are pushed into care that is quickly withdrawn. Resources are concentrated towards people with disruptive behaviors, a population frequently excluded from public care in France.I frame the competing pressures for medicalization and rationalization as creating “classification struggles” between professional groups and administrators over the rules and policies for allocating care ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2ee9skel2g","properties":{"formattedCitation":"(Barman 2013; Bourdieu 1984; Goldberg 2005)","plainCitation":"(Barman 2013; Bourdieu 1984; Goldberg 2005)","noteIndex":0},"citationItems":[{"id":3173,"uris":[""],"uri":[""],"itemData":{"id":3173,"type":"article-journal","abstract":"Employing Pierre Bourdieu’s concept of classificatory struggles and sociological literature on professions’ construction of jurisdiction, this article examines the origins of the National Taxonomy of Exempt Entities (NTEE), the dominant classification system for the US nonprofit sector. Using data drawn from archival research and secondary research, I show that the establishment of the NTEE was part of a larger symbolic struggle over the proper classification of charitable foundations. Philanthropic elites and new nonprofit scholars responded to government threats to foundations by integrating them into the newly created “nonprofit sector,” whose societal value—both philanthropic and economic—would be demonstrated through research on this sector. The NTEE was formed by nonprofit researchers to generate valid data that demonstrated the nonprofit sector’s multiple contributions to society’s well-being. Using a theoretical approach, this article extends Bourdieu’s emphasis on classificatory struggles beyond the study of the construction of the characteristics of social classes to explore contestations over the proper taxonomy of organizations and sectors in society.","container-title":"Social Science History","DOI":"10.1017/S0145553200010580","ISSN":"0145-5532, 1527-8034","issue":"1","page":"103-141","source":"Cambridge Core","title":"Classificatory Struggles in the Nonprofit Sector: The Formation of the National Taxonomy of Exempt Entities, 1969–1987","title-short":"Classificatory Struggles in the Nonprofit Sector","volume":"37","author":[{"family":"Barman","given":"Emily"}],"issued":{"date-parts":[["2013"]]}}},{"id":262,"uris":[""],"uri":[""],"itemData":{"id":262,"type":"book","abstract":"Critique sociale du jugement","event-place":"Cambridge, MA","ISBN":"2-7073-0275-9","number-of-pages":"672","publisher":"Harvard University Press","publisher-place":"Cambridge, MA","source":"","title":"Distinction","author":[{"family":"Bourdieu","given":"Pierre"}],"issued":{"date-parts":[["1984"]],"season":"1979"}}},{"id":3163,"uris":[""],"uri":[""],"itemData":{"id":3163,"type":"article-journal","container-title":"Social Science History","issue":"3","page":"337–371","source":"Google Scholar","title":"Contesting the Status of Relief Workers during the New Deal","volume":"29","author":[{"family":"Goldberg","given":"Chad Alan"}],"issued":{"date-parts":[["2005"]]}}}],"schema":""} (Barman 2013; Bourdieu 1984; Goldberg 2005). Yet the literature is ambiguous about how the resolutions of such struggles translate into practices. Some scholars have identified a straightforward “homology” between official categories and the “principles of division” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2nk92kfoao","properties":{"formattedCitation":"(Bourdieu 1984:471)","plainCitation":"(Bourdieu 1984:471)","noteIndex":0},"citationItems":[{"id":262,"uris":[""],"uri":[""],"itemData":{"id":262,"type":"book","abstract":"Critique sociale du jugement","event-place":"Cambridge, MA","ISBN":"2-7073-0275-9","number-of-pages":"672","publisher":"Harvard University Press","publisher-place":"Cambridge, MA","source":"","title":"Distinction","author":[{"family":"Bourdieu","given":"Pierre"}],"issued":{"date-parts":[["1984"]],"season":"1979"}},"locator":"471"}],"schema":""} (Bourdieu 1984:471) deployed on the ground. Others have focused on how medicalization and rationalization represent distinctive “logics” that clinicians reinterpret and hybridize ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2jf5p99qfi","properties":{"formattedCitation":"(Cain 2019; Dobransky 2014; McPherson and Sauder 2013)","plainCitation":"(Cain 2019; Dobransky 2014; McPherson and Sauder 2013)","noteIndex":0},"citationItems":[{"id":3568,"uris":[""],"uri":[""],"itemData":{"id":3568,"type":"article-journal","abstract":"There is no doubt that the organization of healthcare is currently shifting, partly in response to changing macrolevel policies. Studies of healthcare policies often do not consider healthcare workers’ experiences of policy change, thus limiting our understanding of when and how policies work. This article uses longitudinal qualitative data, including participant observation and semistructured interviews with workers within hospice care as their organizations shifted in response to a Medicare policy change. Prior to the policy change, I find that the main innovation of hospice—the interdisciplinary team—is able to resist logics from the larger medical institution. However, when organizational pressures increase, managers and workers adjust in ways that reinforce medical logics and undermine the interdisciplinary team. These practices illustrate processes by which rationalization of healthcare affects workers’ experiences and the type of care available to patients.","container-title":"Journal of Health and Social Behavior","DOI":"10.1177/0022146518825379","ISSN":"0022-1465","issue":"1","journalAbbreviation":"J Health Soc Behav","language":"en","page":"3-17","source":"SAGE Journals","title":"Agency and Change in Healthcare Organizations: Workers’ Attempts to Navigate Multiple Logics in Hospice Care","title-short":"Agency and Change in Healthcare Organizations","volume":"60","author":[{"family":"Cain","given":"Cindy L."}],"issued":{"date-parts":[["2019"]]}}},{"id":3601,"uris":[""],"uri":[""],"itemData":{"id":3601,"type":"book","event-place":"New Brunswick, NJ","ISBN":"978-0-8135-6308-4","language":"English","number-of-pages":"192","publisher":"Rutgers University Press","publisher-place":"New Brunswick, NJ","source":"Amazon","title":"Managing Madness in the Community: The Challenge of Contemporary Mental Health Care","title-short":"Managing Madness in the Community","author":[{"family":"Dobransky","given":"Kerry Michael"}],"issued":{"date-parts":[["2014"]]}}},{"id":3388,"uris":[""],"uri":[""],"itemData":{"id":3388,"type":"article-journal","abstract":"Drawing on a 15-month ethnographic study of a drug court, we investigate how actors from different institutional and professional backgrounds employ logical frameworks in their micro-level interactions and thus how logics affect day-to-day organizational activity. While institutional theory presumes that professionals closely adhere to the logics of their professional groups, we find that actors exercise a great deal of agency in their everyday use of logics, both in terms of which logics they adopt and for what purpose. Available logics closely resemble tools that can be creatively employed by actors to achieve individual and organizational goals. A close analysis of court negotiations allowed us to identify the logics that are available to these actors, show how they are employed, and demonstrate how their use affects the severity of the court’s decisions. We examine the ways in which professionals with four distinct logical orientations—the logics of criminal punishment, rehabilitation, community accountability, and efficiency—use logics to negotiate decisions in a drug court. We provide evidence of the discretionary use of these logics, specifying the procedural, definitional, and dispositional constraints that limit actors’ discretion and propose an explanation for why professionals stray from their “home” logics and “hijack” the logics of other court actors. Examining these micro-level processes improves our understanding of how local actors use logics to manage institutional complexity, reach consensus, and get the work of the court done.","container-title":"Administrative Science Quarterly","DOI":"10.1177/0001839213486447","ISSN":"0001-8392","issue":"2","journalAbbreviation":"Administrative Science Quarterly","language":"en","page":"165-196","source":"SAGE Journals","title":"Logics in Action: Managing Institutional Complexity in a Drug Court","title-short":"Logics in Action","volume":"58","author":[{"family":"McPherson","given":"Chad Michael"},{"family":"Sauder","given":"Michael"}],"issued":{"date-parts":[["2013"]]}}}],"schema":""} (Cain 2019; Dobransky 2014; McPherson and Sauder 2013). I show in this paper how classification struggles are structured and linked to practices through what Fourcade ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2mk2vkt3ci","properties":{"formattedCitation":"(2016)","plainCitation":"(2016)","noteIndex":0},"citationItems":[{"id":2711,"uris":[""],"uri":[""],"itemData":{"id":2711,"type":"article-journal","abstract":"We can think of three basic principles of classificatory judgment for comparing things and people. I call these judgments nominal (oriented to essence), cardinal (oriented to quantities), and ordinal (oriented to relative positions). Most social orders throughout history are organized around the intersection of these different types. In line with the ideals of political liberalism, however, democratic societies have developed an arsenal of institutions to untangle nominal and ordinal judgments in various domains of social life. In doing so, I suggest, they have contributed to the parallel amplification of both. In this article, I specifically discuss the socio-technical channels through which ordinal judgments are now elaborated, a process I call ordinalization. I conclude by exploring the political and economic possibilities of a society in which ordinal processes are ubiquitous.","container-title":"Sociological Theory","DOI":"10.1177/0735275116665876","ISSN":"0735-2751, 1467-9558","issue":"3","journalAbbreviation":"Sociological Theory","language":"en","page":"175-195","source":"stx.","title":"Ordinalization","volume":"34","author":[{"family":"Fourcade","given":"Marion"}],"issued":{"date-parts":[["2016"]]}},"suppress-author":true}],"schema":""} (2016) calls principles of classification. These principles reflect an ontological assumption about what it is that is being classified and an epistemological one about what kinds of categories can be used to classify it. These meta-level presumptions are part of the underlying structure of a field, and make certain resolutions of the cross-pressures of medicalization and rationalization, and particular translations of them into practice, seem intuitive and logical.As I show, the mental health care system that developed in the 1960s in France institutionalized a classificatory principle of bounding. Policies and regulations largely assumed that the object of the mental health system would be people and that the appropriate way to categorize them was through broad, qualitative nominal typologies. The assumption that mentally ill persons are a discrete population translates into a set of practices that focuses on using professional common sense to maximize the amount of scarce resources delivered to real “malades [sick people].” In the U.S., public mental health is organized against a principle of scaling. This classificatory principle facilitates medicalization through the assumption that all people exist on a continuum between mental health and illness, but also necessitates rationalization to handle increasing numbers of people flowing through the system. On the ground, professional practices center on the problem of calibration: delivering the right amount of care to the right people at the right moment. They do so by assessing behaviors using ordinal scales, rather than by classifying people using typologies.This article proceeds as follows. I first review the literatures on medicalization and rationalization. Both speak to classificatory struggles over who classifies people with mental illness using which specific categories, but offer ambiguous predictions about their ultimate result. I then elaborate on the concept of principles of classification, which takes a step back to examine shared understandings about what is being classified through what kind of categories. After reviewing my qualitative methodology, I discuss the French case, analyzing the gradual institutionalization of bounding in the mental health field and showing how it facilitated resistance to medicalization and rationalization. I then show how clinicians translate this principle into practices for allocating care in Paris. In California, I show the principle of scaling that shapes the extent of medicalization and the development of rationalization. As in France, clinicians deploy a set of practices consistent with these principles, but also struggle when principles collide with their professional identities and the trajectories through care of the people they treat. In the conclusion, I reflect on what this perspective adds to existing studies of medical diagnosis and decision-making. I argue that analyzing principles of classification facilitates comparative study without falling back on stereotyped generalizations about “national cultures.” Literature ReviewMedicalization and Rationalization What are the key factors shaping the allocation of mental health care? As a literature on “medicalization” has documented, psychiatrists have allied with pharmaceutical companies to drive a “process by which nonmedical problems become defined and treated as medical problems” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a15e3nl5ddj","properties":{"unsorted":true,"formattedCitation":"(Conrad 2007:4; see, also, Horwitz 2001)","plainCitation":"(Conrad 2007:4; see, also, Horwitz 2001)","noteIndex":0},"citationItems":[{"id":2977,"uris":[""],"uri":[""],"itemData":{"id":2977,"type":"book","abstract":"Over the past half-century, the social terrain of health and illness has been transformed. What were once considered normal human events and common human problems—birth, aging, menopause, alcoholism, and obesity—are now viewed as medical conditions. For better or worse, medicine increasingly permeates aspects of daily life.Building on more than three decades of research, Peter Conrad explores the changing forces behind this trend with case studies of short stature, social anxiety, \"male menopause,\" erectile dysfunction, adult ADHD, and sexual orientation. He examines the emergence of and changes in medicalization, the consequences of the expanding medical domain, and the implications for health and society. He finds in recent developments—such as the growing number of possible diagnoses and biomedical enhancements—the future direction of medicalization. Conrad contends that the impact of medical professionals on medicalization has diminished. Instead, the pharmaceutical and biotechnical industries, insurance companies and HMOs, and the patient as consumer have become the major forces promoting medicalization. This thought-provoking study offers valuable insight into not only how medicalization got to this point but also how it may continue to evolve.","event-place":"Baltimore, MD","ISBN":"978-0-8018-8585-3","language":"English","number-of-pages":"224","publisher":"Johns Hopkins University Press","publisher-place":"Baltimore, MD","source":"Amazon","title":"The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders","title-short":"The Medicalization of Society","author":[{"family":"Conrad","given":"Peter"}],"issued":{"date-parts":[["2007"]]}},"locator":"4"},{"id":2251,"uris":[""],"uri":[""],"itemData":{"id":2251,"type":"book","abstract":"In this surprising book, Allan V. Horwitz argues that our current conceptions of mental illness as a disease fit only a small number of serious psychological conditions and that most conditions currently regarded as mental illness are cultural constructions, normal reactions to stressful social circumstances, or simply forms of deviant behavior. \n\n\"Thought-provoking and important. . .Drawing on and consolidating the ideas of a range of authors, Horwitz challenges the existing use of the term mental illness and the psychiatric ideas and practices on which this usage is based. . . . Horwitz enters this controversial territory with confidence, conviction, and clarity.\"—Joan Busfield, \n\n\"Horwitz properly identifies the financial incentives that urge therapists and drug companies to proliferate psychiatric diagnostic categories. He correctly identifies the stranglehold that psychiatric diagnosis has on research funding in mental health. Above all, he provides a sorely needed counterpoint to the most strident advocates of disease-model psychiatry.\"—Mark Sullivan,Journal of the American Medical Association\n\n\"Horwitz makes at least two major contributions to our understanding of mental disorders. First, he eloquently draws on evidence from the biological and social sciences to create a balanced, integrative approach to the study of mental disorders. Second, in accomplishing the first contribution, he provides a fascinating history of the study and treatment of mental disorders. . . from early asylum work to the rise of modern biological psychiatry.\"—Debra Umberson, Quarterly Review of Biology","event-place":"Chicago, IL","publisher":"University of Chicago Press","publisher-place":"Chicago, IL","source":"press.uchicago.edu","title":"Creating Mental Illness","author":[{"family":"Horwitz","given":"Allan?V."}],"issued":{"date-parts":[["2001"]]}},"prefix":"see, also, "}],"schema":""} (Conrad 2007:4; see, also, Horwitz 2001). Mental health “consumers” themselves have joined them as they turn to professionals to help them deal with problems of daily life ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"am7u719t83","properties":{"formattedCitation":"(Clarke et al. 2003; Ehrenberg 2005; Jutel 2011)","plainCitation":"(Clarke et al. 2003; Ehrenberg 2005; Jutel 2011)","noteIndex":0},"citationItems":[{"id":2911,"uris":[""],"uri":[""],"itemData":{"id":2911,"type":"article-journal","abstract":"The first social transformation of American medicine institutionally established medicine by the end of World War II. In the next decades, medicalization--the expansion of medical jurisdiction, authority, and practices into new realms--became widespread. Since about 1985, dramatic changes in both the organization and practices of contemporary biomedicine, implemented largely through the integration of technoscientific innovations, have been coalescing into what the authors call biomedicalization, a second \"transformation\" of American medicine. Biomedicalization describes the increasingly complex, multisited, multidirectional processes of medicalization, both extended and reconstituted through the new social forms of highly technoscientific biomedicine. The historical shift from medicalization to biomedicalization is one from control over biomedical phenomena to transformations of them. Five key interactive processes both engender biomedicalization and are produced through it: (1) the political economic reconstitution of the vast sector of biomedicine; (2) the focus on health itself and the elaboration of risk and surveillance biomedicines; (3) the increasingly technological and scientific nature of biomedicine; (4) transformations in how biomedical knowledges are produced, distributed, and consumed, and in medical information management; and (5) transformations of bodies to include new properties and the production of new individual and collective technoscientific identities.","container-title":"American Sociological Review","DOI":"10.2307/1519765","issue":"2","journalAbbreviation":"American Sociological Review","page":"161-194","source":"JSTOR","title":"Biomedicalization: Technoscientific Transformations of Health, Illness, and U.S. Biomedicine","title-short":"Biomedicalization","volume":"68","author":[{"family":"Clarke","given":"Adele E."},{"family":"Shim","given":"Janet K."},{"family":"Mamo","given":"Laura"},{"family":"Fosket","given":"Jennifer Ruth"},{"family":"Fishman","given":"Jennifer R."}],"issued":{"date-parts":[["2003"]]}}},{"id":2445,"uris":[""],"uri":[""],"itemData":{"id":2445,"type":"article-journal","container-title":"Cahiers de recherche sociologique","issue":"41-42","page":"17–41","title":"La plainte sans fin. Réflexions sur le couple souffrance psychique/santé mentale","title-short":"La plainte sans fin","author":[{"family":"Ehrenberg","given":"Alain"}],"issued":{"date-parts":[["2005"]]}}},{"id":2371,"uris":[""],"uri":[""],"itemData":{"id":2371,"type":"book","abstract":"Over a decade after medical sociologist Phil Brown called for a sociology of diagnosis, Putting a Name to It provides the first book-length, comprehensive framework for this emerging subdiscipline of medical sociology.Diagnosis is central to medicine. It creates social order, explains illness, identifies treatments, and predicts outcomes. Using concepts of medical sociology, Annemarie Goldstein Jutel sheds light on current knowledge about the components of diagnosis to outline how a sociology of diagnosis would function. She situates it within the broader discipline, lays out the directions it should explore, and discusses how the classification of illness and framing of diagnosis relate to social status and order. Jutel explains why this matters not just to doctor-patient relationships but also to the entire medical system. As a result, she argues, the sociological realm of diagnosis encompasses not only the ongoing controversy surrounding revisions to the Diagnostic and Statistical Manual of Mental Disorders in psychiatry but also hot-button issues such as genetic screening and pharmaceutical industry disease mongering.Both a challenge and a call to arms, Putting a Name to It is a lucid, persuasive argument for formalizing, professionalizing, and advancing longstanding practice. Jutel’s innovative, open approach and engaging arguments will find support among medical sociologists and practitioners and across much of the medical system.","event-place":"Baltimore, MD","ISBN":"978-1-4214-0067-9","language":"English","number-of-pages":"200","publisher":"Johns Hopkins University Press","publisher-place":"Baltimore, MD","source":"","title":"Putting a Name to It: Diagnosis in Contemporary Society","title-short":"Putting a Name to It","author":[{"family":"Jutel","given":"Annemarie Goldstein"}],"issued":{"date-parts":[["2011"]]}}}],"schema":""} (Clarke et al. 2003; Ehrenberg 2005; Jutel 2011). Government actors add further momentum by pushing mental health providers to “treat” poverty and deviance ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1cds3hsnta","properties":{"formattedCitation":"(Gong 2019; Rose 1998)","plainCitation":"(Gong 2019; Rose 1998)","noteIndex":0},"citationItems":[{"id":3772,"uris":[""],"uri":[""],"itemData":{"id":3772,"type":"article-journal","container-title":"American Sociological Review","issue":"4","page":"664–689","title":"Between Tolerant Containment and Concerted Constraint: Managing Madness for the City and the Privileged Family","volume":"84","author":[{"family":"Gong","given":"Neil"}],"issued":{"date-parts":[["2019"]]}}},{"id":2712,"uris":[""],"uri":[""],"itemData":{"id":2712,"type":"article-journal","container-title":"Psychiatry, Psychology and Law","issue":"2","page":"177–195","source":"Google Scholar","title":"Governing Risky Individuals: The Role of Psychiatry in New Regimes of Control","title-short":"Governing risky individuals","volume":"5","author":[{"family":"Rose","given":"Nikolas"}],"issued":{"date-parts":[["1998"]]}}}],"schema":""} (Gong 2019; Rose 1998). This literature usually takes for granted that actors in the mental health system medicalize through identifying illnesses based on increasingly expansive diagnostic categories. Yet research has shown that tools like the Diagnostic and Statistics Manuel (DSM), which codifies psychiatric diagnoses, are only loosely related to how clinicians identify mental illness ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1dlqhf6pf","properties":{"formattedCitation":"(Schnittker 2017; Whooley 2010)","plainCitation":"(Schnittker 2017; Whooley 2010)","noteIndex":0},"citationItems":[{"id":3184,"uris":[""],"uri":[""],"itemData":{"id":3184,"type":"book","abstract":"Mental illness is many things at once: It is a natural phenomenon that is also shaped by society and culture. It is biological but also behavioral and social. Mental illness is a problem of both the brain and the mind, and this ambiguity presents a challenge for those who seek to accurately classify psychiatric disorders. The leading resource we have for doing so is the American Psychiatric Association’s Diagnostic and Statistical Manual, but no edition of the manual has provided a decisive solution, and all have created controversy. In The Diagnostic System, the sociologist Jason Schnittker looks at the multiple actors involved in crafting the DSM and the many interests that the manual hopes to serve. Is the DSM the best tool for defining mental illness? Can we insure against a misleading approach?Schnittker shows that the classification of psychiatric disorders is best understood within the context of a system that involves diverse parties with differing interests. The public wants a better understanding of personal suffering. Mental-health professionals seek reliable and treatable diagnostic categories. Scientists want definitions that correspond as closely as possible to nature. And all parties seek definitive insight into what they regard as the right target. Yet even the best classification system cannot satisfy all of these interests simultaneously. Progress toward an ideal is difficult, and revisions to diagnostic criteria often serve the interests of one group at the expense of another. Schnittker urges us to become comfortable with the socially constructed nature of categorization and accept that a perfect taxonomy of mental-health disorders will remain elusive. Decision making based on evolving though fluid understandings is not a weakness but an adaptive strength of the mental-health profession, even if it is not a solid foundation for scientific discovery or a reassuring framework for patients.","event-place":"New York, NY","ISBN":"978-0-231-54459-7","publisher":"Columbia University Press","publisher-place":"New York, NY","source":"Columbia University Press","title":"The Diagnostic System: Why the Classification of Psychiatric Disorders Is Necessary, Difficult, and Never Settled","title-short":"The Diagnostic System","author":[{"family":"Schnittker","given":"Jason"}],"issued":{"date-parts":[["2017"]]}}},{"id":208,"uris":[""],"uri":[""],"itemData":{"id":208,"type":"article-journal","abstract":"In 1980 the American Psychiatric Association (APA), faced with increased professional competition, revised the Diagnostic and Statistical Manual of Mental Disorders (DSM). Psychiatric expertise was redefined along a biomedical model via a standardised nosology. While they were an integral part of capturing professional authority, the revisions demystified psychiatric expertise, leaving psychiatrists vulnerable to infringements upon their autonomy by institutions adopting the DSM literally. This research explores the tensions surrounding standardisation in psychiatry. Drawing on in-depth interviews with psychiatrists, I explore the ‘sociological ambivalence’ psychiatrists feel towards the DSM, which arises from the tension between the desire for autonomy in practice and the professional goal of legitimacy within the system of mental health professions. To carve a space for autonomy for their practice, psychiatrists develop ‘workarounds’ that undermine the DSM in practice. These workarounds include employing alternative diagnostic typologies, fudging the numbers (or codes) on official paperwork and negotiating diagnoses with patients. In creating opportunities for patient input and resistance to fixed diagnoses, the varied use of the DSM raises fundamental questions for psychiatrists about the role of the biomedical model of mental illness, especially its particular manifestation in the DSM.","container-title":"Sociology of Health & Illness","DOI":"10.1111/j.1467-9566.2010.01230.x","ISSN":"1467-9566","issue":"3","language":"en","page":"452-469","source":"Wiley Online Library","title":"Diagnostic Ambivalence: Psychiatric Workarounds and the Diagnostic and Statistical Manual of Mental Disorders","title-short":"Diagnostic ambivalence","volume":"32","author":[{"family":"Whooley","given":"Owen"}],"issued":{"date-parts":[["2010"]]}}}],"schema":""} (Schnittker 2017; Whooley 2010). Moreover, the literature assumes that individual clinicians follow their profession as a whole in seeking to expand their jurisdiction ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a4oqrgalol","properties":{"formattedCitation":"(Abbott 1988; Horwitz 2001)","plainCitation":"(Abbott 1988; Horwitz 2001)","noteIndex":0},"citationItems":[{"id":2357,"uris":[""],"uri":[""],"itemData":{"id":2357,"type":"book","abstract":"In The System of Professions Andrew Abbott explores central questions about the role of professions in modern life: Why should there be occupational groups controlling expert knowledge? Where and why did groups such as law and medicine achieve their power? Will professionalism spread throughout the occupational world? While most inquiries in this field study one profession at a time, Abbott here considers the system of professions as a whole. Through comparative and historical study of the professions in nineteenth- and twentieth-century England, France, and America, Abbott builds a general theory of how and why professionals evolve.","event-place":"Chicago, IL","ISBN":"978-0-226-00069-5","language":"English","number-of-pages":"452","publisher":"University of Chicago Press","publisher-place":"Chicago, IL","source":"","title":"The System of Professions: An Essay on the Division of Expert Labor","title-short":"The System of Professions","author":[{"family":"Abbott","given":"Andrew"}],"issued":{"date-parts":[["1988"]]}}},{"id":2251,"uris":[""],"uri":[""],"itemData":{"id":2251,"type":"book","abstract":"In this surprising book, Allan V. Horwitz argues that our current conceptions of mental illness as a disease fit only a small number of serious psychological conditions and that most conditions currently regarded as mental illness are cultural constructions, normal reactions to stressful social circumstances, or simply forms of deviant behavior. \n\n\"Thought-provoking and important. . .Drawing on and consolidating the ideas of a range of authors, Horwitz challenges the existing use of the term mental illness and the psychiatric ideas and practices on which this usage is based. . . . Horwitz enters this controversial territory with confidence, conviction, and clarity.\"—Joan Busfield, \n\n\"Horwitz properly identifies the financial incentives that urge therapists and drug companies to proliferate psychiatric diagnostic categories. He correctly identifies the stranglehold that psychiatric diagnosis has on research funding in mental health. Above all, he provides a sorely needed counterpoint to the most strident advocates of disease-model psychiatry.\"—Mark Sullivan,Journal of the American Medical Association\n\n\"Horwitz makes at least two major contributions to our understanding of mental disorders. First, he eloquently draws on evidence from the biological and social sciences to create a balanced, integrative approach to the study of mental disorders. Second, in accomplishing the first contribution, he provides a fascinating history of the study and treatment of mental disorders. . . from early asylum work to the rise of modern biological psychiatry.\"—Debra Umberson, Quarterly Review of Biology","event-place":"Chicago, IL","publisher":"University of Chicago Press","publisher-place":"Chicago, IL","source":"press.uchicago.edu","title":"Creating Mental Illness","author":[{"family":"Horwitz","given":"Allan?V."}],"issued":{"date-parts":[["2001"]]}}}],"schema":""} (Abbott 1988; Horwitz 2001). However, medical workers in the public system are also “street-level bureaucrats” who have scarce resources that they can give to some only by withholding from others ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aecp0pamog","properties":{"formattedCitation":"(Bosk 2013; Horton 2006)","plainCitation":"(Bosk 2013; Horton 2006)","noteIndex":0},"citationItems":[{"id":2971,"uris":[""],"uri":[""],"itemData":{"id":2971,"type":"article-journal","abstract":"Most of the sociological literature about “troubling” children and youth focuses on how the scientific authority of medical experts, with a discourse of sickness, has come to displace the moral authority of justice enforcement officials and their rhetoric of badness as arbiters of childhood pathology. Yet my experience working with high-risk children and youth during a post-MSW fellowship strongly suggests that discourses of badness have not supplanted discourses of sickness. Indeed, these discourses remain deeply intertwined with implications for the way we conceptualize troubling children and youth, for the treatment we prescribe, and for how children and youth understand themselves. Discussing two composite cases to illustrate how negotiations of badness and sickness unfold, I argue that shifts in attributions of badness and sickness follow predictable patterns generally occurring in response to: (1) changes in the context (whether the child is at home, school, or in a treatment setting); (2) changes in an actor's interests or role (parents may attribute troubling behaviors as badness at home but frame them as sickness with people outside the family); and/or (3) changes in external structures of time (e.g. the end of the school year or the end of a Medicaid authorization). In conclusion, I consider the implications of partial medicalization and these patterns of narrative negotiations for future research and practice.","collection-title":"Place, Power, and Possibility:Remaking Social Work with Children and Youth","container-title":"Children and Youth Services Review","DOI":"10.1016/j.childyouth.2013.04.007","ISSN":"0190-7409","issue":"8","journalAbbreviation":"Children and Youth Services Review","page":"1212-1218","source":"ScienceDirect","title":"Between Badness and Sickness: Reconsidering Medicalization for High Risk Children and Youth","title-short":"Between badness and sickness","volume":"35","author":[{"family":"Bosk","given":"Emily Adlin"}],"issued":{"date-parts":[["2013"]]}}},{"id":3089,"uris":[""],"uri":[""],"itemData":{"id":3089,"type":"article-journal","abstract":"The US Institute of Medicine's (IOM) influential 2003 report has focused attention on disparities in treatment outcomes and health status for American minorities, zeroing in on the role of unconscious bias in the unequal clinical disposition of minority patients. In keeping with the IOM's focus, current examinations of health disparities in the US tend to explore bias in clinical decision-making to the neglect of the political economic trends that buffet health care safety net sites and create the need for financial shortcuts. This paper recontextualizes the study of health disparities in the US by placing it against the backdrop of private sector trends emphasizing fiscal austerity and increased workforce productivity in health care. The social science literature on workers in human service bureaucracies, only recently applied to health care workers, suggests that higher demands for system “accountability” and worker “efficiency” may encourage providers to take shortcuts by treating individuals as mass categories. This ethnography of a Latino mental health clinic in the Northwestern USA shows that new private-sector measures of “productivity” take a toll on both the Latina clinicians whose invisible work subsidizes the system as well as on particular categories of patients—the uninsured and immigrants with serious psychosocial issues. While clinicians attempt to buffer the impacts of such reforms on patients, they also resort to means to increase their productivity such as firing repeated no-show patients and denial of care to the uninsured. This study is relevant for the health care of the poor in all health care systems considering restructuring along managerial principles to increase system ‘efficiencies.’","container-title":"Social Science & Medicine","DOI":"10.1016/j.socscimed.2006.07.003","ISSN":"0277-9536","issue":"10","journalAbbreviation":"Social Science & Medicine","page":"2702-2714","source":"ScienceDirect","title":"The Double Burden on Safety Net Providers: Placing Health Disparities in the Context of the Privatization of Health Care in the US","title-short":"The double burden on safety net providers","volume":"63","author":[{"family":"Horton","given":"Sarah"}],"issued":{"date-parts":[["2006"]]}}}],"schema":""} (Bosk 2013; Horton 2006). We thus need to analyze how clinicians make specific decisions about what to medicalize and what to classify as outside their purview as non-medical.If the literature on medicalization examines how far the mental health system extends, research on rationalization emphasizes how much is allocated within it and by whom. In response to rising costs and an ascendant ideology of market efficiency, governments have reorganized health systems around “productivity, minimization of financial costs, optimization of resources, and ‘outcome targets’” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"j1rMFIEV","properties":{"formattedCitation":"(Quah 2014:2)","plainCitation":"(Quah 2014:2)","noteIndex":0},"citationItems":[{"id":3610,"uris":[""],"uri":[""],"itemData":{"id":3610,"type":"chapter","container-title":"Encyclopedia of Health, Illness, Behavior, and Society","ISBN":"978-1-118-41086-8","language":"en","note":"DOI: 10.1002/9781118410868.wbehibs019","page":"2046-2051","publisher":"Wiley-Blackwell","source":"onlinelibrary.","title":"Rationalization","URL":"","author":[{"family":"Quah","given":"Stella R."}],"editor":[{"family":"Quah","given":"Stella R."},{"family":"Cockerham","given":"William"},{"family":"Dingwall","given":"Robert"}],"accessed":{"date-parts":[["2019",3,26]]},"issued":{"date-parts":[["2014"]]}},"locator":"2"}],"schema":""} (Quah 2014:2). The iconic vessels of rationalization are “managed care” insurance companies that exclude high-cost providers from coverage, require “pre-authorization” for care, and conduct “utilization reviews” of ongoing services ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"acb72lathj","properties":{"formattedCitation":"(Livne 2019; Reich 2014)","plainCitation":"(Livne 2019; Reich 2014)","noteIndex":0},"citationItems":[{"id":3626,"uris":[""],"uri":[""],"itemData":{"id":3626,"type":"book","event-place":"Cambridge, MA","publisher":"Harvard University Press","publisher-place":"Cambridge, MA","title":"Values at the End of Life","author":[{"family":"Livne","given":"Roi"}],"issued":{"date-parts":[["2019"]]}}},{"id":3149,"uris":[""],"uri":[""],"itemData":{"id":3149,"type":"book","abstract":"Health care costs make up nearly a fifth of U.S. gross domestic product, but health care is a peculiar thing to buy and sell. Both a scarce resource and a basic need, it involves physical and emotional vulnerability and at the same time it operates as . . .","event-place":"Princeton, NJ","publisher":"Princeton University Press","publisher-place":"Princeton, NJ","title":"Selling Our Souls","URL":"","author":[{"family":"Reich","given":"Adam D."}],"accessed":{"date-parts":[["2017",9,6]]},"issued":{"date-parts":[["2014"]]}}}],"schema":""} (Livne 2019; Reich 2014). Scholars once argued that the contested nature of mental illness and disagreements about appropriate goals and techniques of treatment for it made rationalization particularly difficult ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"afaae0h0n8","properties":{"formattedCitation":"(Dinitz and Beran 1971; Meyer 1985)","plainCitation":"(Dinitz and Beran 1971; Meyer 1985)","noteIndex":0},"citationItems":[{"id":3784,"uris":[""],"uri":[""],"itemData":{"id":3784,"type":"article-journal","abstract":"[Every system of deviance definition and management must address three basic questions: (1) Who shall be defined as deviant and in need of management? (2) Who shall be the legitimate agents in defining and managing the deviant, and what shall be their respective roles? (3) What shall be done to or for the deviant? In contrast to both the legal and traditional mental health systems, which offer delimited responses to these questions, the community mental health system, in both philosophy and practice, offers such all-inclusive responses that it is developing into a boundaryless system of deviance definition and management. The community mental health approach unavoidably, if not deliberately, confronts and breaks down the boundaries of other deviance management systems and appropriates some of their territories. Of particular significance are the implications of these developments for the future articulation of the legal and mental health systems.]","archive":"JSTOR","container-title":"Journal of Health and Social Behavior","DOI":"10.2307/2948516","ISSN":"0022-1465","issue":"2","page":"99-108","source":"JSTOR","title":"Community Mental Health as a Boundaryless and Boundary-Busting System","volume":"12","author":[{"family":"Dinitz","given":"Simon"},{"family":"Beran","given":"Nancy"}],"issued":{"date-parts":[["1971"]]}}},{"id":3637,"uris":[""],"uri":[""],"itemData":{"id":3637,"type":"article-journal","container-title":"American Behavioral Scientist","DOI":"10.1177/000276485028005003","ISSN":"0002-7642","issue":"5","journalAbbreviation":"American Behavioral Scientist","page":"587-600","source":"journals. (Atypon)","title":"Institutional and Organizational Rationalization in the Mental Health System","volume":"28","author":[{"family":"Meyer","given":"John W."}],"issued":{"date-parts":[["1985"]]}}}],"schema":""} (Dinitz and Beran 1971; Meyer 1985). Just a few decades later, the literature on the U.S. paints a very different picture: psychiatric care was “more severely walloped by managed care policies than any other branch of medicine” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a16b1h089ub","properties":{"formattedCitation":"(Luhrmann 2000:243; see also Scheid 2004)","plainCitation":"(Luhrmann 2000:243; see also Scheid 2004)","noteIndex":0},"citationItems":[{"id":3613,"uris":[""],"uri":[""],"itemData":{"id":3613,"type":"book","abstract":"With sharp and soulful insight, T. R. Luhrmann examines the world of psychiatry, a profession which today is facing some of its greatest challenges from within and without, as it continues to offer hope to many. At a time when mood-altering drugs have revolutionized the treatment of the mentally ill and HMO’s are forcing caregivers to take the pharmocological route over the talking cure, Luhrmann places us at the heart of the matter and allows us to see exactly what is at stake. Based on extensive interviews with patients and doctors, as well as investigative fieldwork in residence programs, private psychiatric hospitals, and state hospitals, Luhrmann’s groundbreaking book shows us how psychiatrists develop and how the enormous ambiguities in the field affect its practitioners and patients.","event-place":"New York","ISBN":"978-0-679-74493-1","language":"English","number-of-pages":"352","publisher":"Alfred A. Knopf","publisher-place":"New York","source":"","title":"Of Two Minds: The Growing Disorder in American Psychiatry","title-short":"Of Two Minds","author":[{"family":"Luhrmann","given":"T. M."}],"issued":{"date-parts":[["2000"]]}},"locator":"243"},{"id":3587,"uris":[""],"uri":[""],"itemData":{"id":3587,"type":"book","abstract":"Tie a Knot and Hang On is an analysis of mental health care work that crosses the borders of diverse sociological traditions. The work seeks to understand the theoretical and empirical linkages between environmental pressures and activities and how these intersect with organizations and individuals. The work draws upon a research tradition that sees the issue of mental health care in terms of institutional pressures and normative values. The author provides a description and a sociological analysis of mental health care work, emphasizing the interaction of professionally generated norms that guide the &quot;emotional labor&quot; of mental health care workers, and the organizational contexts within which mental health care is provided. She concludes with a discussion of emerging institutional forces that will shape the mental health care system in the future. These forces are having greater impact than ever before as managed care comes to have a huge fiscal as well as institutional impact on the work of mental health professionals. Scheid&#39;s book is a brilliant, nuanced effort to explain the institutional demands for efficiency and cost containment with the professional ethics that emphasize quality care for the individual. The book is essential reading for those interested in mental health care organizations and the providers responding to these seemingly larger, abstract demands. The work offers a rich mixture not just of the problems faced by mental health care personnel, but the equilibrium currently in place ?? an equilibrium that shapes the theory of the field, no less than the activities of its practitioners. Teresa L. Scheid is associate professor of sociology, at the University of North Carolina at Charlotte. She has published widely in the area, including major essays in Sociology of Health and Illness, Sociological Quarterly, Perspectives on Social Problems, and The Journal of Applied Behavioral Science.","event-place":"Hawthorne, NY","ISBN":"978-1-4128-4003-3","language":"en","number-of-pages":"212","publisher":"Transaction Publishers","publisher-place":"Hawthorne, NY","source":"Google Books","title":"Tie a Knot and Hang On: Providing Mental Health Care in a Turbulent Environment","title-short":"Tie a Knot and Hang On","author":[{"family":"Scheid","given":"Teresa L."}],"issued":{"date-parts":[["2004"]]}},"prefix":"see also "}],"schema":""} (Luhrmann 2000:243; see also Scheid 2004). Meanwhile, the mental health system in France has largely escaped rationalization, even as the process has advanced elsewhere in the country’s health system ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1u69hrqfc3","properties":{"formattedCitation":"(see Benamouzig 2005; Palier 2005)","plainCitation":"(see Benamouzig 2005; Palier 2005)","noteIndex":0},"citationItems":[{"id":3401,"uris":[""],"uri":[""],"itemData":{"id":3401,"type":"book","event-place":"Paris, France","publisher":"Presses universitaires de France","publisher-place":"Paris, France","source":"Google Scholar","title":"La santé au miroir de l'économie: Une histoire de l'économie de la santé en France","title-short":"La santé au miroir de l'économie","URL":"","author":[{"family":"Benamouzig","given":"Daniel"}],"accessed":{"date-parts":[["2017",5,17]]},"issued":{"date-parts":[["2005"]]}},"prefix":"see "},{"id":2786,"uris":[""],"uri":[""],"itemData":{"id":2786,"type":"book","abstract":"Où en est le modèle social fran?ais ? Créé en et pour des temps aujourd'hui révolus, le système fran?ais de Sécurité sociale est appelé depuis le début des années 1980 à s'adapter au nouveau contexte économique et social. Comment les gouvernements font-ils pour changer une des institutions auxquelles les Fran?ais sont le plus attachés ? Les réformes de la protection sociale qui s'accumulent depuis la fin des années 1980 signifient-elles une transformation profonde des principes et des mécanismes sur lesquels reposait le système fran?ais de protection sociale ? Ce livre analyse l'ensemble des évolutions et des réformes du système fran?ais de protection sociale de 1945 à 2005. Il défend la thèse que les politiques sociales, con?ues dans un contexte keynésien, connaissent au cours des années 1990-2000 une phase de réajustement au nouveau cadre économique, marqué par la domination des politiques néo-classiques centrées sur l'offre, la compétitivité des entreprises et l'orthodoxie budgétaire. Il analyse les conséquences de ces politiques en soulignant les dualisations engendrées par ces réformes : dualisation entre les populations assurées et les populations exclues, entre protection sociale collective, solidaire, et protection individuelle privée, dualisation du système lui-même enfin, avec, d'un c?té, des secteurs de plus en plus étatisés (santé, famille, lutte contre la pauvreté) et, de l'autre, des secteurs assurantiels de plus en plus régis par une logique d'individualisation et de privatisation des risques.","event-place":"Paris, France","ISBN":"978-2-13-055005-1","language":"Fran?ais","number-of-pages":"502","publisher":"Presses Universitaires de France","publisher-place":"Paris, France","title":"Gouverner la sécurité sociale : Les réformes du système fran?ais de protection sociale depuis 1945","title-short":"Gouverner la sécurité sociale","author":[{"family":"Palier","given":"Bruno"}],"issued":{"date-parts":[["2005"]]}}}],"schema":""} (see Benamouzig 2005; Palier 2005). This raises the question of how mental illness and mental health care were redefined in the U.S. to facilitate rationalization, and what blocked this process in France.In addition to its limited comparative leverage, research on rationalization is ambiguous about its impact on practices. Some studies found that American professionals actively resisted or worked around tools of rationalization ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ae55per7uc","properties":{"formattedCitation":"(Luhrmann 2000; Scheid 2004)","plainCitation":"(Luhrmann 2000; Scheid 2004)","noteIndex":0},"citationItems":[{"id":3613,"uris":[""],"uri":[""],"itemData":{"id":3613,"type":"book","abstract":"With sharp and soulful insight, T. R. Luhrmann examines the world of psychiatry, a profession which today is facing some of its greatest challenges from within and without, as it continues to offer hope to many. At a time when mood-altering drugs have revolutionized the treatment of the mentally ill and HMO’s are forcing caregivers to take the pharmocological route over the talking cure, Luhrmann places us at the heart of the matter and allows us to see exactly what is at stake. Based on extensive interviews with patients and doctors, as well as investigative fieldwork in residence programs, private psychiatric hospitals, and state hospitals, Luhrmann’s groundbreaking book shows us how psychiatrists develop and how the enormous ambiguities in the field affect its practitioners and patients.","event-place":"New York","ISBN":"978-0-679-74493-1","language":"English","number-of-pages":"352","publisher":"Alfred A. Knopf","publisher-place":"New York","source":"","title":"Of Two Minds: The Growing Disorder in American Psychiatry","title-short":"Of Two Minds","author":[{"family":"Luhrmann","given":"T. M."}],"issued":{"date-parts":[["2000"]]}}},{"id":3587,"uris":[""],"uri":[""],"itemData":{"id":3587,"type":"book","abstract":"Tie a Knot and Hang On is an analysis of mental health care work that crosses the borders of diverse sociological traditions. The work seeks to understand the theoretical and empirical linkages between environmental pressures and activities and how these intersect with organizations and individuals. The work draws upon a research tradition that sees the issue of mental health care in terms of institutional pressures and normative values. The author provides a description and a sociological analysis of mental health care work, emphasizing the interaction of professionally generated norms that guide the &quot;emotional labor&quot; of mental health care workers, and the organizational contexts within which mental health care is provided. She concludes with a discussion of emerging institutional forces that will shape the mental health care system in the future. These forces are having greater impact than ever before as managed care comes to have a huge fiscal as well as institutional impact on the work of mental health professionals. Scheid&#39;s book is a brilliant, nuanced effort to explain the institutional demands for efficiency and cost containment with the professional ethics that emphasize quality care for the individual. The book is essential reading for those interested in mental health care organizations and the providers responding to these seemingly larger, abstract demands. The work offers a rich mixture not just of the problems faced by mental health care personnel, but the equilibrium currently in place ?? an equilibrium that shapes the theory of the field, no less than the activities of its practitioners. Teresa L. Scheid is associate professor of sociology, at the University of North Carolina at Charlotte. She has published widely in the area, including major essays in Sociology of Health and Illness, Sociological Quarterly, Perspectives on Social Problems, and The Journal of Applied Behavioral Science.","event-place":"Hawthorne, NY","ISBN":"978-1-4128-4003-3","language":"en","number-of-pages":"212","publisher":"Transaction Publishers","publisher-place":"Hawthorne, NY","source":"Google Books","title":"Tie a Knot and Hang On: Providing Mental Health Care in a Turbulent Environment","title-short":"Tie a Knot and Hang On","author":[{"family":"Scheid","given":"Teresa L."}],"issued":{"date-parts":[["2004"]]}}}],"schema":""} (Luhrmann 2000; Scheid 2004). Others show that doctors have embraced limiting care as a moral imperative ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2covl6tvha","properties":{"formattedCitation":"(Livne 2019; Reich 2014)","plainCitation":"(Livne 2019; Reich 2014)","noteIndex":0},"citationItems":[{"id":3626,"uris":[""],"uri":[""],"itemData":{"id":3626,"type":"book","event-place":"Cambridge, MA","publisher":"Harvard University Press","publisher-place":"Cambridge, MA","title":"Values at the End of Life","author":[{"family":"Livne","given":"Roi"}],"issued":{"date-parts":[["2019"]]}}},{"id":3149,"uris":[""],"uri":[""],"itemData":{"id":3149,"type":"book","abstract":"Health care costs make up nearly a fifth of U.S. gross domestic product, but health care is a peculiar thing to buy and sell. Both a scarce resource and a basic need, it involves physical and emotional vulnerability and at the same time it operates as . . .","event-place":"Princeton, NJ","publisher":"Princeton University Press","publisher-place":"Princeton, NJ","title":"Selling Our Souls","URL":"","author":[{"family":"Reich","given":"Adam D."}],"accessed":{"date-parts":[["2017",9,6]]},"issued":{"date-parts":[["2014"]]}}}],"schema":""} (Livne 2019; Reich 2014). The results of rationalization are equivocal. Data from the U.S. suggest that as the system embraced “managed care” the number of people receiving some kind of psychiatric treatment has actually increased ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1dph3bfd0b","properties":{"formattedCitation":"(Frank and Glied 2006; Mechanic et al. 2014)","plainCitation":"(Frank and Glied 2006; Mechanic et al. 2014)","noteIndex":0},"citationItems":[{"id":3599,"uris":[""],"uri":[""],"itemData":{"id":3599,"type":"book","abstract":"The past half-century has been marked by major changes in the treatment of mental illness: important advances in understanding mental illnesses, increases in spending on mental health care and support of people with mental illnesses, and the availability of new medications that are easier for the patient to tolerate. Although these changes have made things better for those who have mental illness, they are not quite enough. In Better But Not Well, Richard G. Frank and Sherry A. Glied examine the well-being of people with mental illness in the United States over the past fifty years, addressing issues such as economics, treatment, standards of living, rights, and stigma. Marshaling a range of new empirical evidence, they first argue that people with mental illness―severe and persistent disorders as well as less serious mental health conditions―are faring better today than in the past. Improvements have come about for unheralded and unexpected reasons. Rather than being a result of more effective mental health treatments, progress has come from the growth of private health insurance and of mainstream social programs―such as Medicaid, Supplemental Security Income, housing vouchers, and food stamps―and the development of new treatments that are easier for patients to tolerate and for physicians to manage. The authors remind us that, despite the progress that has been made, this disadvantaged group remains worse off than most others in society. The \"mainstreaming\" of persons with mental illness has left a policy void, where governmental institutions responsible for meeting the needs of mental health patients lack resources and programmatic authority. To fill this void, Frank and Glied suggest that institutional resources be applied systematically and routinely to examine and address how federal and state programs affect the well-being of people with mental illness.","event-place":"Baltimore, MD","ISBN":"978-0-8018-8443-6","language":"English","number-of-pages":"208","publisher":"Johns Hopkins University Press","publisher-place":"Baltimore, MD","source":"Amazon","title":"Better But Not Well: Mental Health Policy in the United States since 1950","title-short":"Better But Not Well","author":[{"family":"Frank","given":"Richard G."},{"family":"Glied","given":"Sherry A."}],"issued":{"date-parts":[["2006"]]}}},{"id":3589,"uris":[""],"uri":[""],"itemData":{"id":3589,"type":"book","edition":"6th","event-place":"Boston, MA","ISBN":"978-0-205-54593-3","language":"en","number-of-pages":"340","publisher":"Pearson","publisher-place":"Boston, MA","source":"Google Books","title":"Mental Health and Social Policy: Beyond Managed Care","title-short":"Mental Health and Social Policy","author":[{"family":"Mechanic","given":"David"},{"family":"McAlpine","given":"Donna"},{"family":"Rochefort","given":"David"}],"issued":{"date-parts":[["2014"]],"season":"1969"}}}],"schema":""} (Frank and Glied 2006; Mechanic et al. 2014). The impact of rationalization, as with medicalization, is contingent on other, under-examined, factors. Principles of Classification In this paper, I approach conflicts over the boundaries of mental health systems and the prerogative to allocate care within them as “classification struggles.” They entail contestation for “power over…classificatory schemes and systems” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"avggqo4apl","properties":{"formattedCitation":"(Bourdieu 1984:479)","plainCitation":"(Bourdieu 1984:479)","noteIndex":0},"citationItems":[{"id":262,"uris":[""],"uri":[""],"itemData":{"id":262,"type":"book","abstract":"Critique sociale du jugement","event-place":"Cambridge, MA","ISBN":"2-7073-0275-9","number-of-pages":"672","publisher":"Harvard University Press","publisher-place":"Cambridge, MA","source":"","title":"Distinction","author":[{"family":"Bourdieu","given":"Pierre"}],"issued":{"date-parts":[["1984"]],"season":"1979"}},"locator":"479"}],"schema":""} (Bourdieu 1984:479) among medical professionals as well as between them and state administrators or managers from insurance companies. Classification struggles “produce groups” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a86gc69763","properties":{"formattedCitation":"(Bourdieu 1984:479)","plainCitation":"(Bourdieu 1984:479)","noteIndex":0},"citationItems":[{"id":262,"uris":[""],"uri":[""],"itemData":{"id":262,"type":"book","abstract":"Critique sociale du jugement","event-place":"Cambridge, MA","ISBN":"2-7073-0275-9","number-of-pages":"672","publisher":"Harvard University Press","publisher-place":"Cambridge, MA","source":"","title":"Distinction","author":[{"family":"Bourdieu","given":"Pierre"}],"issued":{"date-parts":[["1984"]],"season":"1979"}},"locator":"479"}],"schema":""} (Bourdieu 1984:479)—like the set of persons receiving services—as well as an “unequal distribution of resources” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ajl3g5v5r5","properties":{"formattedCitation":"(Barman 2013:105\\uc0\\u8211{}6)","plainCitation":"(Barman 2013:105–6)","noteIndex":0},"citationItems":[{"id":3173,"uris":[""],"uri":[""],"itemData":{"id":3173,"type":"article-journal","abstract":"Employing Pierre Bourdieu’s concept of classificatory struggles and sociological literature on professions’ construction of jurisdiction, this article examines the origins of the National Taxonomy of Exempt Entities (NTEE), the dominant classification system for the US nonprofit sector. Using data drawn from archival research and secondary research, I show that the establishment of the NTEE was part of a larger symbolic struggle over the proper classification of charitable foundations. Philanthropic elites and new nonprofit scholars responded to government threats to foundations by integrating them into the newly created “nonprofit sector,” whose societal value—both philanthropic and economic—would be demonstrated through research on this sector. The NTEE was formed by nonprofit researchers to generate valid data that demonstrated the nonprofit sector’s multiple contributions to society’s well-being. Using a theoretical approach, this article extends Bourdieu’s emphasis on classificatory struggles beyond the study of the construction of the characteristics of social classes to explore contestations over the proper taxonomy of organizations and sectors in society.","container-title":"Social Science History","DOI":"10.1017/S0145553200010580","ISSN":"0145-5532, 1527-8034","issue":"1","page":"103-141","source":"Cambridge Core","title":"Classificatory Struggles in the Nonprofit Sector: The Formation of the National Taxonomy of Exempt Entities, 1969–1987","title-short":"Classificatory Struggles in the Nonprofit Sector","volume":"37","author":[{"family":"Barman","given":"Emily"}],"issued":{"date-parts":[["2013"]]}},"locator":"105-106"}],"schema":""} (Barman 2013:105–6). Analyses of classification struggles typically portray them as taking place within “fields” or meso-level social order organized around a particular set of “understandings about the purpose of the field…and the rules governing legitimate action” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a26n2nfa00d","properties":{"formattedCitation":"(Fligstein and McAdam 2012:10)","plainCitation":"(Fligstein and McAdam 2012:10)","noteIndex":0},"citationItems":[{"id":11910,"uris":[""],"uri":[""],"itemData":{"id":11910,"type":"book","abstract":"Finding ways to understand the nature of social change and social order-from political movements to market meltdowns-is one of the enduring problems of social science. A Theory of Fields draws together far-ranging insights from social movement theory, organizational theory, and economic and political sociology to construct a general theory of social organization and strategic action. In a work of remarkable synthesis, imagination, and analysis, Neil Fligstein and Doug McAdam propose that social change and social order can be understood through what they call strategic action fields. They posit that these fields are the general building blocks of political and economic life, civil society, and the state, and the fundamental form of order in our world today. Similar to Russian dolls, they are nested and connected in a broader environment of almost countless proximate and overlapping fields. Fields are mutually dependent; change in one often triggers change in another. At the core of the theory is an account of how social actors fashion and maintain order in a given field. This sociological theory of action, what they call \"social skill,\" helps explain what individuals do in strategic action fields to gain cooperation or engage in competition. To demonstrate the breadth of the theory, Fligstein and McAdam make its abstract principles concrete through extended case studies of the Civil Rights Movement and the rise and fall of the market for mortgages in the U.S. since the 1960s. The book also provides a \"how-to\" guide to help others implement the approach and discusses methodological issues. With a bold new approach, A Theory of Fields offers both a rigorous and practically applicable way of thinking through and making sense of social order and change-and how one emerges from the other-in modern, complex societies.","ISBN":"978-0-19-985995-5","language":"en","note":"Google-Books-ID: 7uFoAgAAQBAJ","number-of-pages":"253","publisher":"Oxford University Press","source":"Google Books","title":"A Theory of Fields","author":[{"family":"Fligstein","given":"Neil"},{"family":"McAdam","given":"Doug"}],"issued":{"date-parts":[["2012"]]}},"locator":"10"}],"schema":""} (Fligstein and McAdam 2012:10). My argument is that struggles over the application of particular categories within a field are constrained by just such a shared understanding about the nature of the classification process, or a principle of classification. Fourcade ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1frbldifvb","properties":{"formattedCitation":"(2016)","plainCitation":"(2016)","noteIndex":0},"citationItems":[{"id":2711,"uris":[""],"uri":[""],"itemData":{"id":2711,"type":"article-journal","abstract":"We can think of three basic principles of classificatory judgment for comparing things and people. I call these judgments nominal (oriented to essence), cardinal (oriented to quantities), and ordinal (oriented to relative positions). Most social orders throughout history are organized around the intersection of these different types. In line with the ideals of political liberalism, however, democratic societies have developed an arsenal of institutions to untangle nominal and ordinal judgments in various domains of social life. In doing so, I suggest, they have contributed to the parallel amplification of both. In this article, I specifically discuss the socio-technical channels through which ordinal judgments are now elaborated, a process I call ordinalization. I conclude by exploring the political and economic possibilities of a society in which ordinal processes are ubiquitous.","container-title":"Sociological Theory","DOI":"10.1177/0735275116665876","ISSN":"0735-2751, 1467-9558","issue":"3","journalAbbreviation":"Sociological Theory","language":"en","page":"175-195","source":"stx.","title":"Ordinalization","volume":"34","author":[{"family":"Fourcade","given":"Marion"}],"issued":{"date-parts":[["2016"]]}},"suppress-author":true}],"schema":""} (2016) introduces this concept by typologizing three kinds of categories social actors use: numerical “cardinal” counts, “nominal” typologies, and “ordinal” rankings. Principles of classification are ontological in the sense that they make assumptions about the substance of the thing being classified. They are simultaneously epistemological insofar as they imply that certain kinds of things should be apprehended through certain kinds of categories. For example, Schnittker ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ah1pm98313","properties":{"formattedCitation":"(2017)","plainCitation":"(2017)","noteIndex":0},"citationItems":[{"id":3184,"uris":[""],"uri":[""],"itemData":{"id":3184,"type":"book","abstract":"Mental illness is many things at once: It is a natural phenomenon that is also shaped by society and culture. It is biological but also behavioral and social. Mental illness is a problem of both the brain and the mind, and this ambiguity presents a challenge for those who seek to accurately classify psychiatric disorders. The leading resource we have for doing so is the American Psychiatric Association’s Diagnostic and Statistical Manual, but no edition of the manual has provided a decisive solution, and all have created controversy. In The Diagnostic System, the sociologist Jason Schnittker looks at the multiple actors involved in crafting the DSM and the many interests that the manual hopes to serve. Is the DSM the best tool for defining mental illness? Can we insure against a misleading approach?Schnittker shows that the classification of psychiatric disorders is best understood within the context of a system that involves diverse parties with differing interests. The public wants a better understanding of personal suffering. Mental-health professionals seek reliable and treatable diagnostic categories. Scientists want definitions that correspond as closely as possible to nature. And all parties seek definitive insight into what they regard as the right target. Yet even the best classification system cannot satisfy all of these interests simultaneously. Progress toward an ideal is difficult, and revisions to diagnostic criteria often serve the interests of one group at the expense of another. Schnittker urges us to become comfortable with the socially constructed nature of categorization and accept that a perfect taxonomy of mental-health disorders will remain elusive. Decision making based on evolving though fluid understandings is not a weakness but an adaptive strength of the mental-health profession, even if it is not a solid foundation for scientific discovery or a reassuring framework for patients.","event-place":"New York, NY","ISBN":"978-0-231-54459-7","publisher":"Columbia University Press","publisher-place":"New York, NY","source":"Columbia University Press","title":"The Diagnostic System: Why the Classification of Psychiatric Disorders Is Necessary, Difficult, and Never Settled","title-short":"The Diagnostic System","author":[{"family":"Schnittker","given":"Jason"}],"issued":{"date-parts":[["2017"]]}},"suppress-author":true}],"schema":""} (2017) and Whooley ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2clg7jok9p","properties":{"formattedCitation":"(2019)","plainCitation":"(2019)","noteIndex":0},"citationItems":[{"id":12605,"uris":[""],"uri":[""],"itemData":{"id":12605,"type":"book","abstract":"Psychiatry has always aimed to peer deep into the human mind, daring to cast light on its darkest corners and untangle its thorniest knots, often invoking the latest medical science in doing so. But, as Owen Whooley’s sweeping new book tells us, the history of American psychiatry is really a record of ignorance. On the Heels of Ignorance begins with psychiatry’s formal inception in the 1840s and moves through two centuries of constant struggle simply to define and redefine mental illness, to say nothing of the best way to treat it. Whooley’s book is no antipsychiatric screed, however; instead, he reveals a field that has muddled through periodic reinventions and conflicting agendas of curiosity, compassion, and professional striving. On the Heels of Ignorance draws from intellectual history and the sociology of professions to portray an ongoing human effort to make sense of complex mental phenomena using an imperfect set of tools, with sometimes tragic results.","event-place":"Chicago, IL","ISBN":"978-0-226-61638-4","language":"English","number-of-pages":"304","publisher":"University of Chicago Press","publisher-place":"Chicago, IL","source":"Amazon","title":"On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing","title-short":"On the Heels of Ignorance","author":[{"family":"Whooley","given":"Owen"}],"issued":{"date-parts":[["2019"]]}},"suppress-author":true}],"schema":""} (2019) show that revisions to the DSM reflect distinctive underlying ontologies of what mental illness actually is, from psychological states to neurological pathologies. These are intimately tied to divergent epistemologies that assert mental illness is best identified through cardinal counts of symptoms or nominal categorizations of personality structures. This shift to analyzing classification at a higher level of abstraction parallels that made by Abend ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a17h3jv5pdh","properties":{"formattedCitation":"(2014)","plainCitation":"(2014)","noteIndex":0},"citationItems":[{"id":2329,"uris":[""],"uri":[""],"itemData":{"id":2329,"type":"book","abstract":"In recent years, many disciplines have become interested in the scientific study of morality. However, a conceptual framework for this work is still lacking. In The Moral Background, Gabriel Abend develops just such a framework and uses it to investigate the history of business ethics in the United States from the 1850s to the 1930s. According to Abend, morality consists of three levels: moral and immoral behavior, or the behavioral level; moral understandings and norms, or the normative level; and the moral background, which includes what moral concepts exist in a society, what moral methods can be used, what reasons can be given, and what objects can be morally evaluated at all. This background underlies the behavioral and normative levels; it supports, facilitates, and enables them. Through this perspective, Abend historically examines the work of numerous business ethicists and organizations—such as Protestant ministers, business associations, and business schools—and identifies two types of moral background. “Standards of Practice” is characterized by its scientific worldview, moral relativism, and emphasis on individuals’ actions and decisions. The “Christian Merchant” type is characterized by its Christian worldview, moral objectivism, and conception of a person’s life as a unity. The Moral Background offers both an original account of the history of business ethics and a novel framework for understanding and investigating morality in general.","event-place":"Princeton, NJ","ISBN":"978-0-691-15944-7","language":"English","number-of-pages":"416","publisher":"Princeton University Press","publisher-place":"Princeton, NJ","source":"Amazon","title":"The Moral Background: An Inquiry into the History of Business Ethics","title-short":"The Moral Background","author":[{"family":"Abend","given":"Gabriel"}],"issued":{"date-parts":[["2014"]]}},"suppress-author":true}],"schema":""} (2014) in the sociology of morality. Abend argues that most studies of morality focus on particular moral beliefs and how those translate into specific moral evaluations. But, he argues, behind these are a set of meta-level assumptions about “what can and cannot be morally evaluated, what counts and does not count as a moral argument, and what is and is not a valid moral method” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"anjbcnc1p4","properties":{"formattedCitation":"(Abend 2014:55)","plainCitation":"(Abend 2014:55)","noteIndex":0},"citationItems":[{"id":2329,"uris":[""],"uri":[""],"itemData":{"id":2329,"type":"book","abstract":"In recent years, many disciplines have become interested in the scientific study of morality. However, a conceptual framework for this work is still lacking. In The Moral Background, Gabriel Abend develops just such a framework and uses it to investigate the history of business ethics in the United States from the 1850s to the 1930s. According to Abend, morality consists of three levels: moral and immoral behavior, or the behavioral level; moral understandings and norms, or the normative level; and the moral background, which includes what moral concepts exist in a society, what moral methods can be used, what reasons can be given, and what objects can be morally evaluated at all. This background underlies the behavioral and normative levels; it supports, facilitates, and enables them. Through this perspective, Abend historically examines the work of numerous business ethicists and organizations—such as Protestant ministers, business associations, and business schools—and identifies two types of moral background. “Standards of Practice” is characterized by its scientific worldview, moral relativism, and emphasis on individuals’ actions and decisions. The “Christian Merchant” type is characterized by its Christian worldview, moral objectivism, and conception of a person’s life as a unity. The Moral Background offers both an original account of the history of business ethics and a novel framework for understanding and investigating morality in general.","event-place":"Princeton, NJ","ISBN":"978-0-691-15944-7","language":"English","number-of-pages":"416","publisher":"Princeton University Press","publisher-place":"Princeton, NJ","source":"Amazon","title":"The Moral Background: An Inquiry into the History of Business Ethics","title-short":"The Moral Background","author":[{"family":"Abend","given":"Gabriel"}],"issued":{"date-parts":[["2014"]]}},"locator":"55"}],"schema":""} (Abend 2014:55). Even acrimonious moral debates happen against a shared “moral background” that serves to “facilitate, support, and enable…moral claims, norms, actions, practices and institutions” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ab1huprpd8","properties":{"formattedCitation":"(Abend 2014:53)","plainCitation":"(Abend 2014:53)","noteIndex":0},"citationItems":[{"id":2329,"uris":[""],"uri":[""],"itemData":{"id":2329,"type":"book","abstract":"In recent years, many disciplines have become interested in the scientific study of morality. However, a conceptual framework for this work is still lacking. In The Moral Background, Gabriel Abend develops just such a framework and uses it to investigate the history of business ethics in the United States from the 1850s to the 1930s. According to Abend, morality consists of three levels: moral and immoral behavior, or the behavioral level; moral understandings and norms, or the normative level; and the moral background, which includes what moral concepts exist in a society, what moral methods can be used, what reasons can be given, and what objects can be morally evaluated at all. This background underlies the behavioral and normative levels; it supports, facilitates, and enables them. Through this perspective, Abend historically examines the work of numerous business ethicists and organizations—such as Protestant ministers, business associations, and business schools—and identifies two types of moral background. “Standards of Practice” is characterized by its scientific worldview, moral relativism, and emphasis on individuals’ actions and decisions. The “Christian Merchant” type is characterized by its Christian worldview, moral objectivism, and conception of a person’s life as a unity. The Moral Background offers both an original account of the history of business ethics and a novel framework for understanding and investigating morality in general.","event-place":"Princeton, NJ","ISBN":"978-0-691-15944-7","language":"English","number-of-pages":"416","publisher":"Princeton University Press","publisher-place":"Princeton, NJ","source":"Amazon","title":"The Moral Background: An Inquiry into the History of Business Ethics","title-short":"The Moral Background","author":[{"family":"Abend","given":"Gabriel"}],"issued":{"date-parts":[["2014"]]}},"locator":"53"}],"schema":""} (Abend 2014:53). Classificatory principles function similarly in providing a shared backdrop against which classification struggles take place. For instance, Goldberg ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a16krk5q4vj","properties":{"formattedCitation":"(2005:355)","plainCitation":"(2005:355)","noteIndex":0},"citationItems":[{"id":3163,"uris":[""],"uri":[""],"itemData":{"id":3163,"type":"article-journal","container-title":"Social Science History","issue":"3","page":"337–371","source":"Google Scholar","title":"Contesting the Status of Relief Workers during the New Deal","volume":"29","author":[{"family":"Goldberg","given":"Chad Alan"}],"issued":{"date-parts":[["2005"]]}},"locator":"355","suppress-author":true}],"schema":""} (2005:355) studies how work relief recipients in the New Deal mobilized in order to be classified as “workers.” But what role did the “shared cultural understanding of the rights to which workers are entitled,” with which actors entered this struggle, play in shaping it? In this paper, I argue that a primary principle of classification is part of the “settlement” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aelu0i9mjs","properties":{"formattedCitation":"(Fligstein and McAdam 2012:22)","plainCitation":"(Fligstein and McAdam 2012:22)","noteIndex":0},"citationItems":[{"id":11910,"uris":[""],"uri":[""],"itemData":{"id":11910,"type":"book","abstract":"Finding ways to understand the nature of social change and social order-from political movements to market meltdowns-is one of the enduring problems of social science. A Theory of Fields draws together far-ranging insights from social movement theory, organizational theory, and economic and political sociology to construct a general theory of social organization and strategic action. In a work of remarkable synthesis, imagination, and analysis, Neil Fligstein and Doug McAdam propose that social change and social order can be understood through what they call strategic action fields. They posit that these fields are the general building blocks of political and economic life, civil society, and the state, and the fundamental form of order in our world today. Similar to Russian dolls, they are nested and connected in a broader environment of almost countless proximate and overlapping fields. Fields are mutually dependent; change in one often triggers change in another. At the core of the theory is an account of how social actors fashion and maintain order in a given field. This sociological theory of action, what they call \"social skill,\" helps explain what individuals do in strategic action fields to gain cooperation or engage in competition. To demonstrate the breadth of the theory, Fligstein and McAdam make its abstract principles concrete through extended case studies of the Civil Rights Movement and the rise and fall of the market for mortgages in the U.S. since the 1960s. The book also provides a \"how-to\" guide to help others implement the approach and discusses methodological issues. With a bold new approach, A Theory of Fields offers both a rigorous and practically applicable way of thinking through and making sense of social order and change-and how one emerges from the other-in modern, complex societies.","ISBN":"978-0-19-985995-5","language":"en","note":"Google-Books-ID: 7uFoAgAAQBAJ","number-of-pages":"253","publisher":"Oxford University Press","source":"Google Books","title":"A Theory of Fields","author":[{"family":"Fligstein","given":"Neil"},{"family":"McAdam","given":"Doug"}],"issued":{"date-parts":[["2012"]]}},"locator":"22"}],"schema":""} (Fligstein and McAdam 2012:22) that sets the rules and stakes of a field. For those within an established field, embracing these principles is necessary to “inhabit institutions [and] appropriate them practically” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ammmqqon","properties":{"formattedCitation":"(Bourdieu 1990:57)","plainCitation":"(Bourdieu 1990:57)","noteIndex":0},"citationItems":[{"id":1991,"uris":[""],"uri":[""],"itemData":{"id":1991,"type":"book","abstract":"Our usual representations of the opposition between the \"civilized\" and the \"primitive\" derive from willfully ignoring the relationship of distance our social science sets up between the observer and the observed. In fact, the author argues, the relationship between the anthropologist and his object of study is a particular instance of the relationship between knowing and doing, interpreting and using, symbolic mastery and practical mastery—or between logical logic, armed with all the accumulated instruments of objectification, and the universally pre-logical logic of practice.In this, his fullest statement of a theory of practice, Bourdieu both sets out what might be involved in incorporating one's own standpoint into an investigation and develops his understanding of the powers inherent in the second member of many oppositional pairs—that is, he explicates how the practical concerns of daily life condition the transmission and functioning of social or cultural forms.The first part of the book, \"Critique of Theoretical Reason,\" covers more general questions, such as the objectivization of the generic relationship between social scientific observers and their objects of study, the need to overcome the gulf between subjectivism and objectivism, the interplay between structure and practice (a phenomenon Bourdieu describes via his concept of the habitus), the place of the body, the manipulation of time, varieties of symbolic capital, and modes of domination.The second part of the book, \"Practical Logics,\" develops detailed case studies based on Bourdieu's ethnographic fieldwork in Algeria. These examples touch on kinship patterns, the social construction of domestic space, social categories of perception and classification, and ritualized actions and exchanges.This book develops in full detail the theoretical positions sketched in Bourdieu's Outline of a Theory of Practice. It will be especially useful to readers seeking to grasp the subtle concepts central to Bourdieu's theory, to theorists interested in his points of departure from structuralism (especially fom Lévi-Strauss), and to critics eager to understand what role his theory gives to human agency. It also reveals Bourdieu to be an anthropological theorist of considerable originality and power.","event-place":"Stanford, CA","ISBN":"978-0-8047-2011-3","language":"en","number-of-pages":"348","publisher":"Stanford University Press","publisher-place":"Stanford, CA","source":"Google Books","title":"The Logic of Practice","author":[{"family":"Bourdieu","given":"Pierre"}],"translator":[{"family":"Nice","given":"Richard"}],"issued":{"date-parts":[["1990"]]}},"locator":"57"}],"schema":""} (Bourdieu 1990:57). Actors proposing classification schemes that are incongruous with the classificatory principles of a field thus tend to be “challengers” coming from outside it ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2bmvqb2ob1","properties":{"formattedCitation":"(Fligstein and McAdam 2012)","plainCitation":"(Fligstein and McAdam 2012)","noteIndex":0},"citationItems":[{"id":11910,"uris":[""],"uri":[""],"itemData":{"id":11910,"type":"book","abstract":"Finding ways to understand the nature of social change and social order-from political movements to market meltdowns-is one of the enduring problems of social science. A Theory of Fields draws together far-ranging insights from social movement theory, organizational theory, and economic and political sociology to construct a general theory of social organization and strategic action. In a work of remarkable synthesis, imagination, and analysis, Neil Fligstein and Doug McAdam propose that social change and social order can be understood through what they call strategic action fields. They posit that these fields are the general building blocks of political and economic life, civil society, and the state, and the fundamental form of order in our world today. Similar to Russian dolls, they are nested and connected in a broader environment of almost countless proximate and overlapping fields. Fields are mutually dependent; change in one often triggers change in another. At the core of the theory is an account of how social actors fashion and maintain order in a given field. This sociological theory of action, what they call \"social skill,\" helps explain what individuals do in strategic action fields to gain cooperation or engage in competition. To demonstrate the breadth of the theory, Fligstein and McAdam make its abstract principles concrete through extended case studies of the Civil Rights Movement and the rise and fall of the market for mortgages in the U.S. since the 1960s. The book also provides a \"how-to\" guide to help others implement the approach and discusses methodological issues. With a bold new approach, A Theory of Fields offers both a rigorous and practically applicable way of thinking through and making sense of social order and change-and how one emerges from the other-in modern, complex societies.","ISBN":"978-0-19-985995-5","language":"en","note":"Google-Books-ID: 7uFoAgAAQBAJ","number-of-pages":"253","publisher":"Oxford University Press","source":"Google Books","title":"A Theory of Fields","author":[{"family":"Fligstein","given":"Neil"},{"family":"McAdam","given":"Doug"}],"issued":{"date-parts":[["2012"]]}}}],"schema":""} (Fligstein and McAdam 2012). Advocates for more rationalization in France came up through the Ministry of Health and not psychiatry; critics of expanding medicalization in the U.S. are frequently people thrust into the world of public mental health by a chronically ill family member.These principles of what it is that is being classified and how to do so can be formalized in a “classificatory infrastructure” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1alnqmbgna","properties":{"formattedCitation":"(Bowker and Star 1999)","plainCitation":"(Bowker and Star 1999)","noteIndex":0},"citationItems":[{"id":2367,"uris":[""],"uri":[""],"itemData":{"id":2367,"type":"book","abstract":"What do a seventeenth-century mortality table (whose causes of death include \"fainted in a bath,\" \"frighted,\" and \"itch\"); the identification of South Africans during apartheid as European, Asian, colored, or black; and the separation of machine- from hand-washables have in common? All are examples of classification -- the scaffolding of information infrastructures.In Sorting Things Out, Geoffrey C. Bowker and Susan Leigh Star explore the role of categories and standards in shaping the modern world. In a clear and lively style, they investigate a variety of classification systems, including the International Classification of Diseases, the Nursing Interventions Classification, race classification under apartheid in South Africa, and the classification of viruses and of tuberculosis.The authors emphasize the role of invisibility in the process by which classification orders human interaction. They examine how categories are made and kept invisible, and how people can change this invisibility when necessary. They also explore systems of classification as part of the built information environment. Much as an urban historian would review highway permits and zoning decisions to tell a city's story, the authors review archives of classification design to understand how decisions have been made. Sorting Things Out has a moral agenda, for each standard and category valorizes some point of view and silences another. Standards and classifications produce advantage or suffering. Jobs are made and lost; some regions benefit at the expense of others. How these choices are made and how we think about that process are at the moral and political core of this work. The book is an important empirical source for understanding the building of information infrastructures.","ISBN":"978-0-262-26160-9","language":"en","number-of-pages":"396","publisher":"MIT Press","source":"Google Books","title":"Sorting Things Out: Classification and Its Consequences","title-short":"Sorting Things Out","author":[{"family":"Bowker","given":"Geoffrey C."},{"family":"Star","given":"Susan Leigh"}],"issued":{"date-parts":[["1999"]]}}}],"schema":""} (Bowker and Star 1999) of policies, norms and institutions that limit how classification can take place. For example, Norton ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2nrau55f5t","properties":{"formattedCitation":"(2014)","plainCitation":"(2014)","noteIndex":0},"citationItems":[{"id":3106,"uris":[""],"uri":[""],"itemData":{"id":3106,"type":"article-journal","abstract":"The article argues that coordinated state action depends not just on organizational forms and institutions but also on “cultural infrastructures,” systems of state meaning making. Cultural infrastructures are potentially consequential sites for explaining processes of state formation. The article develops this argument through an analysis of the production of coercive power against piracy in the early modern English empire. It analyzes the cultural dynamics involved in the transformation of piracy from an ambiguous legal category to a violently enforced social boundary, focusing on the interplay of codes, interpretive institutions, and social performances. Violence directed against the pirates in the 1710s and 1720s turned on an earlier, contentious period of state formation focused on the cultural infrastructures that made the authoritative classification of piracy possible.","container-title":"American Journal of Sociology","DOI":"10.1086/676041","ISSN":"0002-9602","issue":"6","journalAbbreviation":"American Journal of Sociology","page":"1537-1575","source":"JSTOR","title":"Classification and Coercion: The Destruction of Piracy in the English Maritime System","title-short":"Classification and Coercion","volume":"119","author":[{"family":"Norton","given":"Matthew"}],"issued":{"date-parts":[["2014"]]}},"suppress-author":true}],"schema":""} (2014) shows how the suppression of piracy in the 18th century required that English authorities find a way to classify acts of piracy (rather than “pirates” themselves) that differentiated them clearly from other, legally sanctioned activities. Their solutions were constrained by the legal fields’ ontological requirement that acts, not people, are objects of legal classification, and the epistemological assumption that differences between them are of type rather than degree. Certain proposals thus seem both problematic and unworkable because they transgress the “categories of thought, of perception, of construction of reality” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a22uhoioq1j","properties":{"formattedCitation":"(Bourdieu 2015:4)","plainCitation":"(Bourdieu 2015:4)","noteIndex":0},"citationItems":[{"id":2852,"uris":[""],"uri":[""],"itemData":{"id":2852,"type":"book","abstract":"What is the nature of the modern state? How did it come into being and what are the characteristics of this distinctive field of power that has come to play such a central role in the shaping of all spheres of social, political and economic life? In this major work the great sociologist Pierre Bourdieu addresses these fundamental questions. Modifying Max Weber’s famous definition, Bourdieu defines the state in terms of the monopoly of legitimate physical and symbolic violence, where the monopoly of symbolic violence is the condition for the possession and exercise of physical violence. The state can be reduced neither to an apparatus of power in the service of dominant groups nor to a neutral site where conflicting interests are played out: rather, it constitutes the form of collective belief that structures the whole of social life. The ‘collective fiction’ of the state ? a fiction with very real effects - is at the same time the product of all struggles between different interests, what is at stake in these struggles, and their very foundation. While the question of the state runs through the whole of Bourdieu’s work, it was never the subject of a book designed to offer a unified theory. The lecture course presented here, to which Bourdieu devoted three years of his teaching at the Collège de France, fills this gap and provides the key that brings together the whole of his research in this field. This text also shows ‘another Bourdieu’, both more concrete and more pedagogic in that he presents his thinking in the process of its development. While revealing the illusions of ‘state thought’ designed to maintain belief in government being oriented in principle to the common good, he shows himself equally critical of an ‘anti-institutional mood’ that is all too ready to reduce the construction of the bureaucratic apparatus to the function of maintaining social order. At a time when financial crisis is facilitating the hasty dismantling of public services, with little regard for any notion of popular sovereignty, this book offers the critical instruments needed for a more lucid understanding of the wellsprings of domination.","event-place":"Cambridge, UK","ISBN":"978-0-7456-6329-6","language":"English","number-of-pages":"480","publisher":"Polity","publisher-place":"Cambridge, UK","source":"Amazon","title":"On the State","author":[{"family":"Bourdieu","given":"Pierre"}],"issued":{"date-parts":[["2015"]]}},"locator":"4"}],"schema":""} (Bourdieu 2015:4) dominant in the field ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2cmfm34i0v","properties":{"formattedCitation":"(see also Barnard 2019; Steensland 2006)","plainCitation":"(see also Barnard 2019; Steensland 2006)","noteIndex":0},"citationItems":[{"id":3700,"uris":[""],"uri":[""],"itemData":{"id":3700,"type":"article-journal","abstract":"The ability to (re)classify populations is a key component of state power, but not all new state classifications actually succeed in changing how people are categorized and governed. This article examines the French state’s partly unsuccessful project in 2005 to use a new classification—“psychic handicap”—to ensure that people with severe mental disorders received services and benefits from separate agencies based on a designation of being both “mentally ill” and “disabled.” Previous research has identified how new classifications can be impeded by cultural and cognitive barriers to their adoption and struggles between professionals or administrators over their implementation. Drawing on 186 interviews, archival sources, and 13 months of observations across different French bureaucracies, I expand on this literature in two ways. First, I use the case of psychic handicap to argue that a new classification can also fail to achieve its intended effect when it constitutes a bureaucratically split personality—a combination of classifications that imply that individuals belong to two, mutually exclusive kinds of people. I show how psychic handicap embodied contradictory expectations about the behavior, characteristics, and institutional trajectory of people with mental disorders. Second, I identify how bureaucrats resolved these contradictions through mechanisms of refractory looping, outsourcing expertise, and classification by default, which in this case led to the reclassification of this population as simply “mentally ill.” This framework calls attention to how practical inconsistencies can limit the impact of new classifications, even absent overt resistance to their elaboration or implementation.","container-title":"Theory and Society","DOI":"10.1007/s11186-019-09364-2","ISSN":"1573-7853","issue":"5","journalAbbreviation":"Theor Soc","language":"en","page":"753-784","source":"Springer Link","title":"Bureaucratically split personalities: (re)ordering the mentally disordered in the French state","title-short":"Bureaucratically split personalities","volume":"48","author":[{"family":"Barnard","given":"Alex V."}],"issued":{"date-parts":[["2019"]]}},"prefix":"see also "},{"id":1760,"uris":[""],"uri":[""],"itemData":{"id":1760,"type":"article-journal","abstract":"There is considerable evidence that cultural categories of worth are central to the ideological foundation of the American welfare state. However, existing perspectives on U.S. welfare policy development grant little explanatory power to the role of culture. For this reason, they cannot adequately explain the dynamics of an important, but frequently overlooked, episode in American welfare state history: the rise and fall of guaranteed annual income proposals in the 1960s and 1970s. The author outlines three mechanisms—schematic, discursive, and institutional—through which culture can influence policy outcomes. He then argues that cultural categories of worthiness affected welfare policy development through their constitutive contribution to cultural schemas, their deployment by actors as resources in expert deliberation and public discourse, and their institutionalization in social programs that reinforced the symbolic and programmatic boundaries between categories of the poor. The author discusses how these cultural mechanisms can be integrated with existing class‐ and institution‐based accounts of welfare policy development.","container-title":"American Journal of Sociology","DOI":"10.1086/ajs.2006.111.issue-5","ISSN":"0002-9602","issue":"5","journalAbbreviation":"American Journal of Sociology","page":"1273-1326","source":"JSTOR","title":"Cultural Categories and the American Welfare State: The Case of Guaranteed Income Policy","title-short":"Cultural Categories and the American Welfare State","volume":"111","author":[{"family":"Steensland","given":"Brian"}],"issued":{"date-parts":[["2006"]]}}}],"schema":""} (see also Barnard 2019; Steensland 2006).As I illustrate, the reconstruction of the field of public mental health in the post-War period in each country instantiated distinctive assumptions about the nature of mental illness and the appropriate way to classify it. A principle of bounding in the French system orients actors towards nominal typologies of persons that sharply differentiate “the mentally ill” from others. This firm boundary presents a cognitive barrier to medicalization and a cultural resource for those resisting rationalization. The principle of scaling predominates in California. This principle facilitates medicalization by presenting a degree of mental illness as both ubiquitous and potentially temporary. Simultaneously, it enables rationalization by centering on behaviors which were susceptible to “objective” measurement, ranking, and alteration through carefully-metered intervention.Classificatory Practices and ContradictionsClassification principles are embedded in regulations for allocating care, payment systems that favor some kinds of patients over others, and in programs that do or do not encourage more people into care. But how do principles of classification translate into classification in practice? Bourdieu ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ak1psu6b1d","properties":{"formattedCitation":"(1996:1)","plainCitation":"(1996:1)","noteIndex":0},"citationItems":[{"id":394,"uris":[""],"uri":[""],"itemData":{"id":394,"type":"book","abstract":"In this major new work, Pierre Bourdieu examines the distinctive forms of power—political, intellectual, bureaucratic, and economic—by means of which contemporary societies are governed. What kinds of competence are claimed by the bureaucrats and technocrats who govern us? And how do those who govern gain our recognition and acquiescence? Bourdieu examines in detail the work of consecration that is carried out by elite education systems—in France by the grande écoles, in the United States by the Ivy League schools, and in England by Oxford and Cambridge. Today, this \"state nobility\" has at its disposal an unprecedented range of powers and distinctive titles to justify its privilege. Bourdieu shows how it is the heir—structural and sometimes genealogical—of the noblesse de robe, which, in order to consolidate its position in relation to other forms of power, had to construct the modern state and the republican myths, meritocracy, and civil service that went along with it. Combining ethnographic description, historical documentation, statistical analysis, and theoretical argument, Bourdieu develops a wide-ranging and highly original account of the forms of power and governance that have come to prevail in our society today.","event-place":"Cambridge, UK","ISBN":"978-0-8047-3346-5","language":"en","number-of-pages":"506","publisher":"Polity Press","publisher-place":"Cambridge, UK","source":"Google Books","title":"The State Nobility: Elite Schools in the Field of Power","title-short":"The State Nobility","author":[{"family":"Bourdieu","given":"Pierre"}],"translator":[{"family":"Clough","given":"Lauretta"}],"issued":{"date-parts":[["1996"]],"season":"1989"}},"locator":"1","suppress-author":true}],"schema":""} (1996:1) sees a straightforward “correspondence between social structures and mental structures, between the objective divisions of the social world...and the principles of vision and division that agents apply to them.” Yet qualitative work on the impact of medicalization and rationalization at ground level calls this simple transmission into question. Clinicians often resist, adapt, or work around external mandates as they navigate between their professional identities as caregivers and new roles as managers of scarce resources ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a8112u5vju","properties":{"formattedCitation":"(Cain 2019; Dobransky 2014; McPherson and Sauder 2013)","plainCitation":"(Cain 2019; Dobransky 2014; McPherson and Sauder 2013)","noteIndex":0},"citationItems":[{"id":3568,"uris":[""],"uri":[""],"itemData":{"id":3568,"type":"article-journal","abstract":"There is no doubt that the organization of healthcare is currently shifting, partly in response to changing macrolevel policies. Studies of healthcare policies often do not consider healthcare workers’ experiences of policy change, thus limiting our understanding of when and how policies work. This article uses longitudinal qualitative data, including participant observation and semistructured interviews with workers within hospice care as their organizations shifted in response to a Medicare policy change. Prior to the policy change, I find that the main innovation of hospice—the interdisciplinary team—is able to resist logics from the larger medical institution. However, when organizational pressures increase, managers and workers adjust in ways that reinforce medical logics and undermine the interdisciplinary team. These practices illustrate processes by which rationalization of healthcare affects workers’ experiences and the type of care available to patients.","container-title":"Journal of Health and Social Behavior","DOI":"10.1177/0022146518825379","ISSN":"0022-1465","issue":"1","journalAbbreviation":"J Health Soc Behav","language":"en","page":"3-17","source":"SAGE Journals","title":"Agency and Change in Healthcare Organizations: Workers’ Attempts to Navigate Multiple Logics in Hospice Care","title-short":"Agency and Change in Healthcare Organizations","volume":"60","author":[{"family":"Cain","given":"Cindy L."}],"issued":{"date-parts":[["2019"]]}}},{"id":3601,"uris":[""],"uri":[""],"itemData":{"id":3601,"type":"book","event-place":"New Brunswick, NJ","ISBN":"978-0-8135-6308-4","language":"English","number-of-pages":"192","publisher":"Rutgers University Press","publisher-place":"New Brunswick, NJ","source":"Amazon","title":"Managing Madness in the Community: The Challenge of Contemporary Mental Health Care","title-short":"Managing Madness in the Community","author":[{"family":"Dobransky","given":"Kerry Michael"}],"issued":{"date-parts":[["2014"]]}}},{"id":3388,"uris":[""],"uri":[""],"itemData":{"id":3388,"type":"article-journal","abstract":"Drawing on a 15-month ethnographic study of a drug court, we investigate how actors from different institutional and professional backgrounds employ logical frameworks in their micro-level interactions and thus how logics affect day-to-day organizational activity. While institutional theory presumes that professionals closely adhere to the logics of their professional groups, we find that actors exercise a great deal of agency in their everyday use of logics, both in terms of which logics they adopt and for what purpose. Available logics closely resemble tools that can be creatively employed by actors to achieve individual and organizational goals. A close analysis of court negotiations allowed us to identify the logics that are available to these actors, show how they are employed, and demonstrate how their use affects the severity of the court’s decisions. We examine the ways in which professionals with four distinct logical orientations—the logics of criminal punishment, rehabilitation, community accountability, and efficiency—use logics to negotiate decisions in a drug court. We provide evidence of the discretionary use of these logics, specifying the procedural, definitional, and dispositional constraints that limit actors’ discretion and propose an explanation for why professionals stray from their “home” logics and “hijack” the logics of other court actors. Examining these micro-level processes improves our understanding of how local actors use logics to manage institutional complexity, reach consensus, and get the work of the court done.","container-title":"Administrative Science Quarterly","DOI":"10.1177/0001839213486447","ISSN":"0001-8392","issue":"2","journalAbbreviation":"Administrative Science Quarterly","language":"en","page":"165-196","source":"SAGE Journals","title":"Logics in Action: Managing Institutional Complexity in a Drug Court","title-short":"Logics in Action","volume":"58","author":[{"family":"McPherson","given":"Chad Michael"},{"family":"Sauder","given":"Michael"}],"issued":{"date-parts":[["2013"]]}}}],"schema":""} (Cain 2019; Dobransky 2014; McPherson and Sauder 2013).In keeping with this latter literature, I show that there is not always a substantive agreement between political or regulatory actors and those on the ground about who should be treated and how much care they should receive. But I do find a degree of concordance at a higher level, driven by shared principles about what is being classified and how. Actors then elaborate these principles into concrete classificatory practices, such professional roles in who classifies, what measurement tools or formal criteria they use, and how they resolve debates between themselves. In this respect, my argument follows recent work in comparative cultural sociology ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2cvpfkvqi3","properties":{"formattedCitation":"(Bonikowski 2017; Christin 2018; Saguy 2003)","plainCitation":"(Bonikowski 2017; Christin 2018; Saguy 2003)","noteIndex":0},"citationItems":[{"id":3329,"uris":[""],"uri":[""],"itemData":{"id":3329,"type":"chapter","container-title":"Everyday Nationhood","page":"147-174","title":"Nationhood as Cultural Repertoire: Collective Identities and Political Attitudes in France and Germany","author":[{"family":"Bonikowski","given":"Bart"}],"editor":[{"family":"Skey","given":"M."},{"family":"Antonsich","given":"M."}],"issued":{"date-parts":[["2017"]]}}},{"id":3381,"uris":[""],"uri":[""],"itemData":{"id":3381,"type":"article-journal","abstract":"Sociological studies often emphasize the role of metrics in broader processes of convergence and homogenization. Yet numbers can take on different meanings depending on their contexts. This article focuses on the case of journalism, a field transformed by quantification in the form of “clicks.” Drawing on ethnographic material gathered at two news websites—one in New York, the other in Paris—it documents important differences in the uses and meanings assigned to audience metrics in the United States and France. At the U.S. website, editors make significant decisions based on metrics, but staff journalists are relatively unconcerned by them. At the French website, however, editors are conflicted about metrics, but staff writers fixate on them. To understand these differences, this article analyzes how the trajectories of the U.S. and French journalistic fields affect newsroom dynamics. It shows how cultural differences can be reproduced at a time of technological convergence.","container-title":"American Journal of Sociology","DOI":"10.1086/696137","ISSN":"0002-9602","issue":"5","journalAbbreviation":"American Journal of Sociology","page":"1382-1415","source":"www-journals-uchicago-edu.libproxy.berkeley.edu (Atypon)","title":"Counting Clicks: Quantification and Variation in Web Journalism in the United States and France","title-short":"Counting Clicks","volume":"123","author":[{"family":"Christin","given":"Angèle"}],"issued":{"date-parts":[["2018"]]}}},{"id":3377,"uris":[""],"uri":[""],"itemData":{"id":3377,"type":"book","event-place":"Berkeley, CA","publisher":"University of California Press","publisher-place":"Berkeley, CA","source":"Google Scholar","title":"What is Sexual Harassment? From Capitol Hill to the Sorbonne","title-short":"What is sexual harassment?","URL":"","author":[{"family":"Saguy","given":"Abigail Cope"}],"accessed":{"date-parts":[["2015",6,12]]},"issued":{"date-parts":[["2003"]]}}}],"schema":""} (Bonikowski 2017; Christin 2018; Saguy 2003) that has focused on identifying distinctive “repertoires,” or “cultural tools” for “construct[ing] and assess[ing]…the world” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aaqevvn98m","properties":{"formattedCitation":"(Lamont and Th\\uc0\\u233{}venot 2000:8\\uc0\\u8211{}9)","plainCitation":"(Lamont and Thévenot 2000:8–9)","noteIndex":0},"citationItems":[{"id":3378,"uris":[""],"uri":[""],"itemData":{"id":3378,"type":"chapter","container-title":"Rethinking Comparative Culture Sociology","event-place":"Cambridge, UK","page":"1-22","publisher":"Cambridge University Press","publisher-place":"Cambridge, UK","title":"Introduction: Toward a Renewed Comparative Cultural Sociology","editor":[{"family":"Lamont","given":"Michèle"},{"family":"Thévenot","given":"Laurent"}],"author":[{"family":"Lamont","given":"Michèle"},{"family":"Thévenot","given":"Laurent"}],"issued":{"date-parts":[["2000"]]}},"locator":"8-9"}],"schema":""} (Lamont and Thévenot 2000:8–9) that are unevenly available across contexts.I expand on this approach, however, by suggesting how an underlying principle of classification ties different aspects of these practical repertoires together. As I show, in the U.S. clinicians actualize a principle of scaling by embracing formalized quantitative assessment tools. This moves the classificatory process from the inscrutable judgment of individual clinicians into an open debate between them ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1lmcods6jr","properties":{"formattedCitation":"(see Porter 1996)","plainCitation":"(see Porter 1996)","noteIndex":0},"citationItems":[{"id":3542,"uris":[""],"uri":[""],"itemData":{"id":3542,"type":"book","event-place":"Princeton, NJ","publisher":"Princeton University Press","publisher-place":"Princeton, NJ","title":"Trust in Numbers: The Pursuit of Objectivity in Science and Public Life","title-short":"Trust in numbers","author":[{"family":"Porter","given":"Theodore M."}],"issued":{"date-parts":[["1996"]]}},"prefix":"see "}],"schema":""} (see Porter 1996). In France, with the assumption that the goal of classification is to identify the “boundaries” of a group of mentally ill persons in France, a holistic assessment that excludes non-medical criteria seems like common sense. Decision-making is hierarchical and the evaluations handed down by psychiatrists are difficult to contest. My findings thus run parallel to Fourcade, who shows how differing conceptions of “nature” shape the calculation of environmental damages in the U.S. and France. As she concludes, practices of standardization, quantification, and commensuration “manage to hold together…[through an] ineffable sense of coherence and overdetermination that we call ‘culture’” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2p3oo5i97h","properties":{"formattedCitation":"(Fourcade 2011:1170)","plainCitation":"(Fourcade 2011:1170)","noteIndex":0},"citationItems":[{"id":3354,"uris":[""],"uri":[""],"itemData":{"id":3354,"type":"article-journal","container-title":"American Journal of Sociology","issue":"6","page":"1721-1777","title":"Cents and Sensibility: Economic Valuation and the Nature of 'Nature'","volume":"116","author":[{"family":"Fourcade","given":"Marion"}],"issued":{"date-parts":[["2011"]]}},"locator":"1170"}],"schema":""} (Fourcade 2011:1170). Nonetheless, the translation of principles into practices produces analytically revealing contradictions. First, in both cases, clinicians face cases that defy easy categorization with the tools they have available. In both, we can see different “ontological myopias” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ai6f9jo71j","properties":{"formattedCitation":"(Rodr\\uc0\\u237{}guez-Mu\\uc0\\u241{}iz 2015:90)","plainCitation":"(Rodríguez-Mu?iz 2015:90)","noteIndex":0},"citationItems":[{"id":12482,"uris":[""],"uri":[""],"itemData":{"id":12482,"type":"article-journal","abstract":"What factors influence the scholarly field of vision, its illuminations and omissions? Reflexive interventions have typically addressed this question via analyses of knowledge producers and their institutional contexts. In contrast, this article foregrounds the inherited cultural infrastructures that enable and constrain knowledge production. I propose a ‘cultural diagnostics’ approach to identify and explain the persistence of what I label ‘ontological myopias’, a type of intellectual constriction rooted in assumptions about the content and composition of the social world. To illustrate the purchase of this analytic strategy, I examine the case of the emerging cultural sociology of poverty. Cultural diagnostics reveal that recent works have, with few exceptions, inherited an underlying presumption of earlier cultural approaches, namely that the ‘poor’ and their lifeworlds should constitute the principal empirical object of poverty research. This myopic focus hinders the creation of a comprehensive and relational approach to the cultural study of poverty and inequality. Ultimately, this article provides grounds to rethink the ontological foundations of contemporary poverty knowledge, and presents, more broadly, a reflexive cultural approach that can be profitably applied to other fields of scholarship.","container-title":"American Journal of Cultural Sociology","DOI":"10.1057/ajcs.2014.16","ISSN":"2049-7121","issue":"1","journalAbbreviation":"Am J Cult Sociol","language":"en","page":"89-122","source":"Springer Link","title":"Intellectual inheritances: Cultural diagnostics and the state of poverty knowledge","title-short":"Intellectual inheritances","volume":"3","author":[{"family":"Rodríguez-Mu?iz","given":"Michael"}],"issued":{"date-parts":[["2015"]]}},"locator":"90"}],"schema":""} (Rodríguez-Mu?iz 2015:90) where principles for classifying mental illness hides other features of patients that might actually help them resolve these dilemmas. The ways that clinicians double-down on their assumptions even when they seem a poor fit suggests the constraining power of classificatory principles.Second, by focusing on specifically classificatory principles, I leave open the possibility that the way actors classify might be in conflict with other aspects of their work. Clinicians do not just evaluate new patients, but they also treat them, communicate about them to other institutions, and interact with them. In France clinicians must negotiate the contradiction between a classificatory principle that orients them towards providing care for a small, bounded group and their identity as public servants operating in a health system founded on universalism ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1j0ri9sl7s","properties":{"formattedCitation":"(see Palier 2005)","plainCitation":"(see Palier 2005)","noteIndex":0},"citationItems":[{"id":2786,"uris":[""],"uri":[""],"itemData":{"id":2786,"type":"book","abstract":"Où en est le modèle social fran?ais ? Créé en et pour des temps aujourd'hui révolus, le système fran?ais de Sécurité sociale est appelé depuis le début des années 1980 à s'adapter au nouveau contexte économique et social. Comment les gouvernements font-ils pour changer une des institutions auxquelles les Fran?ais sont le plus attachés ? Les réformes de la protection sociale qui s'accumulent depuis la fin des années 1980 signifient-elles une transformation profonde des principes et des mécanismes sur lesquels reposait le système fran?ais de protection sociale ? Ce livre analyse l'ensemble des évolutions et des réformes du système fran?ais de protection sociale de 1945 à 2005. Il défend la thèse que les politiques sociales, con?ues dans un contexte keynésien, connaissent au cours des années 1990-2000 une phase de réajustement au nouveau cadre économique, marqué par la domination des politiques néo-classiques centrées sur l'offre, la compétitivité des entreprises et l'orthodoxie budgétaire. Il analyse les conséquences de ces politiques en soulignant les dualisations engendrées par ces réformes : dualisation entre les populations assurées et les populations exclues, entre protection sociale collective, solidaire, et protection individuelle privée, dualisation du système lui-même enfin, avec, d'un c?té, des secteurs de plus en plus étatisés (santé, famille, lutte contre la pauvreté) et, de l'autre, des secteurs assurantiels de plus en plus régis par une logique d'individualisation et de privatisation des risques.","event-place":"Paris, France","ISBN":"978-2-13-055005-1","language":"Fran?ais","number-of-pages":"502","publisher":"Presses Universitaires de France","publisher-place":"Paris, France","title":"Gouverner la sécurité sociale : Les réformes du système fran?ais de protection sociale depuis 1945","title-short":"Gouverner la sécurité sociale","author":[{"family":"Palier","given":"Bruno"}],"issued":{"date-parts":[["2005"]]}},"prefix":"see "}],"schema":""} (see Palier 2005). In the U.S., clinicians’ focus on disruptive behaviors puts them at odds with a welfare system ordinarily oriented towards allocating resources to those who are “deserving” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"anp3ppshmb","properties":{"formattedCitation":"(see Steensland 2006)","plainCitation":"(see Steensland 2006)","noteIndex":0},"citationItems":[{"id":1760,"uris":[""],"uri":[""],"itemData":{"id":1760,"type":"article-journal","abstract":"There is considerable evidence that cultural categories of worth are central to the ideological foundation of the American welfare state. However, existing perspectives on U.S. welfare policy development grant little explanatory power to the role of culture. For this reason, they cannot adequately explain the dynamics of an important, but frequently overlooked, episode in American welfare state history: the rise and fall of guaranteed annual income proposals in the 1960s and 1970s. The author outlines three mechanisms—schematic, discursive, and institutional—through which culture can influence policy outcomes. He then argues that cultural categories of worthiness affected welfare policy development through their constitutive contribution to cultural schemas, their deployment by actors as resources in expert deliberation and public discourse, and their institutionalization in social programs that reinforced the symbolic and programmatic boundaries between categories of the poor. The author discusses how these cultural mechanisms can be integrated with existing class‐ and institution‐based accounts of welfare policy development.","container-title":"American Journal of Sociology","DOI":"10.1086/ajs.2006.111.issue-5","ISSN":"0002-9602","issue":"5","journalAbbreviation":"American Journal of Sociology","page":"1273-1326","source":"JSTOR","title":"Cultural Categories and the American Welfare State: The Case of Guaranteed Income Policy","title-short":"Cultural Categories and the American Welfare State","volume":"111","author":[{"family":"Steensland","given":"Brian"}],"issued":{"date-parts":[["2006"]]}},"prefix":"see "}],"schema":""} (see Steensland 2006).This paper thus builds an explanatory framework that can speak to broader puzzles in the literature on classification. Using the case of mental health care, I show how the outcome of classification struggles over processes like medicalization and rationalization depends in part on shared assumptions that structure those struggles. Overarching principles also shape classificatory practices at ground level, creating coherent and distinct patterns of classification in each case, even when actors diverge from the substance of official classification schemes. Data and MethodsThe primary data for this paper come from ethnographic observations of the evaluation of new patients in a Centre médico-psychologique (“Medical-Psychological Center,” hereafter “CMP”) serving an arrondissement (“district”) of Paris and a public outpatient clinic (hereafter “Clinic”) in California. I chose my field sites with the aim of limiting variation in the surrounding context to focus on differences in the public mental health system itself. The CMP and the Clinic were each the primary public mental health provider for a catchment area of around 150,000 people (I am withholding further details to keep my field sites dis-identified). They served relatively affluent areas, albeit with significant pockets of poverty. They operated in zones with a large number of private mental health providers, meaning that public clinics were not the sole option for patients (in stark contrast to many rural areas). Moreover, each faced municipal governments who were aggressively pushing for the system to expand its reach. In France, the municipality wanted clinicians to resolve problems in public housing and prevent Islamic radicalization; in California, the demand was to address the perceived disruptive behavior of homeless people.As the primary site of public outpatient care, the French CMPs serve a role similar to the Community Mental Health Centers that were central to de-institutionalization in the U.S. But the CMP is part of a larger organizational unit, the secteur (explained below), that also includes hospital beds, therapeutic apartments, and a day hospital. The CMP I studied has two full-time doctors, two social workers, a psychologist, and a dozen nurses. Doctors who work in the hospital also rotate through the CMP to see those patients upon discharge. The CMP conducted hundreds of weekly consultations for an active file of nearly 2,800 patients. Over the course of seven months, I attended weekly meetings in which the team discussed new cases. People asking for care first met with a nurse, who would present a short summary of each patient. A psychiatrist would then decide whether the patient would be seen in the secteur and with whom. All told, I observed the discussion of 260 new patients who presented for a meeting with nurses and 79 who were seen on an emergency basis. I also attended the weekly meeting of the CMP’s social workers as well as discussions between nurses and the head psychiatrist about complex cases.Unlike the French CMP, the Clinic in California depended on external social service and legal agencies to house, hospitalize, and control its 400 clients. At weekly “level of care” meetings, a social worker specialized in performing intakes would present new cases to the heads of the Clinic’s three treatment teams, who would follow a set of formalized tools in deciding where to assign the client. I observed 78 discussions of new cases, 80 decisions over changes to level of care for existing clients (including closures), and 163 status updates about cases of concern. The balance of professional power was quite different from Paris. Treatment teams were headed by social workers or psychologists. A single psychiatrist participated without assuming a leading role. In both cases, I requested to attend meetings after speaking with the clinic director (California) and head psychiatrist (Paris) and with the agreement of all the professionals participating in them. I did not have any contact with the people the clinics were serving.I do not claim that the CMP and the Clinic are comparable in terms of the clients they serve. The population of the Clinic is more male, psychotic, and economically precarious than that of the CMP (see Table 1). However, this is more complicated than the larger public system in France serving the same kinds of “severe” clients as the U.S. plus many milder cases. Clinicians have a different approach to classifying even the most-needy clients at the CMP. The key point of comparison is rather that both public mental health care providers are determining who falls in the bounds of “public” and what “mental health care” for those individuals means. These clinics are an appropriate scale for analysis because each faced external mandates towards medicalization and rationalization but nonetheless retained some discretion in allocation decisions.I contextualized my clinical observations with 186 qualitative interviews in France and 167 in the United States (66 in New York, 101 in California). I targeted policymakers, regulators, and advocates operating at the national/department (for France) or state/county (for the U.S.) level, alongside professionals working at the sites where I did my ethnographic observations and at similar sites in other cities. Interviews lasted between thirty minutes and two-and-a-half hours. In both countries, I collected government reports, classification tools, administrative statistics, newspaper articles, and grey literature on the regulation and allocation of mental health care. Interviews and documents from two states in the U.S. and multiple departments in France strengthen my claim that the patterns I observed reflect field-level principles rather than local idiosyncrasies. I first coded my fieldnotes and interviews in the qualitative analysis software Dedoose, identifying key features of classification decisions in each country. This resulted in over 17,000 coded units of text. I then recoded the fieldnotes treating each discussion of a (potential) new client/patient as a unit of analysis and identifying their race, gender, age, and diagnosis as available. I characterized each decision in terms of a limited set of possible outcomes and the arguments evoked by clinicians for a given decision. This coding allowed me to produce the comparative counts shown in Tables 1-3, although I ultimately found that some aspects of classification (like the arguments used to justify a decision) were so different in the Clinic and CMP that I needed separate sets of categories. Combined, these data allow me to show the correspondence between the principles visible in the structure and regulations of the field, the classificatory practices of clinicians, and the exceptional cases that show the conflicts and tensions with them.France: ‘Bounding’ for the ‘Real Malades’Principles: Resisting Rationalization, Setting BoundariesStarting in 1960, France’s public mental health system was organized into secteurs of 70,000 people, each served by a single psychiatric team. The sectorisation policy charged professionals with an expansive mandate to ensure that “within each territory…all the malades, men and women, have an indispensable continuity of care between screening, treatment…and surveillance.” Yet even if not spelled out in regulations, psychiatrists clearly perceived “malades” to mean “the most diminished and the most disturbing” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a23e52eh8bh","properties":{"formattedCitation":"(qtd. in Velpry 2008:93)","plainCitation":"(qtd. in Velpry 2008:93)","noteIndex":0},"citationItems":[{"id":3583,"uris":[""],"uri":[""],"itemData":{"id":3583,"type":"book","event-place":"Paris, France","publisher":"Armand Colin","publisher-place":"Paris, France","source":"Google Scholar","title":"Le quotidien de la psychiatrie: sociologie de la maladie mentale","title-short":"Le quotidien de la psychiatrie","author":[{"family":"Velpry","given":"Livia"}],"issued":{"date-parts":[["2008"]]}},"locator":"93","prefix":"qtd. in "}],"schema":""} (qtd. in Velpry 2008:93)—above all those who had been lingering in asylums for years but were now being released. Since the 1990s, however, public psychiatry has faced intensifying demands to expand its boundaries and move from addressing “mental illness” towards “mental health” more broadly ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2g9hmah66t","properties":{"formattedCitation":"(Ehrenberg 2005)","plainCitation":"(Ehrenberg 2005)","noteIndex":0},"citationItems":[{"id":2445,"uris":[""],"uri":[""],"itemData":{"id":2445,"type":"article-journal","container-title":"Cahiers de recherche sociologique","issue":"41-42","page":"17–41","title":"La plainte sans fin. Réflexions sur le couple souffrance psychique/santé mentale","title-short":"La plainte sans fin","author":[{"family":"Ehrenberg","given":"Alain"}],"issued":{"date-parts":[["2005"]]}}}],"schema":""} (Ehrenberg 2005). An administrator in the ministry of health expressed this pressure to medicalize: “our position is that mental health goes from well-being to mental illness. The only difference is the gradation in the intensity of psychiatric care” (Interview, 5/10/16). Upper administrators, politicians, and a small number of reform-minded psychiatrists sought to advance this shift through public health campaigns. They often drew explicitly on models from countries where these were much more widespread, including the U.S. For example, in 2005 the state mandated the National Institute for Prevention and Education in Health to carry out a public information campaign on “Depression: Understand More to Overcome It.” Its materials carefully emphasized that sadness and suffering only become depression when they mark a “true rupture with normal functioning” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"MfwghyDf","properties":{"formattedCitation":"(qtd. in Briffault, Morvan, and Du Rosco\\uc0\\u228{}t 2010:6)","plainCitation":"(qtd. in Briffault, Morvan, and Du Rosco?t 2010:6)","noteIndex":0},"citationItems":[{"id":2733,"uris":[""],"uri":[""],"itemData":{"id":2733,"type":"article-journal","container-title":"L'Encéphale","page":"D124–D132","source":"Google Scholar","title":"Les campagnes nationales d’information sur la dépression. Une anthropologie biopsychosociale?","volume":"36","author":[{"family":"Briffault","given":"X."},{"family":"Morvan","given":"Y."},{"family":"Du Rosco?t","given":"E."}],"issued":{"date-parts":[["2010"]]}},"locator":"6","prefix":"qtd. in "}],"schema":""} (qtd. in Briffault, Morvan, and Du Rosco?t 2010:6). Nonetheless, a person involved in the campaign described a “frontal attack” in response from psychiatrists, “who thought the institute was playing as a pawn of the pharmaceutical laboratories” (Interview, 3/12/16) by medicalizing everyday suffering. Practitioners were particularly incensed that the campaign’s materials provided a questionnaire through which people could count their symptoms and diagnose themselves (Interview, 8/31/16). Since then, a ministry official admitted, “mental health has not exactly been a priority for the [prevention] institute” (Interview, 8/17/16).Even proposals that seemed to valorize public psychiatry provoked resistance when they cut against an understanding that it was supposed to serve a finite, discrete set of malades. In 2014, the Health Minister declared mental health to be a “grand issue of public health” and noted that “one person in five” would be “touched by a psychic illness” during their lifetime. Despite this seemingly welcome attention, psychiatric professional organizations issued a joint statement that the minister was “confusing mental health and psychiatry” in a way that “displace[d] the center of gravity of psychiatry and the orientation of its resources, its medical legitimacy, to a vague social register with no limits.” During my fieldwork, the municipal government in Paris organized a “Mental Health Information Week” that publicized that “one in four” French people would have a trouble with mental health at some point (Fieldnotes, 3/22/16). Actors from within the public psychiatric field were visibly absent from these events. As the director of the hospital attached to the clinic I studied complained, “There’s a de-stigmatization…people are less afraid of going to see the psy[chiatrist], and society is not really doing well….so we have an augmentation of people who come for malaise, burn-outs…And is that part of our mission? If we accept this surge, what will happen to our schizophrenics?” (Interview, 7/1/16). Because “schizophrenics” were not liable to stop being schizophrenics, expanding the ambit of the mental health system invariably detracted from meeting their long-term needs.For French public psychiatrists, extending medicalization was problematic partly because the field had an institutionalized financing system that was adapted to treating a small, bounded group. Secteurs are financed through a “global” budget: a yearly sum which they can allocate based on professional discretion between inpatient units, outpatient clinics, day hospitals, or therapeutic apartments. This system allowed clinicians to address the needs of persons in the nominal category of malades holistically. The head of the secteur I studied celebrated: “We never have to stop treating someone. We can say, ‘treatment for life’, and that means care but also accompaniment to rehabilitation, recovery. The patients are 100% taken care of without payment…because we have a global budget” (Interview, 6/28/16). Yet, as one ministry official complained, both the vague mandate for the secteurs and the global budget made it difficult for state officials to shape the quantity and kind of treatment delivered and who received it (Interview, 2/28/16). In the 1990s and 2000s, administrators and consultants in the ministry sought to import rationalizing techniques from elsewhere in the health system. In particular, they pushed to replace global budgets with “payments by the act” (tarification à l’activité, or T2A). T2A entailed a new set of classificatory principles: breaking down the care given by secteurs into distinctive typologies of illnesses (not people) and financing secteurs based on the measurable cost of the standardized set of interventions necessary to treat them ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a4sic479mt","properties":{"formattedCitation":"(see Juven 2018)","plainCitation":"(see Juven 2018)","noteIndex":0},"citationItems":[{"id":3669,"uris":[""],"uri":[""],"itemData":{"id":3669,"type":"article-journal","abstract":"Si, historiquement, la très grande majorité des recherches consacrées à l’h?pital public ont porté la focale sur les soins, les savoirs, les relations entre soignant.e.s ou entre soignant.e.s et soigné.e.s, la prégnance des enjeux économiques en matière de santé indique que le spectre des questionnements doit désormais être étendu. Cet article propose d’étudier au plus près de sa fabrique et de ses effets, la logique économique à l’?uvre à l’h?pital public en France aujourd’hui. En observant les opérations de mise en compte et d’évaluation quantitative des activités, des médecins et des services hospitaliers, des logiques économiques nouvelles apparaissent, logiques que nous proposons d’appeler processus de capitalisation. Un regard porté sur l’économie hospitalière telle qu’elle se fait montre que ces processus supposent une hybridation des logiques économiques et cliniques et que ces logiques coexistent selon des degrés de conflictualité variables.","container-title":"Anthropologie & Santé. Revue internationale francophone d'anthropologie de la santé","DOI":"10.4000/anthropologiesante.2860","ISSN":"2111-5028","issue":"16","language":"fr","source":"journals.","title":"? Des trucs qui rapportent ?. Enquête ethnographique autour des processus de capitalisation à l’h?pital public","URL":"","author":[{"family":"Juven","given":"Pierre-André"}],"accessed":{"date-parts":[["2019",1,21]]},"issued":{"date-parts":[["2018",5,18]]}},"prefix":"see "}],"schema":""} (see Juven 2018). Given that T2A would empower managers over clinicians, it unsurprisingly provoked a classification struggle: the leader of one union of psychiatrists reported that 80% of his membership voted against cooperating in its implementation (Interview, 8/3/16). Psychiatrists sought to make objectifying the costs of different pathologies impossible through a “strike against statistics” in 2004, identifying cases in the electronic heath records reviewed by the ministry as “F99: mental disorder, not otherwise specified” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"5VADQ9eN","properties":{"formattedCitation":"(B\\uc0\\u233{}lart and Dembinski 2012:162)","plainCitation":"(Bélart and Dembinski 2012:162)","noteIndex":0},"citationItems":[{"id":68,"uris":[""],"uri":[""],"itemData":{"id":68,"type":"chapter","container-title":"La politique de santé mentale en France: Acteurs, instruments, controverses","event-place":"Paris, France","ISBN":"978-2-200-27594-5","language":"Fran?ais","page":"143-164","publisher":"Armand Colin","publisher-place":"Paris, France","source":"Amazon","title":"Les nouveaux outils de géstion en psychiatrie","editor":[{"family":"Demailly","given":"Lise"},{"family":"Autès","given":"Michel"}],"author":[{"family":"Bélart","given":"Claire"},{"family":"Dembinski","given":"Olivier"}],"issued":{"date-parts":[["2012"]]}},"locator":"162"}],"schema":""} (Bélart and Dembinski 2012:162).Archives from the state agency responsible for developing T2A show a deeper problem. Information like a patient’s diagnosis was not well correlated with the cost of treating a person, precisely because clinicians were classifying patients not pathologies. The very mission of the secteur to address patients’ entire needs entailed time spent liaising with police, working to find housing, or convincing involuntary patients to accept treatment. None of these fit easily into rationalizing frameworks drawn from elsewhere in the health system. A member of the National Assembly explained that in the process of writing a report on the psychiatric field he learned that “the chronicity of the illness, the notion of intervention to preserve human relations, the idea of rehabilitating rather than curing someone, the need to follow the person over time… all these things mean the T2A is not adapted” (Interview, 6/22/16). By 2006, the government had abandoned the project. In sum, public sector psychiatrists in France struggled, largely successfully, to resist pressure to medicalize a wide swathe of “mental health” conditions, in the name of treating a small group of “mentally ill” persons. They also defended the idea that professionals needed flexibility in assessing their needs and a wide leeway in allocating resources in response. In both cases, they advocated for and reinforced an approach congruent with the classificatory principles institutionalized in the secteur system in the 1960s. Practices: Rushing Care to ‘Real Malades’If the secteur was required to serve all the “all the malades” in a given area, then it is perhaps unsurprising that Friday meetings at the CMP centered on parsing out who these “malades” actually were. I asked the referent for mental health in the High Authority of Health, the government body responsible for providing guidance on best practices, who regulated this decision of who was treated in the secteur. She replied, “Uhh, I would say, first, no one… We’re dealing with clinical practices…the administrative decision of classifying and orienting people is not part of our job…There is a principle of medical judgment that still prevails” (Interview, 2/22/16). The chief psychiatrist of the secteur I studied was very clear what this meant in the context of a finite budget: “The risk we have is that we’re being asked to treat everyone, but it’s not possible. So we do a triage ourselves, and the heart of what we do, it’s real mental illness” (Interview 6/26/16). This section examines how they triaged through practices derived from a principle of bounding.What was “real” mental illness? Even absent formal regulation to this effect, clinicians on the ground operated on the assumption that they were trying to find a group of people who had a package of difficult-to-disentangle medical and social problems. The following case was iconic:Nurse: Man, 28. Hospitalized via the ER for psychotic delirium. Homeless. Has been eating from a dumpster. Heavy marijuana use. Family unknown. Rapid appointment at CMP requested (Fieldnotes, 5/13/16).Afterwards, the psychiatrist made a snap judgment to see the person, with no explanation, which nurses, social workers, and secretaries would work to implement. Although they would be obligated to ultimately put a diagnosis in his file, attempts to refine diagnoses played almost no role in orientation.The practices used in the CMP allowed the team to typologize someone as a malade needing a broad range of interventions, even without more detailed information on the frequency, duration, or intensity of illness:Nurse: Woman, 34 years old. Addressed by [private psychiatrist] who follows her for addiction to alcohol and medication. Eight months pregnant with a girl. Sexual and psychological mistreatment during childhood at the hands of her father. Has a twin sister. Had declared images of violence towards her daughter. Stopped eating for 15 days to kill her. Currently only eats yogurt. Wanted the pregnancy and married since May. Sleeps little. Cold affect. Sentiment of depersonalization. Okay for a [psychiatric] following.After the presentation, there was a long silence, followed by a sigh from the nurse. Then:Head Nurse: She needed to be seen by [head psychiatrist], like, yesterday.Psychiatrist: We should plan a hospitalization, we’re talking about infanticide here. Head Nurse: Yes, this is an emergency. We’ll check on a bed.Secretary: [Head psychiatrist] has an opening next week.Psychiatrist: You’ll have to take someone out of her schedule, get her in faster.Psychologist: This is ridiculous, why hasn’t she been sent here before?Psychiatrist: [To presenting nurse] Something like this needs to be brought up first in our meetings!Nurse: If you look at what I wrote, it’s not so so urgent… There’s nothing about suicide, no history of attempts…Psychiatrist: No way. She’s having deliria about killing her child.Head Nurse: This is going to take two or three months to stabilize. If she gives birth in the hospital, that’s just how it is (Fieldnotes, 3/25/16).The team proposed a hospitalization to the woman, but she didn’t show up. The next week, they went to her house to hospitalize her involuntarily. The aggressive approach taken by the CMP reflected the way that she cumulated three features that frequently pushed people into the category of real malade: uncertainty about whether the person had psychosis, a risk to family, and vulnerability (Table 2). Although people with psychoses were the archetype of real malades, they only constituted about 20% of new demands at the CMP. Other cases presented a more complex challenge of “categorical fitting” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2pdmdtg4uj","properties":{"formattedCitation":"(Fourcade 2016:177)","plainCitation":"(Fourcade 2016:177)","noteIndex":0},"citationItems":[{"id":2711,"uris":[""],"uri":[""],"itemData":{"id":2711,"type":"article-journal","abstract":"We can think of three basic principles of classificatory judgment for comparing things and people. I call these judgments nominal (oriented to essence), cardinal (oriented to quantities), and ordinal (oriented to relative positions). Most social orders throughout history are organized around the intersection of these different types. In line with the ideals of political liberalism, however, democratic societies have developed an arsenal of institutions to untangle nominal and ordinal judgments in various domains of social life. In doing so, I suggest, they have contributed to the parallel amplification of both. In this article, I specifically discuss the socio-technical channels through which ordinal judgments are now elaborated, a process I call ordinalization. I conclude by exploring the political and economic possibilities of a society in which ordinal processes are ubiquitous.","container-title":"Sociological Theory","DOI":"10.1177/0735275116665876","ISSN":"0735-2751, 1467-9558","issue":"3","journalAbbreviation":"Sociological Theory","language":"en","page":"175-195","source":"stx.","title":"Ordinalization","volume":"34","author":[{"family":"Fourcade","given":"Marion"}],"issued":{"date-parts":[["2016"]]}},"locator":"177"}],"schema":""} (Fourcade 2016:177): Nurse: Man, 60. His current [private] doctor is asking for us to take the relay. He was hospitalized involuntarily in 2014 and 2015 for massive suicidal ideas and a risk to himself. He’s subsequently gone through hospitals for alcoholism. Right now, he presents as sad but not suicidal. He used to be a successful architect, but now he sleeps all day and has no desire to work. He’s originally from [Country], and has been here [in France] a while, but never mastered the language. No contact with his two adult children.Head Psychiatrist: They’re [his current doctor and addiction services] passing him off to us. He’s overwhelmed everyone else following him. His depression is just too much. He’s in the process of disconnecting himself [from society]. We need to see him.Psychiatrist: I have space. I’ll see him quickly. This is someone that everyone is trying to get rid of. Definitely not an easy case (Fieldnotes, 4/19/16).Here, the team was characterizing a person with surprisingly little attention to his pathology. They did not quantify risk through formalized tools, as was the best practice for assessing suicidality in the U.S. Instead, the case showed the secteur team’s concern for the person’s set of social inscriptions, vis-à-vis work, family, and society writ large. Indeed, “isolation” was a frequent justification for secteur care. Still, the more difficult work of categorical fitting was visible in that the head psychiatrist felt the need to justify her assessment, which nonetheless was not up for debate. Even absent widespread public health campaigns, a combination of economic precarity, welfare-state retrenchment, and cultural change meant the CMP faced an “explosion of demands related to psychic suffering” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ag3408rnl7","properties":{"formattedCitation":"(Ehrenberg 2005:29)","plainCitation":"(Ehrenberg 2005:29)","noteIndex":0},"citationItems":[{"id":2445,"uris":[""],"uri":[""],"itemData":{"id":2445,"type":"article-journal","container-title":"Cahiers de recherche sociologique","issue":"41-42","page":"17–41","title":"La plainte sans fin. Réflexions sur le couple souffrance psychique/santé mentale","title-short":"La plainte sans fin","author":[{"family":"Ehrenberg","given":"Alain"}],"issued":{"date-parts":[["2005"]]}},"locator":"29"}],"schema":""} (Ehrenberg 2005:29). Nurses characterized half of new cases as having “anxiety” and “depression,” or, ignoring the many gradations and subtypes of these illnesses in formal diagnostic systems, simply “anxio-depression syndrome” (see Table 2). Surveys find that 60% of French people using specialized psychiatric services characterize themselves as having a “psychic trouble” rather than a “psychiatric illness” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2irmmi42uq","properties":{"formattedCitation":"(Chapireau 2012)","plainCitation":"(Chapireau 2012)","noteIndex":0},"citationItems":[{"id":2609,"uris":[""],"uri":[""],"itemData":{"id":2609,"type":"report","collection-title":"?tudes et résultats","event-place":"Paris, France","number":"N° 533","publisher":"Direction de la recherche, des études, de l’évaluation et des statistiques","publisher-place":"Paris, France","source":"Google Scholar","title":"Les recours aux soins spécialisés en santé mentale","author":[{"family":"Chapireau","given":"Fran?ois"}],"accessed":{"date-parts":[["2015",10,30]]},"issued":{"date-parts":[["2012"]]}}}],"schema":""} (Chapireau 2012). Both the public and professionals understood this distinction in a similar way; “troubles” had a cause which was external to the person, while a true malade was defined by their illness ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2c7r43jfh","properties":{"formattedCitation":"(see Velpry 2008)","plainCitation":"(see Velpry 2008)","noteIndex":0},"citationItems":[{"id":3583,"uris":[""],"uri":[""],"itemData":{"id":3583,"type":"book","event-place":"Paris, France","publisher":"Armand Colin","publisher-place":"Paris, France","source":"Google Scholar","title":"Le quotidien de la psychiatrie: sociologie de la maladie mentale","title-short":"Le quotidien de la psychiatrie","author":[{"family":"Velpry","given":"Livia"}],"issued":{"date-parts":[["2008"]]}},"prefix":"see "}],"schema":""} (see Velpry 2008). In their presentations, nurses hinted at the linkage between type of treatment and type of person by noting that those with troubles came not for “soins” (care) but rather “support” “aid” “talk” or “advice” (Table 3). For example:Nurse: Woman, 44. Referral: herself. She asks for support. Says that her partner has left her home, leaving her with four children. Now housed by a pair of friends. The children are struggling to understand what happened and she is having difficulty with respect to this reaction. Unemployed for 14 years. No prior treatment. Anxiety, trouble sleeping, crying, no idées noires [dark ideas]. States that she ‘wants help passing through this difficult moment’ (Fieldnotes, 2/25/16).In most cases, the doctors accepted that, as a public service, they were obligated to take people with psychic troubles. But they found informal ways to limit care. In the example above, they assigned the woman to an intern (a medical resident). Because the interns rotated every few months, there would be a rupture in the woman’s care that likely would push her out. In other cases, people flagged as having “troubles” were given appointments long in the future, with a tacit understanding many would not make it. These instances indicated the “ontological myopias” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"iWkU4TzB","properties":{"formattedCitation":"(Rodr\\uc0\\u237{}guez-Mu\\uc0\\u241{}iz 2015:90)","plainCitation":"(Rodríguez-Mu?iz 2015:90)","noteIndex":0},"citationItems":[{"id":12482,"uris":[""],"uri":[""],"itemData":{"id":12482,"type":"article-journal","abstract":"What factors influence the scholarly field of vision, its illuminations and omissions? Reflexive interventions have typically addressed this question via analyses of knowledge producers and their institutional contexts. In contrast, this article foregrounds the inherited cultural infrastructures that enable and constrain knowledge production. I propose a ‘cultural diagnostics’ approach to identify and explain the persistence of what I label ‘ontological myopias’, a type of intellectual constriction rooted in assumptions about the content and composition of the social world. To illustrate the purchase of this analytic strategy, I examine the case of the emerging cultural sociology of poverty. Cultural diagnostics reveal that recent works have, with few exceptions, inherited an underlying presumption of earlier cultural approaches, namely that the ‘poor’ and their lifeworlds should constitute the principal empirical object of poverty research. This myopic focus hinders the creation of a comprehensive and relational approach to the cultural study of poverty and inequality. Ultimately, this article provides grounds to rethink the ontological foundations of contemporary poverty knowledge, and presents, more broadly, a reflexive cultural approach that can be profitably applied to other fields of scholarship.","container-title":"American Journal of Cultural Sociology","DOI":"10.1057/ajcs.2014.16","ISSN":"2049-7121","issue":"1","journalAbbreviation":"Am J Cult Sociol","language":"en","page":"89-122","source":"Springer Link","title":"Intellectual inheritances: Cultural diagnostics and the state of poverty knowledge","title-short":"Intellectual inheritances","volume":"3","author":[{"family":"Rodríguez-Mu?iz","given":"Michael"}],"issued":{"date-parts":[["2015"]]}},"locator":"90"}],"schema":""} (Rodríguez-Mu?iz 2015:90) of reasoning through typologies. Rapid characterizations of people as having mere “troubles” meant that the team would not learn whether peoples’ difficulties with life circumstances were, in fact, severe. Because they were constantly being bumped off of psychiatrists’ schedules to make space for real malades, the care people with troubles were given was of very low intensity, typically occasional consultations to renew prescriptions for anti-depressants. Meanwhile, the CMP poured its time, personnel, and limited spots in day hospitals or therapeutic apartments to those best incarnating the figure of the real malade. Once stabilized, these patients would largely receive the same monthly meeting with a psychiatrist, support from nurses in medication adherence, and aid from social workers in maintaining benefits. For both groups, the practices that flowed from the principle of bounding—“lumping” disparate individuals together and “splitting” them from other groups ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1vc96pvhs7","properties":{"formattedCitation":"(Zerubavel 1996)","plainCitation":"(Zerubavel 1996)","noteIndex":0},"citationItems":[{"id":2354,"uris":[""],"uri":[""],"itemData":{"id":2354,"type":"article-journal","abstract":"This paper examines the mental process of grouping \"similar\" things together\nin distinct clusters and separating \"different\" clusters from one another. The\nrole language plays in providing us with seemingly homogeneous mental niches\nfor lumping things together yet at the same time allowing us to carve seemingly\ndiscrete categories out of experiential continua directs the sociological study of\nclassification to intersubjective, conventional mindscapes that are neither\npersonal nor \"logical.\" The paper identifies a nonmetric, topological mode of\nthinking that involves playing down intracluster while exaggerating intercluster\nmental distances and ends with some methodological observations of the need\nto approach classification from a comparative perspective as well as\nhighlighting the role of spatial zoning, rites of separation, and Freudian slips\nin the study of the social construction of difference and similarity.","container-title":"Sociological Forum","issue":"3","page":"421–433","source":"Google Scholar","title":"Lumping and Splitting: Notes on Social Classification","title-short":"Lumping and splitting","volume":"11","author":[{"family":"Zerubavel","given":"Eviatar"}],"issued":{"date-parts":[["1996"]]}}}],"schema":""} (Zerubavel 1996)—largely homogenized treatment for those within them. Care was intensive enough to keep most malades in the community but limited enough in frequency that the secteur could offer at least something to each person in its expanding caseload. Contradictions: Pushing the ‘Non-Psy’ Out of Public ServicesThe CMP’s clinicians were working within a broader health system that operated on a promise of permanent, universal solidarity. As the Minister of Health at one point admonished, “the secteur is, above all, an obligation for public services to accept and care for every patient presenting himself to it and who resides in a given geographic area” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1iNyadJZ","properties":{"formattedCitation":"(qtd. in Ayme 1995:442\\uc0\\u8211{}43)","plainCitation":"(qtd. in Ayme 1995:442–43)","noteIndex":0},"citationItems":[{"id":3467,"uris":[""],"uri":[""],"itemData":{"id":3467,"type":"book","event-place":"Ramonville Saint-Agne, France","ISBN":"978-2-86586-356-3","language":"Fran?ais","number-of-pages":"478","publisher":"Eres","publisher-place":"Ramonville Saint-Agne, France","source":"Amazon","title":"Chroniques de la psychiatrie publique. A travers l'histoire d'un syndicat","author":[{"family":"Ayme","given":"Jean"}],"issued":{"date-parts":[["1995"]]}},"locator":"442-443","prefix":"qtd. in "}],"schema":""} (qtd. in Ayme 1995:442–43). Yet, once again, this left the CMP the professional prerogative to define “patient,” even in the face of societal pressures to expand the category. This created contradictions between the practices of bounding and professionals’ identities as public servants.One of the most visible modes of policing the boundaries of the CMP case load was to refer patients out to private psychiatrists, which they did 12% of the time (Table 2). Private psychiatrists require their patients to pay for treatment up front (later reimbursed by National Insurance) or add a supplemental fee. Learning that a patient had a salaried job was usually an immediate disqualifier from secteur care. But private-sector referrals could provoke tension when doctors’ typologizing brushed over the particularities of a case, better known to the nurses: Nurse 1: Madame is 45 years old. Came to us after being referred by the ER for anxiety-depression. Lives in an 18 square meter apartment. Never married, no children. Father died of Alzheimer’s. Worked as a secretary, but stopped in 2013. Traumatizing relationship with boyfriend. States she is ‘disgusted with herself.’ Four months of suicidal ideation, without plan: ‘I want to leave, but I don’t want to go.’ Tried multiple anti-depressants from generalist doctor, but no effect. Somewhat flirty. I’m suggesting Doctor [X].Psychiatrist: Where does she work?Nurse 1: She was a secretary.Psychiatrist: Great. She can go to private.Nurse 2: She can’t advance eighty euros, even if she’s reimbursed…Head Psychiatrist: [Private psychiatrist] loves flirty patients!Nurse 1: She can’t pay! (Fieldnotes, 4/19/16).That nurse later told me, exasperated, “There are times when we really don’t agree with the private orientations. We’re the ones who have to tell them, and they don’t understand” (Interview, 7/15/16). One patient was presented in three subsequent weeks, each time having been sent to a psychiatrist who was not taking new patients. The nurse elaborated, “Some manage to get an appointment [with a private doctor]. Others feel rejected and… well, we don’t follow up.” In other cases, the secteur acted more aggressively to keep out persons who they perceived as having problems that were considered ‘not psy’—not psychiatric at all. A French government initiative in the 2000s promoted “local councils of mental health” to bring together secteur professionals with municipal elected officials. The latter, I learned in interviews, wanted psychiatry to intervene in adolescent drug use, hoarding in public housing, and Islamic radicalization (Interview, 8/13/16). In these council meetings, however, I could see how secteur professionals insisted on their principle of classification against actors intruding on their field. The head psychiatrist spent one meeting explaining to public housing landlords “how to identify what kind of issues are not psychiatric” (Fieldnotes, 4/14/16). At another, the group worked on a form that would allow landlords to flag a case for the secteur’s attention:Psychiatrist: This form asks, ‘what kind of issues does the person have?’ Only a doctor can determine this!Nurse: Seems like people will say ‘psychic troubles’ with no idea what that means…Council Coordinator: Well, we can just put the facts; ‘threatened the neighbors, threw things out the window…’Nurse: Those are just behavioral troubles! Psychiatrist: If you say ‘puts self in danger’ we could be obligated to intervene even if it’s not psychiatric. Nurse: Yeah, I mean, if someone is in danger, call the fire department (Fieldnotes, 7/8/16).Unlike in California, problematic behaviors observable to all were not enough to merit psychiatric care. Instead, boundaries could be established only at the level of the underlying origins of behavior, a mental space that only psychiatrists could access. Even for people who did make it to an intake, the secteur was skeptical when a referral came from a third party who was not a doctor, a signal that their problems were ‘not psy’ (see Table 3). For example, courts were increasingly medicalizing delinquency and drug use by sending defendants to the secteur under a legal “obligation for care.” But as a nurse told me, “It’s true that when we see ‘obligation for care’ we are going to say right away that it’s a person who doesn’t want care, the interview is going to last five minutes and the person just wants a paper to show the judge” (Interview, 7/15/16). This assumption was put into action at CMP meetings:Nurse: Man, 22. Coming in the context of an obligation for care after driving a car under the influence of drugs and alcohol.Head Psychiatrist: So why didn’t this go to an addiction doctor?Nurse: To be clear, he has no demand here. He’s coming because he has to.Head Psychiatrist: It doesn’t sound like this is even pathological.The team assigned the individual to an intern who would sign the paper for the judge and not give a second appointment (Fieldnotes, 2/25/16). When cases were typologized as “not psy” but rather “anti-social” or “addicts,” informal criteria shifted: here, they noted a “lack of demand” even though they frequently pushed care on real malades who didn’t want it. Some secteur professionals saw the contradiction but also couldn’t imagine an alternative approach to classifying people. One veteran nurse observed, “So, the CMP is a public service but… We have criteria anyway, we’re going to orient people elsewhere. It’s not very ‘public service,’ but that’s the way it is” (Interview, 3/20/16). These contradictory acts of exclusion seemed inescapable because of the background assumption that secteurs were treating a group of people who, once identified as malades, would stay that way. A psychiatrist nearing the end of his career explained: The secteur is made to take care of all the pathologies of a given territory, and that means the heaviest pathologies. These are illnesses that are durable, chronic. I see a lot of patients I’ve known for 35 years. Their care is repeated and repetitive, because the treatments aren’t that effective. These are people who are not capable of going anywhere else, and so we’re obligated to keep them, re-hospitalize them from time to time (Interview, 5/17/16).This view seemed to preclude rationalization through “stepping down” patients along gradated levels of care within the CMP and then into the private system. A government best-practices guide for CMPs explicitly noted that “the attentive reader will realize that if the management of entry is rather significantly raised, the question of the end of care is not even mentioned” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1rp52loi8a","properties":{"formattedCitation":"\\uldash{(Mission nationale d\\uc0\\u8217{}expertise et d\\uc0\\u8217{}audit hospitalier 2008:99)}","plainCitation":"(Mission nationale d’expertise et d’audit hospitalier 2008:99)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":2753,"uris":[""],"uri":[""],"itemData":{"id":2753,"type":"report","event-place":"Paris, France","publisher-place":"Paris, France","title":"L’organisation des centres médico-psychologiques","author":[{"literal":"Mission nationale d'expertise et d'audit hospitalier"}],"issued":{"date-parts":[["2008",5]]}},"locator":"99"}],"schema":""} (MNEAH 2008:99).In truth, the discourse of “care for life” ignored how even real malades fell off the CMP’s radar. Around 10% of patients presented at weekly meetings were flagged as “resumption of following.” Their dossiers had never been closed, but they had been gone for long enough that they needed to be re-assigned:Nurse: Man, 41. Brings himself in for anxiety. Was followed by the CMP from 2010 to 2015. First hospitalization was for catatonia [an often-fatal manifestation of schizophrenia]. Stopped care in agreement with Dr. [X]. In interview: difficult contact, distrusting, coherent discourse, no thought troubles, loss of élan vital [life force], medium mood, no suicidal ideas, anxiety tied to fear of a relapse as in 2010. Okay to restart treatment. Upcoming meeting with Dr. [X] (Fieldnotes, 3/11/16).Secteur clinicians started with the assumption that they were classifying people based on nominal typologies. The practices that flowed from this were largely-inscrutable judgments that characterized patients based on an ensemble of characteristics that were rarely ranked or quantified. Although they sought to avoid medicalizing a range of psychic troubles and not-psy problems, they nonetheless faced an ever-accumulating caseload of people receiving low intensity treatment. Yet this made more sense than embracing rationalized tools for ratcheting down care, given that they continued to see their core patient group as real malades who need care to be permanent—even if it wasn’t. California: ‘Scaling’ Up Medicalization and RationalizationPrinciples: Rationalizing Along the Behavioral Health Continuum In this section, I show the development of a principle of scaling in California, which orients clinicians, policymakers, and advocates towards a continuum of mental health classified through rankings of behaviors. This nascent principle was visible in early efforts of American psychiatry to move physically out of the asylum and conceptually from “mental illness” to “mental health.” In response to epidemiological studies showing that one-in-four Americans had a mental illness, the renowned psychiatrist William Menninger told Congress in 1956:Even the most startling of these figures…refer only to extreme cases of mental disorder…[But] the toll of mental ill health must be reckoned as one in one, for there isn’t a person who does not experience frequently a mental or emotional disturbance severe enough to disrupt his functioning as a well-adjusted, happy and efficiently performing individual ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2kar1dbei9","properties":{"formattedCitation":"(qtd. in Staub 2011:37)","plainCitation":"(qtd. in Staub 2011:37)","noteIndex":0},"citationItems":[{"id":3505,"uris":[""],"uri":[""],"itemData":{"id":3505,"type":"book","abstract":"In the 1960s and 1970s, a popular diagnosis for America’s problems was that society was becoming a madhouse. In this intellectual and cultural history, Michael E. Staub examines a time when many believed insanity was a sane reaction to obscene social conditions, psychiatrists were agents of repression, asylums were gulags for society’s undesirables, and mental illness was a concept with no medical basis.\n\"Madness Is Civilization\" explores the general consensus that societal ills—from dysfunctional marriage and family dynamics to the Vietnam War, racism, and sexism—were at the root of mental illness. Staub chronicles the surge in influence of socially attuned psychodynamic theories along with the rise of radical therapy and psychiatric survivors' movements. He shows how the theories of antipsychiatry held unprecedented sway over an enormous range of medical, social, and political debates until a bruising backlash against these theories—part of the reaction to the perceived excesses and self-absorptions of the 1960s—effectively distorted them into caricatures. Throughout, Staub reveals that at stake in these debates of psychiatry and politics was nothing less than how to think about the institution of the family, the nature of the self, and the prospects for, and limits of, social change.\n?The first study to describe how social diagnostic thinking emerged, \"Madness Is Civilization\" casts new light on the politics of the postwar era.","event-place":"Chicago, IL","publisher":"University of Chicago Press","publisher-place":"Chicago, IL","source":"press.uchicago.edu","title":"Madness Is Civilization","URL":"","author":[{"family":"Staub","given":"Michael"}],"accessed":{"date-parts":[["2014",10,12]]},"issued":{"date-parts":[["2011"]]}},"locator":"37","prefix":"qtd. in "}],"schema":""} (qtd. in Staub 2011:37).Unlike the French secteurs, American “Community Mental Health Centers” (CMHCs) set up in the 1960s largely eschewed caring for “the mentally ill” leaving asylums. They focused instead on “general population target groups such as the poor, the aged, children, or the disabled,” many of whom were “not very ill” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a40ol8d9du","properties":{"formattedCitation":"\\uldash{(Comptroller General of the United States 1977:26,73)}","plainCitation":"(Comptroller General of the United States 1977:26,73)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":3602,"uris":[""],"uri":[""],"itemData":{"id":3602,"type":"report","event-place":"Washington, DC","publisher-place":"Washington, DC","title":"Returning the Mentally Disabled to the Community","author":[{"literal":"Comptroller General of the United States"}],"issued":{"date-parts":[["1977"]]}},"locator":"26,73"}],"schema":""} (Comptroller General 1977:26,73). California’ Short-Doyle Act of 1957 represented an early instantiation of medicalization to address a continuum of mental health. It financed not just classic inpatient, outpatient, or rehabilitative services, but also programs that provided “informational and educational services” as well as “mental health consultation for the staffs of schools, public health departments, probation officers, welfare departments and others to help them deal more effectively with…mental health problems” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2kr1kf2euj","properties":{"formattedCitation":"(Auerback 1959:336)","plainCitation":"(Auerback 1959:336)","noteIndex":0},"citationItems":[{"id":11461,"uris":[""],"uri":[""],"itemData":{"id":11461,"type":"article-journal","container-title":"California Medicine","issue":"5","page":"335-338","title":"The Short-Doyle Act","volume":"90","author":[{"family":"Auerback","given":"Alfred"}],"issued":{"date-parts":[["1959",5]]}},"locator":"336"}],"schema":""} (Auerback 1959:336). Unsurprisingly, the system quickly appeared to be “boundaryless” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1inia6itnf","properties":{"formattedCitation":"(Dinitz and Beran 1971)","plainCitation":"(Dinitz and Beran 1971)","noteIndex":0},"citationItems":[{"id":3784,"uris":[""],"uri":[""],"itemData":{"id":3784,"type":"article-journal","abstract":"[Every system of deviance definition and management must address three basic questions: (1) Who shall be defined as deviant and in need of management? (2) Who shall be the legitimate agents in defining and managing the deviant, and what shall be their respective roles? (3) What shall be done to or for the deviant? In contrast to both the legal and traditional mental health systems, which offer delimited responses to these questions, the community mental health system, in both philosophy and practice, offers such all-inclusive responses that it is developing into a boundaryless system of deviance definition and management. The community mental health approach unavoidably, if not deliberately, confronts and breaks down the boundaries of other deviance management systems and appropriates some of their territories. Of particular significance are the implications of these developments for the future articulation of the legal and mental health systems.]","archive":"JSTOR","container-title":"Journal of Health and Social Behavior","DOI":"10.2307/2948516","ISSN":"0022-1465","issue":"2","page":"99-108","source":"JSTOR","title":"Community Mental Health as a Boundaryless and Boundary-Busting System","volume":"12","author":[{"family":"Dinitz","given":"Simon"},{"family":"Beran","given":"Nancy"}],"issued":{"date-parts":[["1971"]]}}}],"schema":""} (Dinitz and Beran 1971):As local services are organized, they are overwhelmed by demands for assistance from all quarters. Every clinic has been swamped with referrals…Because of the heavy demand, every community mental health service has had to establish priorities on the number and the kind of patients that could be accepted for treatment ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aosr2r2slh","properties":{"formattedCitation":"(Auerback 1959:337)","plainCitation":"(Auerback 1959:337)","noteIndex":0},"citationItems":[{"id":11461,"uris":[""],"uri":[""],"itemData":{"id":11461,"type":"article-journal","container-title":"California Medicine","issue":"5","page":"335-338","title":"The Short-Doyle Act","volume":"90","author":[{"family":"Auerback","given":"Alfred"}],"issued":{"date-parts":[["1959",5]]}},"locator":"337"}],"schema":""} (Auerback 1959:337). California’s voraciously expanding public system rationalized from the start. The state’s Welfare and Institutions Code 5600.3 states that care should be given “to the extent resources are available,” thus “ration[ing] access” to services ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a258kvbfs6c","properties":{"formattedCitation":"(Little Hoover Commission 2000:ii)","plainCitation":"(Little Hoover Commission 2000:ii)","noteIndex":0},"citationItems":[{"id":12427,"uris":[""],"uri":[""],"itemData":{"id":12427,"type":"report","event-place":"Sacramento, CA","publisher-place":"Sacramento, CA","title":"Being There: Making a Commitment to Mental Health","author":[{"literal":"Little Hoover Commission"}],"issued":{"date-parts":[["2000",11]]}},"locator":"ii"}],"schema":""} (Little Hoover Commission 2000:ii). The 2004 Mental Health Services Act, a ballot initiative that imposed a one-percent tax on California’s millionaires, offers a striking example of a policy that deepened a principle oriented towards delivering interventions scaled in intensity to match a continuum of need. The act’s preamble offers the kind of epidemiological claim that was controversial in France, that “Mental illnesses are extremely common; they affect almost every family in California. They affect people from every background and occur at any age.” The act’s funds were to be allocated through a stakeholder process that would identify “underserved” groups. As one newspaper reported:When the two hours of discussion were up, about 75 people had identified more than 35 groups in desperate need of mental-health care in the county. The groups included children, at-risk minority youths, the homeless, parolees, Latino families, low-income residents and individuals suffering from post-traumatic stress disorder…Undocumented immigrants and the elderly also were mentioned ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2kfuo5ss8n","properties":{"formattedCitation":"(Wells 2005a)","plainCitation":"(Wells 2005a)","noteIndex":0},"citationItems":[{"id":12432,"uris":[""],"uri":[""],"itemData":{"id":12432,"type":"article-newspaper","container-title":"San Bernardino Sun","title":"Mental-health forum gauges those in need","author":[{"family":"Wells","given":"Annette"}],"issued":{"date-parts":[["2005",6,30]]}}}],"schema":""} (Wells 2005a).In this classificatory principle, mental illness did not constitute a population, but was a fluctuating feature of any group. The MHSA allocated 25% of funds towards prevention, early intervention, and public awareness. By contrast, France’s plan for psychiatry and mental health, promulgated in 2005, put only about 7% of new investments towards these ends ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a12c93drfv7","properties":{"formattedCitation":"\\uldash{(Direction g\\uc0\\u233{}n\\uc0\\u233{}rale de la sant\\uc0\\u233{} 2005)}","plainCitation":"(Direction générale de la santé 2005)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":2417,"uris":[""],"uri":[""],"itemData":{"id":2417,"type":"report","event-place":"Paris, France","page":"42","publisher-place":"Paris, France","title":"Plan psychiatrie et santé mentale, 2005-2008","URL":"","author":[{"literal":"Direction générale de la santé"}],"accessed":{"date-parts":[["2015",7,22]]},"issued":{"date-parts":[["2005"]]}}}],"schema":""} (DGS 2005). Indeed, whereas in France clinicians and policymakers believed prevention and treatment competed with each other for funds, most interviewees in California saw the former as a tool for economizing the latter. To this end, many programs were targeted towards children whose conditions were below the threshold for a diagnosis of mental illness, but for whom interventions like short-term counseling would ultimately, as one county director put it, “keep people out of our system” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1luuvqu0m5","properties":{"formattedCitation":"(Wells 2005b)","plainCitation":"(Wells 2005b)","noteIndex":0},"citationItems":[{"id":12429,"uris":[""],"uri":[""],"itemData":{"id":12429,"type":"article-newspaper","container-title":"San Bernardino Sun","title":"Prop.63 Funding Wanted","author":[{"family":"Wells","given":"Annette"}],"issued":{"date-parts":[["2005",3,15]]}}}],"schema":""} (Wells 2005b). This coincided with a shift in approach visible in the relabeling of county “mental” health departments into “behavioral” ones to incorporate addictive and disruptive conduct. This downplaying of “the individual’s internal or subjective understanding, motivations, and decisions” ADDIN ZOTERO_TEMP ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2ot4s255q3","properties":{"formattedCitation":"(Hudson 2018:32)","plainCitation":"(Hudson 2018:32)","noteIndex":0},"citationItems":[{"id":11636,"uris":[""],"uri":[""],"itemData":{"id":11636,"type":"article-journal","abstract":"Proliferation in the use of the terminology around behavioral mental health suggests, on one hand, an emerging field of service that integrates psychiatric, substance abuse, and related services. On the other hand, this development also raises questions about the coherence of this approach. This review explores the history, definitional issues, current trends, and available data on the impact of this field. It considers a variety of critiques of behavioral mental health, such as possibility that the field attempts to integrate fundamentally incompatible domains, that the term “behavioral mental health” is thus an oxymoron, and that it represents a co-optation by the insurance industry of traditional ideals of mental health and of behavioral medicine or as code for the implementation of a medical model that emphasizes short-term, behavioral, and psychopharmacological treatments at the expense of a truly biopsychosocial orientation. Other concerns include the focus on individual change and the effectiveness of behavioral health as a strategy for destigmatizing mental health. Recommendations for addressing the various barriers to realizing the ideals of behavioral mental health include revamping the role of managed care in oversight of treatment decisions, broadening the implementation of evidence-based treatment, and the development of treatment models that build on traditional social work practice models.","container-title":"Social Work","DOI":"10.1093/sw/swx048","ISSN":"0037-8046, 1545-6846","issue":"1","language":"en","page":"27-36","source":"Crossref","title":"Behavioral Mental Health: An Emerging Field of Service or an Oxymoron?","title-short":"Behavioral Mental Health","volume":"63","author":[{"family":"Hudson","given":"Christopher G"}],"issued":{"date-parts":[["2018"]]}},"locator":"32"}],"schema":""} (Hudson 2018:32) expanded the universe of people who could potentially receive treatment and the range of people qualified to identify them. An interviewee who led trainings in “Mental Health First Aid” for lay people explained, “We’re not teaching the DSM-V, but we want people to look at a behavior and think, ‘I wonder if there might be an underlying mental health issue’” (Interview, 7/7/17).The MHSA coupled low-intensity interventions scaled to low-severity problems with a new, more aggressive service model, Full-Service Partnerships (FSPs). FSPs were designed to send teams into the community to find people who were not receiving regular psychiatric treatment but who were cycling between hospitals, jails, and homeless shelters at high cost to public coffers ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aiof9tf75p","properties":{"formattedCitation":"(Gong 2019; Starks et al. 2017)","plainCitation":"(Gong 2019; Starks et al. 2017)","noteIndex":0},"citationItems":[{"id":3772,"uris":[""],"uri":[""],"itemData":{"id":3772,"type":"article-journal","container-title":"American Sociological Review","issue":"4","page":"664–689","title":"Between Tolerant Containment and Concerted Constraint: Managing Madness for the City and the Privileged Family","volume":"84","author":[{"family":"Gong","given":"Neil"}],"issued":{"date-parts":[["2019"]]}}},{"id":2960,"uris":[""],"uri":[""],"itemData":{"id":2960,"type":"article-journal","abstract":"Objective:The study evaluated the effect of California’s Mental Health Services Act (MHSA) on the structure, volume, location, and patient centeredness of Los Angeles County public mental health services.Methods:This prospective mixed-methods study (2006–2013) was based in five Los Angeles County public mental health clinics, all with usual care and three with full-service partnerships (FSPs). FSPs are MHSA-funded programs designed to “do whatever it takes” to provide intensive, recovery-oriented, team-based, integrated services for clients with severe mental illness. FSPs were compared with usual care on outpatient services received (claims data) and on organizational climate, recovery orientation, and provider-client working alliance (surveys and semistructured interviews), with regression adjustment for client and provider characteristics.Results:In the first year after admission, FSP clients (N=174) received significantly more outpatient services than did usual care clients (N=298) (5,238 versus 1,643 minutes, p<.001), and a larger proportion of these services were field based (22% versus 2%, p<.001). Compared with usual care clients, FSP clients reported more recovery-oriented services (p<.001) and a better provider-client working alliance (p=.01). Compared with usual care providers (N=130), FSP providers (N=42) reported more stress (p<.001) and lower morale (p<.001).Conclusions:Los Angeles County’s public mental health system was able to transform service delivery in response to well-funded policy mandates. For providers, a structure emphasizing accountability and patient centeredness was associated with greater stress, despite smaller caseloads. For clients, service structure and volume created opportunities to build stronger provider-client relationships and address their needs and goals.","container-title":"Psychiatric Services","DOI":"10.1176/appi.ps.201500390","ISSN":"1075-2730","issue":"6","journalAbbreviation":"PS","page":"587-595","source":"ps. (Atypon)","title":"System Transformation Under the California Mental Health Services Act: Implementation of Full-Service Partnerships in L.A. County","title-short":"System Transformation Under the California Mental Health Services Act","volume":"68","author":[{"family":"Starks","given":"Sarah L."},{"family":"Arns","given":"Paul G."},{"family":"Padwa","given":"Howard"},{"family":"Friedman","given":"Jack R."},{"family":"Marrow","given":"Jocelyn"},{"family":"Meldrum","given":"Marcia L."},{"family":"Bromley","given":"Elizabeth"},{"family":"Kelly","given":"Erin L."},{"family":"Brekke","given":"John S."},{"family":"Braslow","given":"Joel T."}],"issued":{"date-parts":[["2017"]]}}}],"schema":""} (Gong 2019; Starks et al. 2017). FSPs would then provide an exhaustive host of services, from medication to housing to help with welfare benefits. The Deputy Director of the California Department of Mental Health explained the paradox of this focus on bringing “underserved” people into a system that was rationing services for its current clients:Do you prioritize those who are not in the system, or do you prioritize those who are in the system? We were trying to make it consistent with what people who had voted on it were told…it was gonna reduce homelessness, you know, so that’s [people] who weren’t in the system, right? But that’s very frustrating to people who have been in the system and underserved.This medicalizing model depended on rationalization. As the Director of the Los Angeles Department of Mental Health explained, “In the long-run, [FSPs] will be overwhelmed by the need…So we need to use the early intervention strategies to slow down the stream of people being disabled by mental illness.”In fact, the MHSA actually forbade using its funds to finance existing services in public clinics, and its roll-out coincided with budget cuts that decreased the number of people receiving care in the public sector by a third from 2007 to 2009 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2b0t301vad","properties":{"formattedCitation":"(de S\\uc0\\u225{} 2011)","plainCitation":"(de Sá 2011)","noteIndex":0},"citationItems":[{"id":12508,"uris":[""],"uri":[""],"itemData":{"id":12508,"type":"article-newspaper","container-title":"Contra Costa Times","title":"Mental health spending creating haves and have-nots in California","author":[{"family":"Sá","given":"Karen","non-dropping-particle":"de"}],"issued":{"date-parts":[["2011",6,26]]}}}],"schema":""} (de Sá 2011). The most vocal critics of the MHSA I encountered were parents who had been thrust into the system by the need to advocate for care for a child who was not homeless, not incarcerated, but chronically ill. Some argued that “the mentally ill” were marginalized in the MHSA stakeholder process. As one dissenting proposal for reform insisted, “mental health and mental illness are not part of a continuum” and “behaviors of choice” like addiction “must be differentiated from behavioral by-products caused by symptoms” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a27oq08n2oj","properties":{"formattedCitation":"(LPS Reform Task Force 1999)","plainCitation":"(LPS Reform Task Force 1999)","noteIndex":0},"citationItems":[{"id":12423,"uris":[""],"uri":[""],"itemData":{"id":12423,"type":"report","event-place":"Long Beach, CA","publisher-place":"Long Beach, CA","title":"A New Vision for Mental Health Treatment Laws","author":[{"literal":"LPS Reform Task Force"}],"issued":{"date-parts":[["1999",2]]}}}],"schema":""} (LPS Reform Task Force 1999). Yet I saw little professional resistance to an approach centered on a continuum of behaviors. When I pointed out to a prominent psychiatrist that many programs seemed to underinvest in those with chronic illnesses, he replied, “I’m not worried at all that severe mental illness is being left out. The issue of severity, I like to say, is more a ‘state’ than a ‘trait’…Folks can be in deep trouble for a while, and then they may not be at the same level, and that is going to vary over time” (Interview, 1/5/17). The principle of scaling is now embedded in a set of formalized criteria that Californian clinicians use to place individuals on a series of ordinal measures of behaviors and service use. As the state Department of Health Care Services directed, new demands for care in the public system should be “assessed…through the use of a MediCal [California’s version of Medicaid] clinical tool” to determine “medical necessity” alongside consideration of “appropriate service usage” “cost and effectiveness” “service alternatives” and “potential fraud, waste, and abuse” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1vq8oint3o","properties":{"formattedCitation":"\\uldash{(Department of Health Care Services 2017:3)}","plainCitation":"(Department of Health Care Services 2017:3)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":3627,"uris":[""],"uri":[""],"itemData":{"id":3627,"type":"report","event-place":"Sacramento, CA","publisher-place":"Sacramento, CA","title":"MediCal Managed Care Plan Responsibilities for Outpatient Mental Health Services","author":[{"literal":"Department of Health Care Services"}],"issued":{"date-parts":[["2017",10,27]]}},"locator":"3"}],"schema":""} (DHCS 2017:3). Clients with “severe” impairments “in an important area of life functioning” go to specialty mental health services funded directly by individual counties, like FSPs. This public care is to be “titrat[ed]…by giving them [clients] what they need when they need it and not giving them more than they need when they don’t need it.” One legal advocacy group published a critical report noting that applying fixed criteria to clients in a fluctuating state meant they were “referred back and forth,” experienced “gaps in services,” and were “forced to change providers when the severity of their condition changes” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"afl39k2h05","properties":{"formattedCitation":"(Lewis and Coursolle 2017:6)","plainCitation":"(Lewis and Coursolle 2017:6)","noteIndex":0},"citationItems":[{"id":3629,"uris":[""],"uri":[""],"itemData":{"id":3629,"type":"report","event-place":"Los Angeles, CA","publisher":"National Health Law Program","publisher-place":"Los Angeles, CA","title":"Mental Health Services in Medi-Cal","author":[{"family":"Lewis","given":"Kim"},{"family":"Coursolle","given":"Abbi"}],"issued":{"date-parts":[["2017",1,12]]}},"locator":"6"}],"schema":""} (Lewis and Coursolle 2017:6). Yet for most interviewees in the field, this movement was precisely what a rationalized approach founded on an assumption of scaling should work towards: a dynamic and ongoing calibration of care to match how severe (or problematic) someone’s behaviors were. This would ensure that people did not stagnate on the continuum, instead pushing out the overserved to medicalize the underserved. Practices: Granting Services to Reduce ServicesThe clinic I studied served a much narrower population than the CMP, with most clients looking like the segment of patients the French called “real malades.” Yet the classificatory practices emerging from a principle of scaling differed enormously. Clinicians constrained their own discretion over how to allocate care with apparently objective behavioral criteria. One time the program director lectured, “As we know, when we say that we use discretion, it creates inequity—we serve the clients we like, and make the ones we don’t leave” (Fieldnotes, 1/11/19). Their decision-making reproduced the particular combination of medicalization and rationalization that structured California’s public mental health system as a whole. As part of a frequently-articulated concern about individuals not in care, the clinic had rolled out mobile crisis teams (MCT) and homeless outreach teams (HoT), which added to the prevention and screening services funded through the MHSA. Unlike in France, they accepted the city’s push to medicalize people with problematic behaviors, so long as the person could articulate at least a half-hearted demand for services. An MCT clinician presented the case of a 41-year-old white woman with “somatic symptom disorder.” Her intake sheet noted that she had seen HoT seventy times in the last year.MCT: She is in constant crisis in the community, and very high profile. We’ve paid for a few nights in a hotel just to calm her down.Intake Social Worker: And is she, like, homeless-on-the-street homeless?MCT: Yes. Her exaggerated somatic complaints—she claims her six-year-old has ‘whooping cough’—mean that she’s refusing to live in a shelter. She’s denying substance abuse, but we have collateral from the [homeless] encampment that says otherwise.Clinic Director: Oh—this is the one where she was living in a rat-infested, moldy RV, and the city took it away. She went to the city council meeting and talked so long they had to go into recess.MCT: Right. We have pressure from the city manager to do a full court press here. Initially, one clinician observed that this woman was not a “classic presentation” because she did not have schizophrenia, bipolar disorder, or depression. Rather, she had disruptive behaviors loosely tied to a diagnosis that was barely discussed. The director responded, “I agree it’s not a classic client. But the times are changin’. The system is more inclusive, and we have more and more non-typical people” (Fieldnotes, 12/7/18). Even as it solicited new clients, the clinic carefully modulated care among them through assignment into three teams, “Full-Service Partnership” (FSP), “Intensive Case Management” (ICM), and “Commitment to Community Living” (CCL). They used a flow chart spelling out internally-developed criteria for each level of care. The most involved discussions were about access to the city’s FSP team. It had a generous twelve-to-one client-to-staff ratio, the ability to go in teams to meet its sixty clients outside the clinic multiple times a week, and, perhaps most importantly, funds to pay for housing. This intensity of care did not exist at the French CMP. It was, unsurprisingly, expensive, at $18,000 per client per year. At the Clinic, the basic threshold for FSP was having three of the following risk factors: “Co-occurring substance abuse or medical conditions,” “Transitional-age youth or older adult,” “Repeated, recent hospitalizations [measured either in the number of days or admissions],” “Homelessness or risk of homelessness,” and “Criminal justice involvement.” The most easily objectified criteria, homelessness, and straightforwardly quantifiable, hospitalizations, were also the strongest arguments for getting someone into FSP (Table 2). The team debated the case of a 60-year-old black man who had schizophrenia. He was recently hospitalized for threating the employees of a local bookstore:MCT: So, do we know why he was being violent and disruptive?Intake: Alcohol. He seems motivated to go into recovery now, though. He brought himself in.Psychiatrist: Okay, but he should not be served [in person] in the clinic. He belongs on FSP and needs to be served in the community.FSP: What are his case management needs?Intake: I talked to him and asked, ‘Do you want to stay out of jail? Do you want to stay out of the hospital?’FSP: You’re a bit ‘leading the witness’ there…MCT: That’s what we do! Director: The problem is that what’s happening is an escalation, but he doesn’t meet FSP criteria based on his current use of the system. But he’s heading there.Intake: Can we qualify him based on our safety exception? He has had four 5150s [involuntary ER evaluations] in four months…MCT: Okay, we put him on FSP. But he won’t last long. In any case, this whole thing reeks of meth (Fieldnotes, 3/15/18).Here, clinicians disciplined their own emotional and intuitive response to the case by referring back to criteria ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"arifherbd3","properties":{"formattedCitation":"(Craciun 2018)","plainCitation":"(Craciun 2018)","noteIndex":0},"citationItems":[{"id":3369,"uris":[""],"uri":[""],"itemData":{"id":3369,"type":"article-journal","container-title":"American Journal of Sociology","DOI":"10.1086/695682","ISSN":"0002-9602, 1537-5390","issue":"4","language":"en","page":"959-1003","source":"CrossRef","title":"Emotions and Knowledge in Expert Work: A Comparison of Two Psychotherapies","title-short":"Emotions and Knowledge in Expert Work","volume":"123","author":[{"family":"Craciun","given":"Mariana"}],"issued":{"date-parts":[["2018"]]}}}],"schema":""} (Craciun 2018). Ordinal measures—does this person have a sufficient number of incarcerations, hospitalizations, or crisis contacts?—overwhelmed the typological one used in Paris—is this person severely ill? For ICM, the level of care one step lower, the key criterion was less about peoples’ overuse of services and more their inability to navigate other agencies’ services based on a “functional impairment.” When these potential clients arrived, some were asking for medication (rarely therapy), but equally frequently help applying for housing or obtaining government benefits (Table 3). One day, the team debated whether a middle-aged white man should continue to be served by ICM:ICM: He’s been calling asking to change case managers. He has been mad ever since he was kicked of SSDI [disability income]. Intake: Basically, he just wants housing. ICM: Honestly, he barely belongs here. He’s more anti-social than anything.Psychiatrist: There might be an underlying thought disorder, but it’s hard to know because he’s always on drugs. He’s definitely violent.MCT: I hate to go all ‘shrink’ on you, but do we think there’s a reason he’s so aggrieved? Director: It doesn’t matter. He’s ours. (Fieldnotes, 3/15/18).Many clinicians felt that the real origin of clients’ behaviors were substances. As the head of FSP observed, “I’ve been doing this for 18 years, and now we have 80% of people for whom the main issue is substance abuse. We have fewer and fewer people with what I would call classic severe mental illness.” But while the classificatory practices of the clinic opened up space for debating the medical and psychological origins of clients’ problems, clinicians ultimately acceded to scalable behavioral criteria that largely ignored them. The Clinic’s lowest long-term level of care, Commitment to Community Living, provided ongoing monitoring for stabilized clients who were housed and no longer using emergency services. The CCL team had at least some clients who weren’t taking medication at all, but whose housing vouchers or parole officers required they be “in treatment.” In turn, CCL clients could be smoothly bumped back up to ICM when their behaviors threatened their life in the community. This was the case of a 44-year-old white woman with schizophrenia:CCL: She has no recent hospitalizations or criminal justice contacts, with limited heroin use. But right now, she’s at risk of losing housing because she’s not paying rent. That means homelessness for her and her child. She’s refusing meds but will accept housing support.Director: So she’s disengaged with any case management?CCL: Not really, just not taking the meds. Director: So the idea is, with more regular case management, she’ll engage more with treatment? MCT: It doesn’t matter, a threat to housing is enough…FSP: Are there any behavioral issues that might lead her to stop paying rent?CCL: She had white powder on her nose when we saw her.Director: Okay, we move her up to ICM based on her housing status (Fieldnotes, 8/3/18).Cases like these were emblematic of how clearly-defined criteria provided the basis for consensual calibration of care. The classificatory practices rationalized allocation based on the principle that mental illness manifested itself in fluctuating behaviors more than types of people. Contradictions: Deservingness and Dialing DownWhile in France, contradictions between principle and practice hinged on the tension between categorical exclusions and the universalistic ethos of “public service,” in California it was between behavioral criteria and clinicians’ conceptions of deservingness and need. As one psychologist noted, “We are concerned about equity…[because] women are typically not as violent…[and] have less criminal justice involvement. They are more likely to have PTSD [Post-Traumatic Stress Disorder] and engage in avoidant behavior. So how do we make sure they’re also getting care?” (Interview, 1/19/18). One day, an intern presented the case of a woman diagnosed with major depression and PTSD whose behaviors placed her low on the measures used to evaluate new cases:Director: So she’s already getting medication from [Private Clinic]?Intern: Yeah, she’s a very tough one [to decide if she qualifies for the Clinic’s services].ICM: It says she was homeless for 27 years but now she’s… actually housed.Intern: If you can believe it, she has a bachelor’s degree and was working. But she lost her job and her insurance and… if you look at her, she’s cut herself from here to here [motions the entire length of her arm].Director: To be clear, there haven’t been any hospitalizations, just two visits to the ER?MCT: Yes but… look at this history. She has had to prostitute herself. There’s a crazy history of abuse. She could really benefit from a strong relationship with a therapist and a bit of case management. It’s true she’s been savvy and stayed out of the hospital…ICM: I’m seeing from the intake that there are multiple rapes and suicide attempts.The team continued to express dismay at the suffering coming through in her write-up, but the Director moved to bring the conversation to a close:Director: Well, she doesn’t really meet our criteria. There’s no hospitalization, and she’s not homeless. But we know that we under-serve women and people with trauma tend to under-report their symptoms. So given that, I’m okay with serving her.ICM: This really isn’t a fit for our services. Could we just refer her out [to a private therapist]?MCT: I’m not sure she’ll actually make it…Director: Let’s try it [ICM]. She has trauma, and the idea is to develop a therapeutic relationship. We’ll focus on the clinical dimension, rather than trying to get her to do stuff in terms of case management (Fieldnotes, 1/11/19).The case was remarkable for its asymmetry with France. The CMP frequently rejected people who were showing up in the system as a result of perceived character flaws or substance use; the Clinic rapidly qualified these individuals for services. But in California someone whose severe symptoms or suicidality might have easily bumped them into the range of real malade needed an exception. The push of people into care via techniques of medicalization in the U.S. is closely tied to rationalized protocols for ultimately scaling treatment in the public system down to zero. Some struggled with how this required that clinicians deliver interventions and seek outcomes that were not particularly clinical in nature. The intake social worker explained: If you look at the history of the mental health system in California…at some point, they [state government] started pushing us to stop doing therapy, which was what was interesting and we were trained to do, and focus more on problem solving, like teaching people how to use a phone and pay their bills (Interview, 3/15/19)In this framework, progress for clients was as much about invisibility as stability ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2bcen0ikvu","properties":{"formattedCitation":"(see, also, Gong 2019)","plainCitation":"(see, also, Gong 2019)","noteIndex":0},"citationItems":[{"id":3772,"uris":[""],"uri":[""],"itemData":{"id":3772,"type":"article-journal","container-title":"American Sociological Review","issue":"4","page":"664–689","title":"Between Tolerant Containment and Concerted Constraint: Managing Madness for the City and the Privileged Family","volume":"84","author":[{"family":"Gong","given":"Neil"}],"issued":{"date-parts":[["2019"]]}},"prefix":"see, also, "}],"schema":""} (see, also, Gong 2019). They could move to lower levels of care by containing their behaviors in ways that hid them from the radar screens of police or the city council:ICM: This is a client who was homeless in a tent, now she’s in a supported housing. She gets along with her building manager… a bit less so with the other tenants, but it’s okay. She still has delusions and hears voices all the time, but she adamantly does not want medication. She needs to stay with us to keep her housing voucher.Intake: I remember her! She was really lovely until she talked about voices telling her to stab people…ICM: She hasn’t been violent.MCT: Well, good work. Let’s move her down [to CCL] (Fieldnotes, 3/15/19).The woman was refusing the main medical service CCL provided, medication management. But continued check-ins from a Clinic case manager would allow her to keep her housing. This, combined with her behavioral control, was on balance a positive outcome. Yet even as this approach to classification was necessary to meet documentation requirements and keep clients moving, some recognized how it clashed with their own professional identity. One disaffected psychologist, who had been trained in a now-dissident psychoanalytic tradition in the ‘60s ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1lt6kp4r01","properties":{"formattedCitation":"(see Craciun 2018; Whooley 2019)","plainCitation":"(see Craciun 2018; Whooley 2019)","noteIndex":0},"citationItems":[{"id":3369,"uris":[""],"uri":[""],"itemData":{"id":3369,"type":"article-journal","container-title":"American Journal of Sociology","DOI":"10.1086/695682","ISSN":"0002-9602, 1537-5390","issue":"4","language":"en","page":"959-1003","source":"CrossRef","title":"Emotions and Knowledge in Expert Work: A Comparison of Two Psychotherapies","title-short":"Emotions and Knowledge in Expert Work","volume":"123","author":[{"family":"Craciun","given":"Mariana"}],"issued":{"date-parts":[["2018"]]}},"prefix":"see"},{"id":12605,"uris":[""],"uri":[""],"itemData":{"id":12605,"type":"book","abstract":"Psychiatry has always aimed to peer deep into the human mind, daring to cast light on its darkest corners and untangle its thorniest knots, often invoking the latest medical science in doing so. But, as Owen Whooley’s sweeping new book tells us, the history of American psychiatry is really a record of ignorance. On the Heels of Ignorance begins with psychiatry’s formal inception in the 1840s and moves through two centuries of constant struggle simply to define and redefine mental illness, to say nothing of the best way to treat it. Whooley’s book is no antipsychiatric screed, however; instead, he reveals a field that has muddled through periodic reinventions and conflicting agendas of curiosity, compassion, and professional striving. On the Heels of Ignorance draws from intellectual history and the sociology of professions to portray an ongoing human effort to make sense of complex mental phenomena using an imperfect set of tools, with sometimes tragic results.","event-place":"Chicago, IL","ISBN":"978-0-226-61638-4","language":"English","number-of-pages":"304","publisher":"University of Chicago Press","publisher-place":"Chicago, IL","source":"Amazon","title":"On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing","title-short":"On the Heels of Ignorance","author":[{"family":"Whooley","given":"Owen"}],"issued":{"date-parts":[["2019"]]}}}],"schema":""} (see Craciun 2018; Whooley 2019), noted, “If somebody comes in and says, ‘I was so depressed, now I’m feeling so much better, the meds are working, I’m optimistic,’ you can’t write that [in the medical file] any more. You have to show that improvement results in behaviors” (Interview, 3/19/19).A more visible contradiction was that scaling downward after a certain point rarely worked. As Dobransky ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2ms51vb99q","properties":{"formattedCitation":"(2014:37)","plainCitation":"(2014:37)","noteIndex":0},"citationItems":[{"id":3601,"uris":[""],"uri":[""],"itemData":{"id":3601,"type":"book","event-place":"New Brunswick, NJ","ISBN":"978-0-8135-6308-4","language":"English","number-of-pages":"192","publisher":"Rutgers University Press","publisher-place":"New Brunswick, NJ","source":"Amazon","title":"Managing Madness in the Community: The Challenge of Contemporary Mental Health Care","title-short":"Managing Madness in the Community","author":[{"family":"Dobransky","given":"Kerry Michael"}],"issued":{"date-parts":[["2014"]]}},"locator":"37","suppress-author":true}],"schema":""} (2014:37) observes, “recovery” as defined in the U.S. increasingly means not just “independence in general” but “especially, independence from the mental health system.” Yet virtually no one actually left the Clinic through a smooth dialing down of care (Table 2). More frequently, people disappeared (33%), refused services (30%), or moved away (17%):Director: This is the case of a forty-six-year-old white male, diagnosed with schizoaffective disorder. He’s been disengaged since he left his housing in 2016. He was on CCL, moved up to ICM, and then was hospitalized for psychosis. He was the one talking about ‘teaching the Star Trek Opera.’ We managed to get him into a sub-acute facility, but he left after one night. The only contact we’ve had was [FSP] seeing him in his bathrobe near [lake]. We filed a missing person’s report and… well…MCT: We should close. I always say, ‘an open chart is not treatment.’Intake: We’ll get him the next time around [hospitalization] (Fieldnotes, 4/15/18).30% of new clients had previously been seen in the clinic; of those, 60% had come for an intake but never actually received treatment.In short, as in France, clients floated in and out of care. Unlike in France, those cases were formally closed, keeping the number of people on the Clinic’s rolls down and creating an image of ongoing successful transitions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a20ov09tgba","properties":{"formattedCitation":"(Lara-Mill\\uc0\\u225{}n 2017)","plainCitation":"(Lara-Millán 2017)","noteIndex":0},"citationItems":[{"id":2995,"uris":[""],"uri":[""],"itemData":{"id":2995,"type":"chapter","abstract":"The state is central to social scientific and historical inquiry today, reflecting its importance in domestic and international affairs. States kill, coerce, fight, torture, and incarcerate, yet they also nurture, protect, educate, redistribute, and invest. It is precisely because of the complexity and wide-ranging impacts of states that research on them has proliferated and diversified. Yet, too many scholars inhabit separate academic silos, and theorizing of states has become dispersed and disjointed. This book aims to bridge some of the many gaps between scholarly endeavors, bringing together scholars from a diverse array of disciplines and perspectives who study states and empires. The book offers not only a sample of cutting-edge research that can serve as models and directions for future work, but an original conceptualization and theorization of states, their origins and evolution, and their effects.","container-title":"The Many Hands of the State: Theorizing Political Authority and Social Control","event-place":"New York, NY","ISBN":"978-1-316-50113-9","language":"English","page":"81-102","publisher":"Cambridge University Press","publisher-place":"New York, NY","source":"Amazon","title":"States as a Series of People Exchanges","editor":[{"family":"Morgan","given":"Kimberly J."},{"family":"Orloff","given":"Ann Shola"}],"author":[{"family":"Lara-Millán","given":"Armando"}],"issued":{"date-parts":[["2017"]]}}}],"schema":""} (Lara-Millán 2017). This reinforced the background assumption that, to borrow the terminology of the psychiatrist quoted above, mental illness was a “state”—even in the face of people whose pathology seemed to be a persistent “trait.” These practices at times contradicted clinicians’ professional identities and sense of deservingness. But it was hard for them to imagine another classificatory system that would offer the seeming fairness of objective measures of behaviors or that would avoid locking people who were supposed to exist on a continuum of mental health into a fixed category of “mentally ill.” ConclusionContemporary medical professionals are buffeted by competing demands to deliver quality care at limited costs in line with tightening external requirements for documentation and evaluation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ad6vim9mku","properties":{"formattedCitation":"(Cain 2019; Livne 2019; Reich 2014)","plainCitation":"(Cain 2019; Livne 2019; Reich 2014)","noteIndex":0},"citationItems":[{"id":3568,"uris":[""],"uri":[""],"itemData":{"id":3568,"type":"article-journal","abstract":"There is no doubt that the organization of healthcare is currently shifting, partly in response to changing macrolevel policies. Studies of healthcare policies often do not consider healthcare workers’ experiences of policy change, thus limiting our understanding of when and how policies work. This article uses longitudinal qualitative data, including participant observation and semistructured interviews with workers within hospice care as their organizations shifted in response to a Medicare policy change. Prior to the policy change, I find that the main innovation of hospice—the interdisciplinary team—is able to resist logics from the larger medical institution. However, when organizational pressures increase, managers and workers adjust in ways that reinforce medical logics and undermine the interdisciplinary team. These practices illustrate processes by which rationalization of healthcare affects workers’ experiences and the type of care available to patients.","container-title":"Journal of Health and Social Behavior","DOI":"10.1177/0022146518825379","ISSN":"0022-1465","issue":"1","journalAbbreviation":"J Health Soc Behav","language":"en","page":"3-17","source":"SAGE Journals","title":"Agency and Change in Healthcare Organizations: Workers’ Attempts to Navigate Multiple Logics in Hospice Care","title-short":"Agency and Change in Healthcare Organizations","volume":"60","author":[{"family":"Cain","given":"Cindy L."}],"issued":{"date-parts":[["2019"]]}}},{"id":3626,"uris":[""],"uri":[""],"itemData":{"id":3626,"type":"book","event-place":"Cambridge, MA","publisher":"Harvard University Press","publisher-place":"Cambridge, MA","title":"Values at the End of Life","author":[{"family":"Livne","given":"Roi"}],"issued":{"date-parts":[["2019"]]}}},{"id":3149,"uris":[""],"uri":[""],"itemData":{"id":3149,"type":"book","abstract":"Health care costs make up nearly a fifth of U.S. gross domestic product, but health care is a peculiar thing to buy and sell. Both a scarce resource and a basic need, it involves physical and emotional vulnerability and at the same time it operates as . . .","event-place":"Princeton, NJ","publisher":"Princeton University Press","publisher-place":"Princeton, NJ","title":"Selling Our Souls","URL":"","author":[{"family":"Reich","given":"Adam D."}],"accessed":{"date-parts":[["2017",9,6]]},"issued":{"date-parts":[["2014"]]}}}],"schema":""} (Cain 2019; Livne 2019; Reich 2014). Mental health clinicians, in particular, are torn between their commitments to patients and their obligations to funders and regulators ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a9lvt34sip","properties":{"formattedCitation":"(Dobransky 2014; Luhrmann 2000; Scheid 2004)","plainCitation":"(Dobransky 2014; Luhrmann 2000; Scheid 2004)","noteIndex":0},"citationItems":[{"id":3601,"uris":[""],"uri":[""],"itemData":{"id":3601,"type":"book","event-place":"New Brunswick, NJ","ISBN":"978-0-8135-6308-4","language":"English","number-of-pages":"192","publisher":"Rutgers University Press","publisher-place":"New Brunswick, NJ","source":"Amazon","title":"Managing Madness in the Community: The Challenge of Contemporary Mental Health Care","title-short":"Managing Madness in the Community","author":[{"family":"Dobransky","given":"Kerry Michael"}],"issued":{"date-parts":[["2014"]]}}},{"id":3613,"uris":[""],"uri":[""],"itemData":{"id":3613,"type":"book","abstract":"With sharp and soulful insight, T. R. Luhrmann examines the world of psychiatry, a profession which today is facing some of its greatest challenges from within and without, as it continues to offer hope to many. At a time when mood-altering drugs have revolutionized the treatment of the mentally ill and HMO’s are forcing caregivers to take the pharmocological route over the talking cure, Luhrmann places us at the heart of the matter and allows us to see exactly what is at stake. Based on extensive interviews with patients and doctors, as well as investigative fieldwork in residence programs, private psychiatric hospitals, and state hospitals, Luhrmann’s groundbreaking book shows us how psychiatrists develop and how the enormous ambiguities in the field affect its practitioners and patients.","event-place":"New York","ISBN":"978-0-679-74493-1","language":"English","number-of-pages":"352","publisher":"Alfred A. Knopf","publisher-place":"New York","source":"","title":"Of Two Minds: The Growing Disorder in American Psychiatry","title-short":"Of Two Minds","author":[{"family":"Luhrmann","given":"T. M."}],"issued":{"date-parts":[["2000"]]}}},{"id":3587,"uris":[""],"uri":[""],"itemData":{"id":3587,"type":"book","abstract":"Tie a Knot and Hang On is an analysis of mental health care work that crosses the borders of diverse sociological traditions. The work seeks to understand the theoretical and empirical linkages between environmental pressures and activities and how these intersect with organizations and individuals. The work draws upon a research tradition that sees the issue of mental health care in terms of institutional pressures and normative values. The author provides a description and a sociological analysis of mental health care work, emphasizing the interaction of professionally generated norms that guide the &quot;emotional labor&quot; of mental health care workers, and the organizational contexts within which mental health care is provided. She concludes with a discussion of emerging institutional forces that will shape the mental health care system in the future. These forces are having greater impact than ever before as managed care comes to have a huge fiscal as well as institutional impact on the work of mental health professionals. Scheid&#39;s book is a brilliant, nuanced effort to explain the institutional demands for efficiency and cost containment with the professional ethics that emphasize quality care for the individual. The book is essential reading for those interested in mental health care organizations and the providers responding to these seemingly larger, abstract demands. The work offers a rich mixture not just of the problems faced by mental health care personnel, but the equilibrium currently in place ?? an equilibrium that shapes the theory of the field, no less than the activities of its practitioners. Teresa L. Scheid is associate professor of sociology, at the University of North Carolina at Charlotte. She has published widely in the area, including major essays in Sociology of Health and Illness, Sociological Quarterly, Perspectives on Social Problems, and The Journal of Applied Behavioral Science.","event-place":"Hawthorne, NY","ISBN":"978-1-4128-4003-3","language":"en","number-of-pages":"212","publisher":"Transaction Publishers","publisher-place":"Hawthorne, NY","source":"Google Books","title":"Tie a Knot and Hang On: Providing Mental Health Care in a Turbulent Environment","title-short":"Tie a Knot and Hang On","author":[{"family":"Scheid","given":"Teresa L."}],"issued":{"date-parts":[["2004"]]}}}],"schema":""} (Dobransky 2014; Luhrmann 2000; Scheid 2004). Medicalization pulls them towards expanding the boundaries of the mental health system and rationalization towards restricting the allocation of care within it. This paper analyzes what comes out on the other end of this mix of mandates and why it varies across different countries’ fields of public mental health.I have advanced an explanation that hinges on identifying the distinctive principles that structure classificatory struggles over policy and regulation as well as a practical framework for classificatory practices. My attempt is to get beyond approaches that see a straightforward “homology” between official classification schemes and practices ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a28ln2mglmc","properties":{"formattedCitation":"(Bourdieu 1996)","plainCitation":"(Bourdieu 1996)","noteIndex":0},"citationItems":[{"id":394,"uris":[""],"uri":[""],"itemData":{"id":394,"type":"book","abstract":"In this major new work, Pierre Bourdieu examines the distinctive forms of power—political, intellectual, bureaucratic, and economic—by means of which contemporary societies are governed. What kinds of competence are claimed by the bureaucrats and technocrats who govern us? And how do those who govern gain our recognition and acquiescence? Bourdieu examines in detail the work of consecration that is carried out by elite education systems—in France by the grande écoles, in the United States by the Ivy League schools, and in England by Oxford and Cambridge. Today, this \"state nobility\" has at its disposal an unprecedented range of powers and distinctive titles to justify its privilege. Bourdieu shows how it is the heir—structural and sometimes genealogical—of the noblesse de robe, which, in order to consolidate its position in relation to other forms of power, had to construct the modern state and the republican myths, meritocracy, and civil service that went along with it. Combining ethnographic description, historical documentation, statistical analysis, and theoretical argument, Bourdieu develops a wide-ranging and highly original account of the forms of power and governance that have come to prevail in our society today.","event-place":"Cambridge, UK","ISBN":"978-0-8047-3346-5","language":"en","number-of-pages":"506","publisher":"Polity Press","publisher-place":"Cambridge, UK","source":"Google Books","title":"The State Nobility: Elite Schools in the Field of Power","title-short":"The State Nobility","author":[{"family":"Bourdieu","given":"Pierre"}],"translator":[{"family":"Clough","given":"Lauretta"}],"issued":{"date-parts":[["1996"]],"season":"1989"}}}],"schema":""} (Bourdieu 1996) or which focus on multiple, fragmented, and competing logics that are hard to add up to any coherent pattern ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wkh7lqqu","properties":{"formattedCitation":"(Cain 2019; Dobransky 2014; McPherson and Sauder 2013)","plainCitation":"(Cain 2019; Dobransky 2014; McPherson and Sauder 2013)","noteIndex":0},"citationItems":[{"id":3568,"uris":[""],"uri":[""],"itemData":{"id":3568,"type":"article-journal","abstract":"There is no doubt that the organization of healthcare is currently shifting, partly in response to changing macrolevel policies. Studies of healthcare policies often do not consider healthcare workers’ experiences of policy change, thus limiting our understanding of when and how policies work. This article uses longitudinal qualitative data, including participant observation and semistructured interviews with workers within hospice care as their organizations shifted in response to a Medicare policy change. Prior to the policy change, I find that the main innovation of hospice—the interdisciplinary team—is able to resist logics from the larger medical institution. However, when organizational pressures increase, managers and workers adjust in ways that reinforce medical logics and undermine the interdisciplinary team. These practices illustrate processes by which rationalization of healthcare affects workers’ experiences and the type of care available to patients.","container-title":"Journal of Health and Social Behavior","DOI":"10.1177/0022146518825379","ISSN":"0022-1465","issue":"1","journalAbbreviation":"J Health Soc Behav","language":"en","page":"3-17","source":"SAGE Journals","title":"Agency and Change in Healthcare Organizations: Workers’ Attempts to Navigate Multiple Logics in Hospice Care","title-short":"Agency and Change in Healthcare Organizations","volume":"60","author":[{"family":"Cain","given":"Cindy L."}],"issued":{"date-parts":[["2019"]]}}},{"id":3601,"uris":[""],"uri":[""],"itemData":{"id":3601,"type":"book","event-place":"New Brunswick, NJ","ISBN":"978-0-8135-6308-4","language":"English","number-of-pages":"192","publisher":"Rutgers University Press","publisher-place":"New Brunswick, NJ","source":"Amazon","title":"Managing Madness in the Community: The Challenge of Contemporary Mental Health Care","title-short":"Managing Madness in the Community","author":[{"family":"Dobransky","given":"Kerry Michael"}],"issued":{"date-parts":[["2014"]]}}},{"id":3388,"uris":[""],"uri":[""],"itemData":{"id":3388,"type":"article-journal","abstract":"Drawing on a 15-month ethnographic study of a drug court, we investigate how actors from different institutional and professional backgrounds employ logical frameworks in their micro-level interactions and thus how logics affect day-to-day organizational activity. While institutional theory presumes that professionals closely adhere to the logics of their professional groups, we find that actors exercise a great deal of agency in their everyday use of logics, both in terms of which logics they adopt and for what purpose. Available logics closely resemble tools that can be creatively employed by actors to achieve individual and organizational goals. A close analysis of court negotiations allowed us to identify the logics that are available to these actors, show how they are employed, and demonstrate how their use affects the severity of the court’s decisions. We examine the ways in which professionals with four distinct logical orientations—the logics of criminal punishment, rehabilitation, community accountability, and efficiency—use logics to negotiate decisions in a drug court. We provide evidence of the discretionary use of these logics, specifying the procedural, definitional, and dispositional constraints that limit actors’ discretion and propose an explanation for why professionals stray from their “home” logics and “hijack” the logics of other court actors. Examining these micro-level processes improves our understanding of how local actors use logics to manage institutional complexity, reach consensus, and get the work of the court done.","container-title":"Administrative Science Quarterly","DOI":"10.1177/0001839213486447","ISSN":"0001-8392","issue":"2","journalAbbreviation":"Administrative Science Quarterly","language":"en","page":"165-196","source":"SAGE Journals","title":"Logics in Action: Managing Institutional Complexity in a Drug Court","title-short":"Logics in Action","volume":"58","author":[{"family":"McPherson","given":"Chad Michael"},{"family":"Sauder","given":"Michael"}],"issued":{"date-parts":[["2013"]]}}}],"schema":""} (Cain 2019; Dobransky 2014; McPherson and Sauder 2013). Classificatory principles are a set of ontological assumptions about what is being classified and epistemological ones about what kinds of categories are appropriate for doing so. They thus structure the form that classification takes even when the substance of specific classifications is contested. If ethnography reveals fragmentation, comparative research allows us to piece those fragments back together to show how systems are based on distinctive principles: bounding in France and scaling in the U.S. (see Table 4 for a summary). In both cases, these principles were embedded in the restructuring of the public mental health field to include care outside hospitals in the 1960s. Except in moments where outside actors attempted to upend the mental health field, like when state administrators in France sought to introduce payment by the activity, these principles have deepened over time as policy conflicts and classificatory challenges are resolved in ways consistent with them. Over three-hundred interviews across multiple French departments and two American states strongly suggest that, despite local idiosyncrasies, the underlying principles of bounding and scaling are dominant in each. I have largely not asked why the principles adopted in the 1960s differed, nor whether this reflects a consistent cross-national difference. Certainly, other scholars have found parallels between practices of classification across domains in each country. For example, in measuring intelligence or assessing the costs and benefits of infrastructure projects, France has put faith in holistic expert judgment and the U.S. in external quantitative measures ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a11b42ulpbg","properties":{"unsorted":true,"formattedCitation":"(Carson 2007; Porter 1996; cf. Christin 2018)","plainCitation":"(Carson 2007; Porter 1996; cf. Christin 2018)","noteIndex":0},"citationItems":[{"id":2393,"uris":[""],"uri":[""],"itemData":{"id":2393,"type":"book","abstract":"How have modern democracies squared their commitment to equality with their fear that disparities in talent and intelligence might be natural, persistent, and consequential? In this wide-ranging account of American and French understandings of merit, talent, and intelligence over the past two centuries, John Carson tells the fascinating story of how two nations wrestled scientifically with human inequalities and their social and political implications. Surveying a broad array of political tracts, philosophical treatises, scientific works, and journalistic writings, Carson chronicles the gradual embrace of the IQ version of intelligence in the United States, while in France, the birthplace of the modern intelligence test, expert judgment was consistently prized above such quantitative measures. He also reveals the crucial role that determinations of, and contests over, merit have played in both societies--they have helped to organize educational systems, justify racial hierarchies, classify army recruits, and direct individuals onto particular educational and career paths. A contribution to both the history of science and intellectual history, The Measure of Merit illuminates the shadow languages of inequality that have haunted the American and French republics since their inceptions.","event-place":"Princeton, NJ","ISBN":"978-0-691-01715-0","language":"English","number-of-pages":"424","publisher":"Princeton University Press","publisher-place":"Princeton, NJ","source":"","title":"The Measure of Merit: Talents, Intelligence, and Inequality in the French and American Republics, 1750-1940","title-short":"The Measure of Merit","author":[{"family":"Carson","given":"John"}],"issued":{"date-parts":[["2007"]]}}},{"id":3542,"uris":[""],"uri":[""],"itemData":{"id":3542,"type":"book","event-place":"Princeton, NJ","publisher":"Princeton University Press","publisher-place":"Princeton, NJ","title":"Trust in Numbers: The Pursuit of Objectivity in Science and Public Life","title-short":"Trust in numbers","author":[{"family":"Porter","given":"Theodore M."}],"issued":{"date-parts":[["1996"]]}}},{"id":3381,"uris":[""],"uri":[""],"itemData":{"id":3381,"type":"article-journal","abstract":"Sociological studies often emphasize the role of metrics in broader processes of convergence and homogenization. Yet numbers can take on different meanings depending on their contexts. This article focuses on the case of journalism, a field transformed by quantification in the form of “clicks.” Drawing on ethnographic material gathered at two news websites—one in New York, the other in Paris—it documents important differences in the uses and meanings assigned to audience metrics in the United States and France. At the U.S. website, editors make significant decisions based on metrics, but staff journalists are relatively unconcerned by them. At the French website, however, editors are conflicted about metrics, but staff writers fixate on them. To understand these differences, this article analyzes how the trajectories of the U.S. and French journalistic fields affect newsroom dynamics. It shows how cultural differences can be reproduced at a time of technological convergence.","container-title":"American Journal of Sociology","DOI":"10.1086/696137","ISSN":"0002-9602","issue":"5","journalAbbreviation":"American Journal of Sociology","page":"1382-1415","source":"www-journals-uchicago-edu.libproxy.berkeley.edu (Atypon)","title":"Counting Clicks: Quantification and Variation in Web Journalism in the United States and France","title-short":"Counting Clicks","volume":"123","author":[{"family":"Christin","given":"Angèle"}],"issued":{"date-parts":[["2018"]]}},"prefix":"cf."}],"schema":""} (Carson 2007; Porter 1996; cf. Christin 2018). Even further afield, the French classify wine based on their provenance from incommensurable terroirs—a fuzzy mixture of land, history, and practices—while U.S. viticulturers aspire to improve their rankings on 100-point rating scales based on “objective” sensory criteria ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a4c0giqs0b","properties":{"formattedCitation":"(Fourcade 2016)","plainCitation":"(Fourcade 2016)","noteIndex":0},"citationItems":[{"id":2711,"uris":[""],"uri":[""],"itemData":{"id":2711,"type":"article-journal","abstract":"We can think of three basic principles of classificatory judgment for comparing things and people. I call these judgments nominal (oriented to essence), cardinal (oriented to quantities), and ordinal (oriented to relative positions). Most social orders throughout history are organized around the intersection of these different types. In line with the ideals of political liberalism, however, democratic societies have developed an arsenal of institutions to untangle nominal and ordinal judgments in various domains of social life. In doing so, I suggest, they have contributed to the parallel amplification of both. In this article, I specifically discuss the socio-technical channels through which ordinal judgments are now elaborated, a process I call ordinalization. I conclude by exploring the political and economic possibilities of a society in which ordinal processes are ubiquitous.","container-title":"Sociological Theory","DOI":"10.1177/0735275116665876","ISSN":"0735-2751, 1467-9558","issue":"3","journalAbbreviation":"Sociological Theory","language":"en","page":"175-195","source":"stx.","title":"Ordinalization","volume":"34","author":[{"family":"Fourcade","given":"Marion"}],"issued":{"date-parts":[["2016"]]}}}],"schema":""} (Fourcade 2016). It is a task for further research to see whether the intuition of Durkheim and Mauss ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1dmk4seoie","properties":{"unsorted":true,"formattedCitation":"(1967:24; see also Bourdieu 2015)","plainCitation":"(1967:24; see also Bourdieu 2015)","noteIndex":0},"citationItems":[{"id":1949,"uris":[""],"uri":[""],"itemData":{"id":1949,"type":"book","event-place":"Chicago, IL","ISBN":"0-226-17334-8","number-of-pages":"143","publisher":"University of Chicago Press","publisher-place":"Chicago, IL","source":"","title":"Primitive Classification","author":[{"family":"Durkheim","given":"Emile"},{"family":"Mauss","given":"Marcel"}],"translator":[{"family":"Needham","given":"Rodney"}],"issued":{"date-parts":[["1967"]],"season":"1903"}},"locator":"24","suppress-author":true},{"id":2852,"uris":[""],"uri":[""],"itemData":{"id":2852,"type":"book","abstract":"What is the nature of the modern state? How did it come into being and what are the characteristics of this distinctive field of power that has come to play such a central role in the shaping of all spheres of social, political and economic life? In this major work the great sociologist Pierre Bourdieu addresses these fundamental questions. Modifying Max Weber’s famous definition, Bourdieu defines the state in terms of the monopoly of legitimate physical and symbolic violence, where the monopoly of symbolic violence is the condition for the possession and exercise of physical violence. The state can be reduced neither to an apparatus of power in the service of dominant groups nor to a neutral site where conflicting interests are played out: rather, it constitutes the form of collective belief that structures the whole of social life. The ‘collective fiction’ of the state ? a fiction with very real effects - is at the same time the product of all struggles between different interests, what is at stake in these struggles, and their very foundation. While the question of the state runs through the whole of Bourdieu’s work, it was never the subject of a book designed to offer a unified theory. The lecture course presented here, to which Bourdieu devoted three years of his teaching at the Collège de France, fills this gap and provides the key that brings together the whole of his research in this field. This text also shows ‘another Bourdieu’, both more concrete and more pedagogic in that he presents his thinking in the process of its development. While revealing the illusions of ‘state thought’ designed to maintain belief in government being oriented in principle to the common good, he shows himself equally critical of an ‘anti-institutional mood’ that is all too ready to reduce the construction of the bureaucratic apparatus to the function of maintaining social order. At a time when financial crisis is facilitating the hasty dismantling of public services, with little regard for any notion of popular sovereignty, this book offers the critical instruments needed for a more lucid understanding of the wellsprings of domination.","event-place":"Cambridge, UK","ISBN":"978-0-7456-6329-6","language":"English","number-of-pages":"480","publisher":"Polity","publisher-place":"Cambridge, UK","source":"Amazon","title":"On the State","author":[{"family":"Bourdieu","given":"Pierre"}],"issued":{"date-parts":[["2015"]]}},"prefix":"see also "}],"schema":""} (1967:24; see also Bourdieu 2015) that each society has a distinctive “logical system” holds at scales above that of a meso-level field.This approach seeks to help reconcile older aspirations of comparative cultural sociology with contemporary theorizing. Dated theories of “national culture” might explain the difference between my cases as a sign that the French value “solidarity” and Americans “markets.” But as Bonikowski ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a1j0vdm4gs7","properties":{"formattedCitation":"(2017:148)","plainCitation":"(2017:148)","noteIndex":0},"citationItems":[{"id":3329,"uris":[""],"uri":[""],"itemData":{"id":3329,"type":"chapter","container-title":"Everyday Nationhood","page":"147-174","title":"Nationhood as Cultural Repertoire: Collective Identities and Political Attitudes in France and Germany","author":[{"family":"Bonikowski","given":"Bart"}],"editor":[{"family":"Skey","given":"M."},{"family":"Antonsich","given":"M."}],"issued":{"date-parts":[["2017"]]}},"locator":"148","suppress-author":true}],"schema":""} (2017:148) notes, these have been rightly “discarded…as analytically problematic and empirically inaccurate.” But, he observes, a shift towards seeing culture as a fragmented toolkit may have the “unintended consequence…[of] the abandonment of country-level comparisons.” I do not find a set of widely-held normative commitments that might explain why rationalization and medicalization appear to be more advanced in one country (given, for example, the extensive rationalization of other parts of the French health system). Indeed, I have shown contradictions between the classificatory principles of the mental health system and other aspects of clinicians’ professional identities and the broader logics of each country’s welfare state. But classificatory principles help identify how actors in different countries nonetheless approach novel problems with distinctive heuristics and assumptions, without assuming their responses are preordained.This article speaks to ongoing debates on the basis of medical decision-making. Scholars have assumed that, in an era of medicalization, “the diagnosis determines the institutional fate” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GkRnA3aP","properties":{"formattedCitation":"(Castel 1988:150)","plainCitation":"(Castel 1988:150)","noteIndex":0},"citationItems":[{"id":3455,"uris":[""],"uri":[""],"itemData":{"id":3455,"type":"book","abstract":"Robert Castel's work constitutes an important recent body of critical scholarship on psychiatry and its history. Available for the first time in English, this book examines the rise of French psychiatry in the nineteenth century. It argues that this development must be situated in the specific context of the foundation of a new social order after the French Revolution. The author examines the disputed borderlines between the judiciary and psychiatry, emphasizing that the role of the medical profession is to create rather than capture new territory. In this vein, he shares key concepts with Michel Foucault, with whom he was associated early in his career.","event-place":"Paris, France","ISBN":"978-0-7456-0348-3","language":"Inglés","number-of-pages":"272","publisher":"Polity Press","publisher-place":"Paris, France","source":"","title":"The Regulation of Madness: The Origins of Incarceration in France","title-short":"The Regulation of Madness","author":[{"family":"Castel","given":"Robert"}],"translator":[{"family":"Halls","given":"W. D."}],"issued":{"date-parts":[["1988"]],"season":"1977"}},"locator":"150"}],"schema":""} (Castel 1988:150) of severely mentally ill persons. This is consistent with Foucault’s ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a14o4h9jesq","properties":{"formattedCitation":"(1994)","plainCitation":"(1994)","noteIndex":0},"citationItems":[{"id":2904,"uris":[""],"uri":[""],"itemData":{"id":2904,"type":"book","event-place":"New York","publisher":"Vintage","publisher-place":"New York","title":"The Birth of the Clinic: An Archaeology of Medical Perception","author":[{"family":"Foucault","given":"Michel"}],"translator":[{"family":"Sheridan Smith","given":"A.M."}],"issued":{"date-parts":[["1994"]],"season":"1963"}},"suppress-author":true}],"schema":""} (1994) depiction of the modern “medical gaze” as fixated on identifying symptoms to make precise diagnoses, an orientation encapsulated by the question “where does it hurt?” The DSM, in particular, appears as a “rationalizing force” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0p9DEisp","properties":{"formattedCitation":"(Brown and Cooksey 1989:1135)","plainCitation":"(Brown and Cooksey 1989:1135)","noteIndex":0},"citationItems":[{"id":3615,"uris":[""],"uri":[""],"itemData":{"id":3615,"type":"article-journal","abstract":"Over the past 30 years, a number of important changes have occured in the mental health system. This paper examines the origins and effects of these changes, utilizing a political-economic framework. Three main areas are emphasized: the increasing absorption of mental health care into the health care system in general; the ways in which care has been transferred away from traditional settings and responsibilities; and the movement of for-profit chains into mental health services. Particular focus is placed on the rationalizing and monopolizing tendencies increasingly evidenced in the mental health field.","container-title":"Social Science & Medicine","DOI":"10.1016/0277-9536(89)90005-1","ISSN":"0277-9536","issue":"11","journalAbbreviation":"Social Science & Medicine","page":"1129-1138","source":"ScienceDirect","title":"Mental health monopoly: Corporate trends in mental health services","title-short":"Mental health monopoly","volume":"28","author":[{"family":"Brown","given":"Phil"},{"family":"Cooksey","given":"Elizabeth"}],"issued":{"date-parts":[["1989"]]}},"locator":"1135"}],"schema":""} (Brown and Cooksey 1989:1135) that homogenizes this diagnostic practice across countries. But even within the U.S., the DSM is the subject of virulent debate over diagnostic categories’ underlying assumptions about mental illness ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2q7i7fpt1a","properties":{"formattedCitation":"(Schnittker 2017; Whooley 2019)","plainCitation":"(Schnittker 2017; Whooley 2019)","noteIndex":0},"citationItems":[{"id":3184,"uris":[""],"uri":[""],"itemData":{"id":3184,"type":"book","abstract":"Mental illness is many things at once: It is a natural phenomenon that is also shaped by society and culture. It is biological but also behavioral and social. Mental illness is a problem of both the brain and the mind, and this ambiguity presents a challenge for those who seek to accurately classify psychiatric disorders. The leading resource we have for doing so is the American Psychiatric Association’s Diagnostic and Statistical Manual, but no edition of the manual has provided a decisive solution, and all have created controversy. In The Diagnostic System, the sociologist Jason Schnittker looks at the multiple actors involved in crafting the DSM and the many interests that the manual hopes to serve. Is the DSM the best tool for defining mental illness? Can we insure against a misleading approach?Schnittker shows that the classification of psychiatric disorders is best understood within the context of a system that involves diverse parties with differing interests. The public wants a better understanding of personal suffering. Mental-health professionals seek reliable and treatable diagnostic categories. Scientists want definitions that correspond as closely as possible to nature. And all parties seek definitive insight into what they regard as the right target. Yet even the best classification system cannot satisfy all of these interests simultaneously. Progress toward an ideal is difficult, and revisions to diagnostic criteria often serve the interests of one group at the expense of another. Schnittker urges us to become comfortable with the socially constructed nature of categorization and accept that a perfect taxonomy of mental-health disorders will remain elusive. Decision making based on evolving though fluid understandings is not a weakness but an adaptive strength of the mental-health profession, even if it is not a solid foundation for scientific discovery or a reassuring framework for patients.","event-place":"New York, NY","ISBN":"978-0-231-54459-7","publisher":"Columbia University Press","publisher-place":"New York, NY","source":"Columbia University Press","title":"The Diagnostic System: Why the Classification of Psychiatric Disorders Is Necessary, Difficult, and Never Settled","title-short":"The Diagnostic System","author":[{"family":"Schnittker","given":"Jason"}],"issued":{"date-parts":[["2017"]]}}},{"id":12605,"uris":[""],"uri":[""],"itemData":{"id":12605,"type":"book","abstract":"Psychiatry has always aimed to peer deep into the human mind, daring to cast light on its darkest corners and untangle its thorniest knots, often invoking the latest medical science in doing so. But, as Owen Whooley’s sweeping new book tells us, the history of American psychiatry is really a record of ignorance. On the Heels of Ignorance begins with psychiatry’s formal inception in the 1840s and moves through two centuries of constant struggle simply to define and redefine mental illness, to say nothing of the best way to treat it. Whooley’s book is no antipsychiatric screed, however; instead, he reveals a field that has muddled through periodic reinventions and conflicting agendas of curiosity, compassion, and professional striving. On the Heels of Ignorance draws from intellectual history and the sociology of professions to portray an ongoing human effort to make sense of complex mental phenomena using an imperfect set of tools, with sometimes tragic results.","event-place":"Chicago, IL","ISBN":"978-0-226-61638-4","language":"English","number-of-pages":"304","publisher":"University of Chicago Press","publisher-place":"Chicago, IL","source":"Amazon","title":"On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing","title-short":"On the Heels of Ignorance","author":[{"family":"Whooley","given":"Owen"}],"issued":{"date-parts":[["2019"]]}}}],"schema":""} (Schnittker 2017; Whooley 2019). Despite this, my argument is that there is a shared, practical understanding of mental illness that is the condition for functioning in each country’s public mental health field ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2qqtkr5g2i","properties":{"formattedCitation":"(see Bourdieu 1990)","plainCitation":"(see Bourdieu 1990)","noteIndex":0},"citationItems":[{"id":1991,"uris":[""],"uri":[""],"itemData":{"id":1991,"type":"book","abstract":"Our usual representations of the opposition between the \"civilized\" and the \"primitive\" derive from willfully ignoring the relationship of distance our social science sets up between the observer and the observed. In fact, the author argues, the relationship between the anthropologist and his object of study is a particular instance of the relationship between knowing and doing, interpreting and using, symbolic mastery and practical mastery—or between logical logic, armed with all the accumulated instruments of objectification, and the universally pre-logical logic of practice.In this, his fullest statement of a theory of practice, Bourdieu both sets out what might be involved in incorporating one's own standpoint into an investigation and develops his understanding of the powers inherent in the second member of many oppositional pairs—that is, he explicates how the practical concerns of daily life condition the transmission and functioning of social or cultural forms.The first part of the book, \"Critique of Theoretical Reason,\" covers more general questions, such as the objectivization of the generic relationship between social scientific observers and their objects of study, the need to overcome the gulf between subjectivism and objectivism, the interplay between structure and practice (a phenomenon Bourdieu describes via his concept of the habitus), the place of the body, the manipulation of time, varieties of symbolic capital, and modes of domination.The second part of the book, \"Practical Logics,\" develops detailed case studies based on Bourdieu's ethnographic fieldwork in Algeria. These examples touch on kinship patterns, the social construction of domestic space, social categories of perception and classification, and ritualized actions and exchanges.This book develops in full detail the theoretical positions sketched in Bourdieu's Outline of a Theory of Practice. It will be especially useful to readers seeking to grasp the subtle concepts central to Bourdieu's theory, to theorists interested in his points of departure from structuralism (especially fom Lévi-Strauss), and to critics eager to understand what role his theory gives to human agency. It also reveals Bourdieu to be an anthropological theorist of considerable originality and power.","event-place":"Stanford, CA","ISBN":"978-0-8047-2011-3","language":"en","number-of-pages":"348","publisher":"Stanford University Press","publisher-place":"Stanford, CA","source":"Google Books","title":"The Logic of Practice","author":[{"family":"Bourdieu","given":"Pierre"}],"translator":[{"family":"Nice","given":"Richard"}],"issued":{"date-parts":[["1990"]]}},"prefix":"see "}],"schema":""} (see Bourdieu 1990). These largely elide more abstract debates, suggesting the need to be careful in assuming, as many exposés of the DSM do, that diagnostic revisions translate into changes on the ground ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a22a135c6n3","properties":{"formattedCitation":"(Conrad 2007; Horwitz 2001)","plainCitation":"(Conrad 2007; Horwitz 2001)","noteIndex":0},"citationItems":[{"id":2977,"uris":[""],"uri":[""],"itemData":{"id":2977,"type":"book","abstract":"Over the past half-century, the social terrain of health and illness has been transformed. What were once considered normal human events and common human problems—birth, aging, menopause, alcoholism, and obesity—are now viewed as medical conditions. For better or worse, medicine increasingly permeates aspects of daily life.Building on more than three decades of research, Peter Conrad explores the changing forces behind this trend with case studies of short stature, social anxiety, \"male menopause,\" erectile dysfunction, adult ADHD, and sexual orientation. He examines the emergence of and changes in medicalization, the consequences of the expanding medical domain, and the implications for health and society. He finds in recent developments—such as the growing number of possible diagnoses and biomedical enhancements—the future direction of medicalization. Conrad contends that the impact of medical professionals on medicalization has diminished. Instead, the pharmaceutical and biotechnical industries, insurance companies and HMOs, and the patient as consumer have become the major forces promoting medicalization. This thought-provoking study offers valuable insight into not only how medicalization got to this point but also how it may continue to evolve.","event-place":"Baltimore, MD","ISBN":"978-0-8018-8585-3","language":"English","number-of-pages":"224","publisher":"Johns Hopkins University Press","publisher-place":"Baltimore, MD","source":"Amazon","title":"The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders","title-short":"The Medicalization of Society","author":[{"family":"Conrad","given":"Peter"}],"issued":{"date-parts":[["2007"]]}}},{"id":2251,"uris":[""],"uri":[""],"itemData":{"id":2251,"type":"book","abstract":"In this surprising book, Allan V. Horwitz argues that our current conceptions of mental illness as a disease fit only a small number of serious psychological conditions and that most conditions currently regarded as mental illness are cultural constructions, normal reactions to stressful social circumstances, or simply forms of deviant behavior. \n\n\"Thought-provoking and important. . .Drawing on and consolidating the ideas of a range of authors, Horwitz challenges the existing use of the term mental illness and the psychiatric ideas and practices on which this usage is based. . . . Horwitz enters this controversial territory with confidence, conviction, and clarity.\"—Joan Busfield, \n\n\"Horwitz properly identifies the financial incentives that urge therapists and drug companies to proliferate psychiatric diagnostic categories. He correctly identifies the stranglehold that psychiatric diagnosis has on research funding in mental health. Above all, he provides a sorely needed counterpoint to the most strident advocates of disease-model psychiatry.\"—Mark Sullivan,Journal of the American Medical Association\n\n\"Horwitz makes at least two major contributions to our understanding of mental disorders. First, he eloquently draws on evidence from the biological and social sciences to create a balanced, integrative approach to the study of mental disorders. Second, in accomplishing the first contribution, he provides a fascinating history of the study and treatment of mental disorders. . . from early asylum work to the rise of modern biological psychiatry.\"—Debra Umberson, Quarterly Review of Biology","event-place":"Chicago, IL","publisher":"University of Chicago Press","publisher-place":"Chicago, IL","source":"press.uchicago.edu","title":"Creating Mental Illness","author":[{"family":"Horwitz","given":"Allan?V."}],"issued":{"date-parts":[["2001"]]}}}],"schema":""} (Conrad 2007; Horwitz 2001). Revealingly, while diagnosis figured into allocating care in both countries, it was determinative in neither. In Paris the core question was instead “who are you?” as clinicians oriented themselves less to what patients had but who they were. In California, what clients were suffering from was secondary to the question “What are you doing?” (in terms of service utilization) and “what are you capable of doing?” (in navigating a fragmented safety net).This paper offers a cautionary take on sweeping claims about expanding rationalization and medicalization in health systems. “Medicalization” in the U.S., as measured by an ever-expanding pile up of diagnoses, implies that patients are receiving bio-medical treatments even though they might just be getting help with housing or a phone. This process seems to have made an unsolicited if steady advance in French psychiatry. But aggregate statistics hide just how many of French patients were receiving minimal care or simply lingering administratively because, on principle, the CMP did not close dossiers. Meanwhile, if the U.S. seems to have “rationalized” care by stepping people down, a striking proportion of closures happened because people simply disappeared. This fact that was less distressing to clinicians because they knew they would be back anyway. In a world of triumphant bio-medicine and inexorable rationalization, the fact that French and American mental health professionals see themselves as similarly beleaguered by these pressures is unsurprising. The extent to which distinctive principles of classification serve as a bulwark against convergence is more notable.Critics of rationalization in the public mental health system are quick to decry the way it has made care “a commodity” and clinics “businesses…providing a low-cost service” to “consumers” ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GlXV3Z5X","properties":{"formattedCitation":"(Scheid 2004:74)","plainCitation":"(Scheid 2004:74)","noteIndex":0},"citationItems":[{"id":3587,"uris":[""],"uri":[""],"itemData":{"id":3587,"type":"book","abstract":"Tie a Knot and Hang On is an analysis of mental health care work that crosses the borders of diverse sociological traditions. The work seeks to understand the theoretical and empirical linkages between environmental pressures and activities and how these intersect with organizations and individuals. The work draws upon a research tradition that sees the issue of mental health care in terms of institutional pressures and normative values. The author provides a description and a sociological analysis of mental health care work, emphasizing the interaction of professionally generated norms that guide the &quot;emotional labor&quot; of mental health care workers, and the organizational contexts within which mental health care is provided. She concludes with a discussion of emerging institutional forces that will shape the mental health care system in the future. These forces are having greater impact than ever before as managed care comes to have a huge fiscal as well as institutional impact on the work of mental health professionals. Scheid&#39;s book is a brilliant, nuanced effort to explain the institutional demands for efficiency and cost containment with the professional ethics that emphasize quality care for the individual. The book is essential reading for those interested in mental health care organizations and the providers responding to these seemingly larger, abstract demands. The work offers a rich mixture not just of the problems faced by mental health care personnel, but the equilibrium currently in place ?? an equilibrium that shapes the theory of the field, no less than the activities of its practitioners. Teresa L. Scheid is associate professor of sociology, at the University of North Carolina at Charlotte. She has published widely in the area, including major essays in Sociology of Health and Illness, Sociological Quarterly, Perspectives on Social Problems, and The Journal of Applied Behavioral Science.","event-place":"Hawthorne, NY","ISBN":"978-1-4128-4003-3","language":"en","number-of-pages":"212","publisher":"Transaction Publishers","publisher-place":"Hawthorne, NY","source":"Google Books","title":"Tie a Knot and Hang On: Providing Mental Health Care in a Turbulent Environment","title-short":"Tie a Knot and Hang On","author":[{"family":"Scheid","given":"Teresa L."}],"issued":{"date-parts":[["2004"]]}},"locator":"74"}],"schema":""} (Scheid 2004:74). By looking comparatively, though, we can analyze the impacts of bounding and scaling not relative to some idealized image of ever-abundant care but to the very real trade-offs clinicians must make. A more expansive public system in France did not mean a straightforwardly more inclusionary one. For example, while clinicians in California vocalized their concern that their focus on behaviors meant they under-served women, the CMP arguably under-served men whose gendered cultural scripts channeled their distress into addiction or anti-social behavior. Classificatory principles provide an intelligible, often automatic way to orient action in a complex and contested field. They frequently legitimate the exclusions they themselves generate.Works Cited ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY Abbott, Andrew. 1988. The System of Professions: An Essay on the Division of Expert Labor. Chicago, IL: University of Chicago Press.Abend, Gabriel. 2014. The Moral Background: An Inquiry into the History of Business Ethics. Princeton, NJ: Princeton University Press.Auerback, Alfred. 1959. “The Short-Doyle Act.” California Medicine 90(5):335–38.Ayme, Jean. 1995. Chroniques de la psychiatrie publique. A travers l’histoire d’un syndicat. 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Chicago, IL: University of Chicago Press.Zerubavel, Eviatar. 1996. “Lumping and Splitting: Notes on Social Classification.” Sociological Forum 11(3):421–433.TablesTable 1: New Clients / Patients in the Clinic (California) and CMP (Paris)Clinic (California)CMP (Paris)GenderMaleFemaleTrans60%37%3%39%61%[None identified]RaceWhiteBlackLatinxAsianOther40%40%8%5%6%N/AOriginAll ForeignNorth African /ArabAfricanEuropeanOtherN/A28%12%3%7%5%Average Age4639DiagnosisPsychosis*BiPolar DisorderMoodPersonalityPTSD/TraumaOtherNone / Unclear52%21%22%9%14%8%N/A14%4%35%5%5%9%10%Substance UseAnyMethOpioids / HeroinMarijuanaAlcoholCocaine / Halluc.65%30%0%37%36%9%30%N/A<1%8%16%4%* Includes Schizophrenia, Schizo-Affective Disorder, and Psychosis NoS, rarely differentiated in France. Includes Dementia, Intellectual Disabilities, Insomnia, Eating Disorders, Obsessive-Compulsive Disorder, and Somatoform Disorders. In the U.S., patients could have multiple diagnoses.In France, addiction could be a stand-alone condition: in the U.S., it was always coupled with another diagnosis. For the U.S., this includes only ‘active’ or ‘recent’ substance use; for France, it excludes use (almost always alcohol) deemed unproblematic or ‘festive’.Table 2: Decisions and ReasoningClinic (California)CMP (Paris)Level of Care AssignedFull-Service PartnershipIntensive Case ManagementCommitment to Community LivingExtended TherapyDefer DecisionRefer OutClose12%40%6%3%6%6%27%HospitalizationSecteur PsychiatristIntern (Medical Trainee)Private PractitionerDeferOther*4%61%15%12%1%7%Reason for a Higher Level of CareHigh Service UseHomelessness / Risk to HousingHigh Case Management NeedsSeverity / DecompensationDanger to Self / SuicidalityDanger to Others / RiskCriminal Justice InvolvementLow Engagement / No DemandVulnerabilityCo-Morbidities23%20%20%15%8%8%7%7%5%5%“Isolated”, “Fragile”, or “Vulnerable”Risk to FamilyLack of ResourcesUncertainty About SituationSeverityPrior Secteur TreatmentRisk to Self27%18%13%13%11%5%5%Reasons for a Lower Level of Care or Referral OutStable Housing / HousedLow Service UseStabilityLow EngagementHigh EngagementTreated ElsewhereLow Danger/ RiskNot Mental Illness26%18%14%12%9%5%5%3%No DemandPsychological / ReactionalNot SevereNot PsychiatricSecteur InappropriateCan Pay Private DoctorNot UrgentAdministrative19%18%16%13%8%8%8%4%Reasons for ClosureDisappearedRefuses ServicesMovedReceiving Services ElsewhereInstitutionalized / Incarcerated33%30%17%13%6%N/AN/AThis table codes instances where a reason for a decision was explicitly articulated. In many cases, especially in France, no reason was explicitly stated and decisions were made without discussion. Although the reasoning was usually clear, I have not inferred motivations in constructing this table.* Such as an addiction specialist. Such as not having an address in the secteur (France) or having a chart open with another provider (CA).Table 3: Reasons for ConsultationClinic (California)CMP (Paris)Referral SourceSocial ServicesHospitalSelfOther Public MHFamily / FriendPrivate Provider*Courts / JailCrisis Services18%18%14%14%11%7%5%5%4%14%34%7%5%16%3%17%Stated DemandMedical TreatmentAdministrativeResistant / OpposedPsychological SupportNone/Unclear37%36%10%7%7%13%7%29%32%8%* Such as help filling in paperwork for disability benefits, housing, or the judicial system. For France, this would be “liberal psychiatrist / psychologist,” “generalist doctor,” a doctor of another specialty, or a work doctor (médecin de travail). In the U.S., these were rarely solo practitioners but primary care or specialty mental health clinics for people on Medicaid.In France, characterized as demands for “support”, “advice”, “talking”, or “psychotherapy.”Table 4: Classification in France and the United StatesFrance – BoundingUnited States - ScalingPrinciple of ClassificationClassification of persons based on nominal categories; mentally ill as discrete group.Classification of behaviors based on ordinal scales; all individuals on a continuum of mental health.Medicalization and RationalizationLogic encourages resistance to medicalization and creates barriers to rationalization.Logic promotes medicalization and necessitates as well as facilitates rationalization.Classificatory PracticesUse of professional judgment to allocate care based on three categories: “real malades,” people with “psychic troubles,” and those with problems that are “not psy”; hierarchical decision-making.Use of formalized tools to calibrate intervention based on objective criteria of service use, functional impairments, and behaviors; debate between clinicians.Contradictions Conflict over focus on a narrow group of malades and mission of public service; contradiction between commitment to permanent care and the reality of patients moving in and out.Conflict over prioritizing clients with behavioral problems versus clinical need and deservingness; contradiction between emphasis on titrating care downward and reality of client dependence. ................
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