This article examines the ways in which psychiatrists differentially deploy schizophrenia and addiction diagnoses among white, privately insured patients in comparison with black and Latino patients in a public psychiatric unit. Drawing on critical race theory and the anthropology of moral agency, the article tracks the ways in which the overlapping and competing diagnostic frames of schizophrenia and addiction are structured by, and structure, the personhood and political position of those who are subjected to them. It ends by identifying and tracking these logics of diagnosis and treatment, and their racially stratifying influence, in recent calls for integration of mental health with physical health care. Enhancing the agency of people who are subject to psychiatric diagnoses, and dampening the racializing and segregating impulse of diagnoses, ultimately requires clinical rejection of codified “evidence‐based medicine” in favor of spaces that serve, following Cheryl Mattingly, as moral laboratories for creating social selves.

The Duality of Diagnosis Jonathan1 was brought to the inpatient unit of a private hospital where I was a resident training in psychiatry, his hands raw and cracked from hundreds of washings with industrial cleaners and bleach designed to kill the bacteria that he knew were invading his body. After an injection of antipsychotics for agitation and paranoia, he slept in his bed as the director, the social worker of the unit, and I elicited a careful history from his parents. A gifted college student, Jonathan had been sidetracked by these episodes before. His parents noted that they often coincided with increased marijuana use. Jonathan's urine drug test, positive for marijuana use, confirmed our anticipated diagnosis of substance‐induced psychosis. Within three days, the attending psychiatrist on the unit asked the social worker on the team and me to discharge Jonathan to a private psychiatrist for addiction‐focused psychotherapy and tapering of his antipsychotic medication. Two weeks later, I was reassigned to the inpatient unit of a large public hospital where I did an intake interview with Ibrahim. Ibrahim accused the FBI of tapping his phone and wiring his bedroom in an effort to peg him as a terrorist. He had torn up his room looking for implanted devices in the walls and behind the moldings. He'd lost his messenger job by opening packages that seemed suspicious. Like Jonathan, he'd been hospitalized before with these symptoms, and like Jonathan, he had urine toxicology showing marijuana use. Unlike Jonathan, he was disconnected from his family and had no one advocating for him to be spared a stigmatizing diagnosis of psychotic disorder that would follow him as a part of his patient record. Our treatment team gave him a diagnosis of schizophrenia and referred him to a public psychiatry clinic dedicated to treating chronic psychosis. The diagnostic difference between these cases was patterned by race and class, but the reasons for this pattern were not obvious to outsiders. The contrast of Jonathan's preoccupation with contagion and alien invaders of his otherwise protective (white) skin on one hand, with Ibrahim's preoccupation with state control and incarceration on the other, was significant given their divergent life courses. Jonathan was the son of two professional parents, who were present upon his hospitalization and likely influenced his psychiatrist's assessment of him and his best interests. He aspired to law school. A diagnosis of schizophrenia would not allow him to follow in his parents’ footsteps; marijuana dependence would render him more “treatable”—in other words, redeemable. In contrast, Ibrahim was African American, alienated from his family, and had been arrested for charges related to his psychosis. He had converted to Islam in prison, and, after his assault in a public shelter postrelease, had found temporary housing with members of local mosques, at least until they tired of his accusations. The treatment team wanted to keep him housed and out of prison. In their minds, Social Security represented a possible source of income for him, but due to a 1996 federal law excluding substance‐use disorders as Social Security eligible, only his psychosis would qualify him for benefits (Hansen, Bourgois, and Drucker 2013). In fact, any hint of substance use as a cause of his symptoms would put his application in jeopardy. Aware of this and seeking to secure support for Ibrahim, the treatment team dutifully focused on his chronicity and the resistance of his psychosis to treatment in his Social Security application, downplaying the role that his continued marijuana use might have had. These kinds of moments reveal the ways that clinical teams make patients into moral subjects that will be deemed deserving by the state, putting racially coded policies into clinical practice in ways that are structurally overdetermined by the limited options open to people like Ibrahim. As Cheryl Mattingly points out in her study of the “moral laboratories” of everyday life, “moral striving seems to matter a great deal to people in all sorts of societies. [Yet] What constitutes the good life may vary widely from society to society” (Mattingly 2014, 11). And moral striving may also vary from clinic to clinic, where mental health providers’ pursuit of the good may vary widely by the patients’ race and class, the good being structurally predetermined before a patient is even seen by institutional racism that shapes possibilities for benefits and for care. The moral strivings of clinical practitioners, policymakers, and advocates therefore work in concert to produce diagnoses, treatment, and lives that, I argue, ultimately sharpen race and class divides in unanticipated ways. Thus, the “first‐person perspective” of practitioners on relations of care reveals how categories like race and class in health care become “real…the way that reality presents itself to us as something ‘out there’ only through our own engagement with it” (13). In the cases of Jonathan and Ibrahim, however, clinical practitioners’ engagement with reality is shaped by racialized institutional structures that delimit the subjective experience of clinicians within relations of care. At stake in this racialized diagnostic divide is whether people who are psychiatrically diagnosed are left with the ability to exercise moral agency. Although the term “moral agency” has a long history in Western philosophical debates, from Immanuel Kant to Jeremy Bentham to John Rawls, and has more recent purchase in anthropological theories of the culturally contextual nature of morality (Mattingly 2014; Robins 2013), here I use “moral agency” in a more specific way that is articulated in Neely Myer's ethnographic analysis of the trajectories of people diagnosed with schizophrenia (Myers 2015, 2016). She finds that a central dilemma of the diagnosed is their erosion of self‐in‐relation‐to‐others. A crucial element to their stories of success or failure in recovery after diagnosis is their ability to rebuild this relational self—a “social basis for self respect” in which they exercise “autobiographical power.” This often hinges on resources ranging from cultural capital, such as having a doctoral‐level education allowing one to draw on one's personal experience with psychosis to refashion oneself as a mental health professional, to social capital, working as a peer discussion leader or member of a spiritual or religious community. In addition to these dynamics as described by Myers, I argue that the type of diagnosis given and the manner in which it is treated in itself may serve as a resource for, or a detriment to, moral agency. In this article, I draw on my own clinical engagements with psychosis and addiction over 12 years of psychiatric training and practice, as well as a reanalysis of patient and provider interviews from a five‐year NIH‐funded study of the introduction of opioid maintenance treatments for addiction into public primary care practices, to demonstrate how patients are rendered morally repairable or morally recovered based on an intersection of race and class that have grown out of a moral division between addiction (for which patients are responsible but which also makes them moral agents) and psychotic disorder (for which patients are not responsible but which robs them of agency). This division has left addiction and psychotic disorder spatially, biomedically, and racially segregated from one another in psychiatry. Ironically, the same logics are at play in primary care clinics’ melding of addiction and psychosis with physical health in an effort to “integrate” care. The separation of addiction and psychosis in psychiatry produces two entities that might otherwise have blended: self‐medication of psychosis on one hand, and substance induced psychosis on the other. Their segregation solves problems of middle‐class social reproduction and moral economies of stratified mental health care. But it also produces failures in the form of college students for whom addiction treatment cannot help toward graduation and psychotic young men whose antipsychotic medications cannot keep them off the streets. And even the agency afforded those diagnosed with addiction is racially stratified, in that white patients with substance‐use disorder are more likely to be clinically treated (Blume, Resor, and Kantin 2009), and black and Latinos with substance‐use disorders are more likely to be sentenced to prison (Alexander 2010). On the other hand, efforts to integrate “behavioral health care” (the new euphemism for addictions and mental health) with primary physical health care also stratify people by guarding the white race and middle‐class in a less stigmatizing setting for care. Segregation of addiction from mental health, and integration of behavioral health with primary care, have paradoxically similar effects. They reveal futures and potentialities cut short by clinical failures to contain moral and medical divides. These divides, as demonstrated by Jonathan and Ibrahim's encounters with mental health care, underscore how race and class shapes clinical responses. Here I will analyze how these responses shape trajectories of recovery, care, and moral repair.

A Hierarchy of Diagnoses The received wisdom among schizophrenia scientists and addiction scientists is that if clinicians, and eventually the popular culture, would accept schizophrenia and addiction as biologically based, the stigma and social isolation of the people affected would dissipate. Moral judgments should presumably falter in the face of evidence of differences in brain architecture, neurophysiology, and genetic markers distinguishing the psychotic from the nonpsychotic and the addicted from the nonaddicted. In practice, of course, this has not been a clean break. Although surveyed Americans see schizophrenia and addiction as more biological than they did a decade ago, their biological explanatory model does not reduce stigma as it was hoped—rather, those surveyed believe addiction and schizophrenia are irreversible traits that increase sufferers’ propensity to social rejection (Pescosolido et al. 2010). In addition, the diagnosis of paranoid schizophrenia in particular was historically developed in an era of civil rights activism by white psychiatrists seeking to dismiss the political claims of African‐American men as due to paranoia (Metzl 2010), serving to further marginalize them. At the same time, however, clinical distinctions between addiction and psychosis that are based on moral and racial distinctions abound. One of the great puzzles in US psychiatry is why psychosis and mood disorders are treated on different units, and by different practitioners, than addiction. When I trained in psychiatry, I was repeatedly informed that the majority of people with psychosis and severe mood disorders use nonprescribed psychoactive substances, and the majority of people who use nonprescribed psychoactive substances also have symptoms of psychosis and/or mood disorders. As my addiction psychiatry fellowship director said, “They are the same patients.” In emergency rooms and on hospital units across the United States, clinical teams spend days to weeks determining whether the symptoms they are treating are due primarily to substance use, or primarily to psychotic and mood symptoms that sufferers “self ‐medicate” with substances. Once they settle on a diagnosis, they transfer patients either to an addictions clinic or to a general mental health clinic that excludes people with “primary addiction.” These two types of clinics are often regulated by separate state entities, are paid different rates using different insurance codes, and employ different psychotherapies, although increasingly they prescribe psychiatric medications from the same drug classes regardless of diagnosis. For example, New York State has two separate agencies that license and regulate addiction treatment on one hand, and mental health treatment, on the other. The two agencies have separate funding streams, oversight, and training requirements. Rarely do the two agencies communicate with each other. This pattern persists despite decades of professional acknowledgment that the vast majority of patients are “comorbid”—diagnosable with both addiction and a mental illness such as a psychotic or severe mood disorder—and that their outcomes are better when they are treated for both simultaneously by dually trained teams (Drake et al. 2001). As a result, staff in addictions clinics complain about patients who are too distracted by psychosis (or, when treated, too sedated by their antipsychotics) to be mindful of their triggers or to reorient their thinking away from illegal substances with cognitive behavioral therapy. The staff of general mental health clinics complain about hidden substance use that they do not feel qualified to help patients manage. The professional lore is that many generations of clinical practitioners have advocated for integration of the two treatment systems, for one set of clinics capable of treating “Mentally Ill and Chemically Addicted” (MICA) patients, “dual diagnosis,” or, more recently, “comorbid” patients. These movements well up every decade or so, get small grants for experimental units that report relative success, and then fade away. Separate funding streams mean different state agencies have stakes in accounting for patients separately (Barry and Huskamp 2011; Drake et al. 2001). Political support for mental health and addiction services are weak (Bastiampillai, Sharfstein, & Allison 2016); therefore, politicians have few incentives to worry about the quality of care in either. Or so it is said. After years of clinical practice in both private and public sectors, I noticed that this diagnostic segregation mirrors forms of race and class segregation in which psychiatric practice is a critical participant. I wondered if something more was at stake in the systemic negation of the duality of diagnosis. What if the stratifying distinctions between addiction and psychosis, between substance‐induced psychosis and self‐medicated psychosis, were not a bureaucratic accident? What if the separation between mental health and addiction treatment systems was not simply an inconvenience and gap in logic, but served to sort and rank people in invisible, apparently “color blind” ways? Addiction, for its part, is diagnosed, rendered legible, responded to through prisms of race and class. For instance, it serves as a permanent biological trait for those who are consumers of patented maintenance medications, such as white middle‐class buprenorphine (commercially known as Suboxone) (Netherland and Hansen 2017). At the same time, it serves as a moral trait for purposes of minimum sentencing and mass incarceration under drug laws that are disproportionately enforced in unruly black and Latino inner cities. This juxtaposition of attributions of the biological and moral nature of addiction as a trait demonstrates a continuity with earlier claims of biological inferiority and constitutional weakness in the racial discourse of psychiatry (Metzl 2010). Given this racialized history, alternating biological and moral attributions to addiction only contribute to the virulence of stigma. Either way, addiction has a different political and moral valence than psychosis, in that psychosis renders diagnosed people blameless even if marginal. But what if they also use narcotics, exercising the agency to be “bad patients,” to make bad choices against medical advice? People who have symptoms of both addiction and psychosis reveal key tensions and contradictions in the ways US psychiatry renders some patients morally redeemable and others not, a moral reckoning that often takes place along lines of race and class. The hierarchy and racial coloring of these two systems plays out in nuanced ways. For instance, I have observed that psychotic‐disorder diagnoses are less often given in the private setting in which Jonathan was treated and are more common in public clinics. White patients are disproportionately diagnosed with mood disorders and black patients with schizophrenia (Anglin and Malaspina 2008; Barnes 2014; Hamilton et al. 2015). This may be due in large part to the fact that depression and bipolar disorder are more compatible with white middle‐class social reproduction than psychotic disorder. Countless successful business people, media personalities, and academics have “come out” as bipolar or depressed. And bipolar has been romanticized as the source of creative genius by self‐identified bipolar scholars (Jamison 1993), while more critical readings reveal mania to be a desirable trait, even promoted, in late capitalist finance and service industries (Martin 2007).

Capitalism and “Care” The duality of psychosis versus severe mood disorder is further highlighted by the secondary indications that virtually all newly patented antipsychotics now have for depression and bipolar disorder and the fact that the majority of antipsychotic prescriptions are now for conditions other than psychotic disorders (Alexander 2010; Glick et al. 2001). Antipsychotic manufacturers routinely pursue FDA indication for treatment‐resistant depression and bipolar disorder (Olfson et al. 2012; Pillarella et al. 2012). This allows them to advertise these antipsychotics as antidepressants and mood stabilizers. What this does is to create a middle‐class “cover” for treatment with antipsychotic medications of what, in a public clinic population, might have been described as psychosis. It shifts their diagnosis to depression or mania with psychotic features. The antipsychotics in question are on patent and too expensive for publicly insured patients, so the closer an antipsychotic is to the beginning of its patent life, the more it implicitly signifies middle‐class status and the more heavily it is marketed for mood disorders instead of psychosis, even though it is classified as an antipsychotic. Addiction, on the other hand, is variably deployed and variably signified. Some of the variation comes from the race and class associations of the drug being used itself. Powder cocaine abuse in a patient's chart has a different meaning than crack smoking. Nonmedical prescription opioid use has a different meaning than heroin injection. But even these associations can shift with ample media‐induced imagery. Take, for example, the emergence of white, suburban middle‐class heroin use after Prescription Drug Monitoring Programs and tamper‐resistant formulations of Oxycontin and its equivalents made prescription opioids difficult to get (Cicero and Surratt 2012). This was followed by a media blitz of sympathetic stories of unwitting suburban high‐school athletes and housewives whose doctors got them hooked on pain prescriptions, then left them to drift to heroin (Netherland and Hansen 2016). Addiction is a negotiable element in diagnosis, a potential moral trump card that can get middle‐class psychiatric patients out of a severe psychiatric diagnosis. In contrast, certain types of addiction diagnoses and treatments are symbolically associated with black people and make them irredeemable: for instance, crack smoking or heroin injection followed by methadone treatment. In fact, the way we view drug use and addiction in the United States is structured along lines of race and class. Michelle Alexander (2010) has forcefully argued that “color blind” drug‐war policies deploy an unspoken geography of race that keeps the United States residentially segregated and which exposes black and Latino residents to disproportionate searches, arrests, and felony convictions. Much has also been made of the linkage between prisons and asylums, the overlap in their techniques, and in the populations under their care and control (Dumont et al. 2012; Foucault 1977). Psychiatrists who have shepherded their patients through the era of deinstitionalization and homelessness after the mass closure of state mental hospitals now speak of the reinstitutionalization or transinstitutionalization of their patients, this time in prison beds (Prins 2011). The connections between carceral and mental health interventions abound. Although it is not documented in the literature, in my interviews with participants in these systems, I discovered that for‐profit prison‐management companies now hire psychiatrists to design new prisons on the model of psychiatric wards. Addiction plays a key mediating role for those who travel these “institutional circuits” of homeless services, public mental health care, and the carceral system (Hopper et al. 1997). Too morally inflected to qualify the undeserving poor for the social security disability payments and Medicaid coverage, addiction is increasingly addressed in drug courts where patient/inmates are sentenced to treatment. In a parallel process, with the surge in social security benefit applications (SSI) based on psychiatric diagnoses after passage of welfare reform and its five‐year term limits, even those with psychotic disorder diagnoses are having difficulty qualifying for benefits, and the psychotic poor are increasingly seen not in the psychiatric inpatient units that are rapidly closing, but in mental health courts that also sentence patients/inmates to outpatient treatment enforced by probation officers (Lowder, Rade, and Desmarais 2017). Separately, pharmaceutical marketing to the insured middle class has come under anthropological and sociological scrutiny. Chronic diseases, maintenance medications, psychotropics, and lifestyle drugs are lucrative markets, so an ever‐expanding base of everyday diagnoses for mainstream American consumers must be carefully planted, tended, and harvested, and stigma in diagnosis, which is toxic to drug sales, leads advertisers to systematic euphemism and altered strategies in campaigns for psychotropic medications (Foster 2010; McKeever 2014). It is within this market logic of drugs for life (Dumit 2012) that, through a sleight of hand, psychosis among middle‐class consumers becomes drug‐induced psychosis or becomes depression or mania with psychotic features, and antipsychotics become mood stabilizers, adjuvants for antidepressants, or part of a maintenance regimen in addiction treatment. This downgrading of diagnostic severity and of corresponding treatments is implicitly racial, as schizophrenia is symbolically linked to blackness. And this racial symbolism involves descending amounts of moral agency; (implicitly) white people with mood disorders can nonetheless take on their illness with “insight” and deliberated self‐care, while schizophrenic “others” often are said to lack insight and require paternalistic clinical and state intervention. These are the twin trajectories by which psychosis or addiction diagnosis determines racialized subjectivities, subjectivities shaped by state mandate versus consumer choice. Most black people, who are disproportionately diagnosed with schizophrenia, are channeled through the public mental health system where treatment decisions are generally made for them, while white, insured middle‐class people are seen as coveted consumers and are offered their choice of newly patented medications. The parallel trajectories of psychosis and mood disorders are two halves of a whole in which psychosis and addiction are mutually constitutive, but seen as independent from one another. Distinctions between addiction and psychosis serve as a form of “racial grammar” in psychiatry (Bonilla‐Silva 2006): a “deep structure” of communication and social interaction that shapes what is thought and felt about race, often in ways that leave race unspoken and invisible. For example, in the case of Jonathan in my opening vignette, the clinical team immediately thought of his middle‐class future in their treatment planning; it was never explicitly discussed in terms of either his race or his social class. Finding a less stigmatizing diagnostic frame with a better resulting prognosis for Jonathan's professional career was assumed and unspoken in a way that was only visible when contrasted with the unspoken, assumed goal set by the Ibrahim's clinical team to qualify Ibrahim for lifelong disability subsidy using a schizophrenia diagnosis. In a US culture of moral judgment of dependency and valorization of work, these two trajectories are morally laden, redeeming the Jonathans with a path to self‐improvement, and consigning the Ibrahims to a subordinate position of irreparability from which it is virtually impossible to escape. For psychosis and addiction to work as instruments of statecraft and of consumer culture, they must be distinguished from one another diagnostically, pharmacologically, and demographically. It is in the malleable space between these two poles that a neurochemical alchemy of race and class, biology and morality is active, and this alchemy requires clinical failure in the form of denial and negation of dual diagnosis. Dual diagnosis would confuse the moral calculation of these two frames, making it more difficult, structurally, diagnostically, or institutionally, to view one set of patients as morally redeemable and the other as incapable of moral repair.

Psychiatry as a Social Determinant of Health Increasingly I have noticed debates among clinicians on the topic of how to address social determinants of mental health (Adler, Glymour, and Fielding 2016; Oreskovic et al. 2017; Satcher and Rachel 2016). Then it dawned on me: before we talk about how psychiatry can address the social determinants of health, we have to ask how psychiatry itself already is a social determinant of health. Through diagnostic and therapeutic algorithms that sort and consign patients to different social identities and life chances, psychiatry alters the social experience of patients in a way that in itself profoundly shapes their health outcomes. Critical psychiatry and “antipsychiatry” have already raised a version of this question. These movements emerged in the 1960s in reaction to the total psychiatric institutions of the time; drawing on sociological labeling theories asserting that psychiatric diagnoses created the very social marginalization and “deviance” that diagnoses claimed to explain and prevent (Goffman 1961; Laing 1960). Appealing to civil rights logics of freedom of expression and respect for difference, they exposed psychiatry as an instrument of social control and political repression. But how has the landscape of mental health institutions changed since then? Part of the answer includes the war on drugs, which feeds mass incarceration, and welfare reform feeding dramatic growth in social security disability benefits as a safety net of last resort for the poor. Race‐ and class‐stratified mental health systems of redemption versus moral failure in essence negate the social value of those who are irredeemable failures, whose psychiatric diagnoses contribute to the loss of their claims on citizenship and participation in society, through a process that is an inversion of enhancement of their capabilities (Hopper 2007). Another part of the answer includes the efforts of health policymakers to mainstream addiction and mental health treatment into general medicine, which has funneled treatment into the form of brief, periodic medication checks and prescriptions for pharmaceuticals as dictated by evidence‐based medicine, as well as expanding, race‐ and class‐ segmented markets for those pharmaceuticals. These institutional trends are shaping the daily experiences and life chances of individuals (Jenkins 2010), and they are reproducing race and class on the level of populations. The war on drugs and welfare reform operate in the hospital where I work, a large New York City public hospital serving mostly Medicaid and uninsured patients from poor neighborhoods all over the city. An entire floor of the hospital is part of the jail system. One of my most painful experiences there was working with Troy, a young Jamaican migrant living in the South Bronx who was transferred to the dual‐diagnosis unit when his charges for waving a gun during a paranoid episode were dropped. He'd had many bouts of paranoia after smoking marijuana and crack. But when he was not paranoid, he was an attentive father. He used his disability checks to pay rent for his daughter Lianna and her mother, and he walked Lianna to and from school every day in a part of the South Bronx carpeted with crack vials and guns. Troy struggled with nightmares from childhood sexual trauma and the retraumatization that he suffered in prison. He wanted desperately to leave prison behind and be present for Lianna to make sure she didn't suffer the same. Troy was recuperating well, but my efforts to discharge Troy and reunite him with his family were foiled by a call from his probation officer informing me that he would be rearrested for outstanding drug charges. I met with his clinical team hour after hour to strategize about helping Troy to avoid rearrest. Up his dose of antipsychotics and chart as many symptoms as possible in order to buy his lawyer time to negotiate with the prosecutors? Given that our hospital management was limiting lengths of stay, should we beg his long‐term psychiatrist at another hospital to accept his transfer there so that he didn't get discharged and therefore subject to rearrest? But that involved a delicate balance of making him look, as the team would say, not so sick that the other hospital refused him, but sick enough that he needed hospitalization. Troy upped the ante in frustration and punched a wall so hard he broke his hand. This ruined our chances for transferring him to another hospital. By the third day, hospital administrators forced us to discharge him, and police officers waited outside the door to ambush him with handcuffs. It illustrates an everyday ethics of psychiatric care in which clinical teams are faced with multiple constraints on their choices and a lack of control over the outcomes of their choices in optimizing patient care (Brodwin 2013; Myers 2016), an ethics that also manifests the racialized forces driving disproportionate incarceration of black and Latino patients with mental illness. Troy's story illustrates a few points. Three decades into the war on drugs, not only do we have the highest incarceration rate in the world, but our prison and jail systems have become the largest providers of psychiatric services (Justice Center 2017). The majority of those in prison are there on drug charges, and the majority of people with addiction have a co‐occurring psychiatric diagnosis. Psychiatric and carceral institutions are blended, the proverbial distinction between sick and bad is directly challenged by the structure of these intertwined institutions, and what we can do therapeutically is severely limited by it. And, of course, the majority of those in prison are black or Latino and poor; the vast majority of them come from a handful of census tracks in American cities that are the poorest tracks (Badger 2015). One organization that formed in order to challenge these trends is “From Prisons to Public Health,” a New York City‐based collaboration of discontented corrections officials, advocates for incarcerated people, public health and mental health workers.2 The logical end of their work is not only reversal of mandatory drug sentencing and targeted searches and arrests in poor neighborhoods, but also the abolition of prisons. They see themselves as confronting drug laws and drug trade as major drivers of mental health, as acting on the public abandonment of the poor through welfare reform, regressive housing policies and neighborhood disinvestments, and the corresponding pharmaceuticalization of poverty that has been the price that many people pay for survival. There is a flip side of psychiatric melding with institutions of poverty like prisons and welfare. It is the mainstreaming of psychiatric treatment into general medicine, where it is also shaping white affluence.

“Integration” of Psychiatry with Medicine as an Agent of Segregation Biopsychiatry's ascendance on the heels of George H. W. Bush's “Decade of the Brain,” its ambition to solve a crisis of identity by establishing psychiatry as “applied neuroscience”—a scientific specialty—plus pressure from health reform to cut costs by shifting mental health treatment into general medicine clinics, has produced vigorous efforts to integrate “behavioral health care” into general medicine clinics as evidence‐based medicine (Kathol and Rollman 2014; Vogel et al. 2017). One story I've been tracking that illustrates this principle of integration and how it relates to addiction, race, and class begins with the FDA‐approved Oxycontin in 1996 as a “minimally addictive pain opioid pain reliever” and Purdue Pharma's promoting it among suburban and rural general practitioners for patients with moderate pain such as lower back pain, some of whom quickly learned to crush the time‐release capsule and inject or snort the contents. Within six years, Oxycontin and other prescription drugs overtook heroin as the major substance of abuse in the United States. Most of the users were overwhelmingly white and middle class, and the American policy response was not to criminalize them, but rather to pharmaceuticalize them. In 2002, Buprenorphine, commercially known as Suboxone, a drug with pharmacological properties similar to methadone, was approved by the FDA and embraced by addiction specialists, the US Congress, and Decade of the Brain‐era NIDA researchers. It was billed as a state‐of‐the‐art, neurospecific smart drug for addiction that would clean addiction of its messy social trappings, and Federal law was changed enabling general medicine doctors to prescribe it from their offices, reversing a prohibition on opioid maintenance treatment that had been in place since the 1914 Harrison Act (Netherland and Hansen 2017). NIDA and Congress were looking for a less stigmatized and regulated treatment than methadone for largely affluent and white Oxycontin‐addicted people. In congressional debates leading to legalization of office‐based buprenorphine, there is a clear emphasis on a “new kind of drug user,” one that is young, suburban, and “not hardcore” and, implicitly, white. Alan Leshner, then director of NIDA, testified that buprenorphine is uniquely appropriate for a new kind of opioid user as opposed to methadone: “which tends to [be] concentrated in urban areas [and] is a poor fit for the suburban spread of narcotic addiction” (Congressional Record 1999, S1092). In the same congressional hearing, then Health & Human Services Director Secretary Shalala noted that buprenorphine, as an alternative to methadone, would serve a new kind of addict, “including citizens who would not normally be associated with the term addiction” (Congressional Record, 2000, S9113). This required orchestrated changes to federal law and DEA regulations allowing private office‐based treatment, as well as Internet‐based provider referrals and Internet ad campaigns to establish buprenorphine as a drug limited to those with the means to pay a specially certified buprenorphine prescriber. This strategy worked: the first and last US national study of buprenorphine found users more likely to be white (92% vs. 53% of methadone patients), employed (56% vs 29% on methadone), and to have some college education (56% vs 19% on methadone) (Stanton et al. 2006). With this exclusive but lucrative niche market, buprenorphine became a blockbuster drug at $1.2 billion in annual US sales by 2012 (CESAR FAX 2012), dwarfed only by Oxycontin's sales at $3 billion in the United States per year (Eban 2011). Buprenorphine is paradigmatic of the current mantra in health policy of the integration of addiction and mental health care into general medicine. This is an appealing idea to a wide range of psychiatrists because, in theory, it expands access to treatment and puts psychiatric problems on par with physical problems in their importance and their treatment as “real” biomedical problems. The received wisdom is that getting addiction and mental health treated in general medicine clinics reduces the stigma of treatment for mental problems. It is clear, however, that this version of integration was not intended for people like Ibrahim, whose mental‐health‐care providers were under pressure to highlight his diagnostic severity for purposes of social security benefit eligibility. Alternately, people who contend with serious distress within the integrated behavioral health system may find themselves more isolated with their “mental” problems in primary care settings, where they get cues not to discuss them from staff who don't have the skills or time or resources to address them. In a general medical setting—and even more than in a psychiatric setting—all treatments get whittled down to those that can be given in the monthly medication checks that general practitioners (GPs) are equipped to provide. Even if they had access to primary care‐based behavioral health management, people with complex trauma histories, legal statuses, and diagnostic pressures related to their poverty and race would find few resources to address these complexities in a primary care clinic. What “integration” of primary care with behavioral health services really achieved was to expand the number of people getting medicated for mental health and addiction problems. GPs write far more prescriptions for antidepressants, antianxiety drugs, and now, opioid maintenance medication for opiate addiction than psychiatrists. They represent an exponentially larger pool of physicians and patients. Therefore, it is GPs who are responsible for psychotropic drugs being the most profitable single category of pharmaceuticals on the market (Frank, Conti, and Goldman 2005). But an additional item that the story of buprenorphine points to is the segmented, stratified nature of psychotropic drug marketing. Buprenorphine's manufacturer amplified physiological differences in action between buprenorphine, an opioid, and methadone, an opioid, and tied them to a time‐tested logic of race and class that has led to vastly different regulations and treatment settings for vastly different patient populations. For example, what I came to see in buprenorphine was the flip side of pharmaceuticalization of poverty; it is the pharmaceuticalization of affluence. Another example is ADHD, which is diagnosed and treated in a bimodal way, with poor children on Medicaid getting second‐generation antipsychotics to tranquilize their “behavioral problems” (Vanderwerker et al. 2014) and affluent children getting stimulants to enhance their academic performance (Yallop et al. 2015). Psychotropic drugs are shaping class and race at both ends, through the moral actions of psychiatrists with both affluent white patients who pursue social advantages through medicalization of their behavior and with low‐income nonwhite patients who lose moral agency through medically authoritative designations that they are irredeemable.

Coda: Growing Gardens How can psychiatrists (re)create themselves to serve as positive, transformative determinants of health? In the terms articulated by Cheryl Mattingly, how might they create a “moral laboratory, [in which] participants are not only working with the odds but also, in important ways, against them… to create something new—to begin something unexpected[?]And in this creation of ‘the new’ they create themselves” (Mattingly 2014, 17). I saw a window on how this might be done in a community garden at a large public hospital that on any given weekend is being cultivated by patients and staff from the dual‐diagnosis clinic. The psychiatrist who created the garden 30 years ago is also a visual artist, who describes her clinical work as art with found objects. She says that her role as a psychiatrist is not to cleanse people of their pasts but to help them gather the shards of their life and put them into new and beautiful arrangements. Much of this work happens in the garden itself, where weeding, planting, and harvesting is a productive metaphor for people who are recovering from trauma and rebuilding their sense of self. This also happens in the creative arts therapy groups that take place inside the clinic that uses music, visual arts, video self‐documentary, and even cooking in a communal kitchen to help people find their identities and connect with each other. The groups are peer‐led, and decision‐making in the clinic happens through patient government. People who have finished their course of treatment often volunteer in the clinic and help to usher new people into the fold. There are some dramatic success stories, like Ruben, a Puerto Rican man who was homeless before coming to the clinic and had his first experience with art in an art therapy group at 57 years of age and then went on to win statewide art competitions and to have international gallery exhibits. But the everyday difference that these groups make is manifest in the depth of members’ commitment to each other: their celebration of birthdays and anniversaries, their coaching of each other in getting housing and jobs through the maze of public benefit offices, their memorialization of those who die. This is critical because the many people referred to the clinic come from the City's homeless shelter, cut off from their families and neighborhoods in “zones of abandonment” (Biehl and Eskerod 2005) that are growing in American cities. There is a place for gardens in psychiatry clinics. Experiments in social psychiatry have shown that remedying abandonment and acknowledging the social value of patients can be the focus of successful psychiatric intervention, such as that in Trieste, Italy. Trieste was the site of an antiasylum movement heralded by the 1978 Basaglia Law placing patients in community integrated, socially enriched housing, and culminating in 1998 with the abolition of mental hospitals in Italy. Franco Basaglia, leader of the movement, asserted that small, creative efforts to help people connect with who they are, and connect with others, such as street theater, concerts, and public debates that include psychiatric patients, go a long way (Foot 2014). The problem now is that these so‐called small things are not among the service and outcome measures that hospitals are paid and measured by because they're seen as expendable, and therefore they are now being expended in the midst of budget cuts, which lay off art therapists and therapists. Yet, such small things, on the part of both patients who use them to find a sense of social value through their contribution to the collective, and on the part of clinical practitioners who use them to capacitate themselves to heal, help both patients and healers to transcend the race‐ and class‐stratifying diagnostic and treatment systems around which psychosis and addiction are now based. These small things are indispensable vehicles of their redemptive moral agency, a moral agency which underpins the economic and policy interventions that are necessary to stem the syndemics—the overlapping and mutually exacerbating epidemics (Singer 2009)—of addiction, psychosis, and mood disorders that riddle both poor and rich neighborhoods. In the process, they work against the role of psychiatric diagnosis in race‐ and class‐based marking, sorting, and industrial extraction.

Acknowledgments The author would like to acknowledge the deeply thoughtful and generative suggestions of Neely Myers and Kristin Yarris, the encouraging feedback on earlier versions of this article from Elizabeth Bromley and the Berkeley Critical Psychiatry Network organized by Nancy Scheper‐Hughes, as well as the able collaboration of research coordinators Sonia Mendoza, Laura Duncan, and Mary Skinner, and research assistants Allyssa Rivera, Alexandrea Hatcher, and Parth Patel. This work was supported by grants from the American Psychiatric Association/SAMHSA Minority Fellowship, NIH grant DA032674, and the Robert Wood Johnson Foundation Health Policy Investigator Award with IRB approval from NYU's Langone Human Subjects Research Office.

Biography HELENA HANSEN is Associate Professor in the Department of Psychiatry at New York University.