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How do public safety net and elite private mental health providers cope with a key dilemma since psychiatric deinstitutionalization—managing madness when people have the right to refuse care? I observed two approaches to voluntary community-based services, one that tolerates “non-compliance” and deviant choices, and another that attempts to therapeutically discipline clientele. The puzzle, given theories of the paternalistic governance of poverty, is that select poor patients are given autonomy while the privileged are micro-managed. Drawing on comparative fieldwork in Los Angeles, I show how contrasting ecological pressures and resource bases shape divergent practices. In the context of urban poverty governance, mental health care and low-barrier housing offer a way to remove problem people from public space. This “tolerant containment” is linked to limited therapeutic capacity and the construction of clients as beyond transformation. In the context of family systems governance, elite private mental health care is a project to reform wayward relatives and equip them with respectable futures. A “concerted constraint” of deviance, akin to Lareau’s theory of privileged childrearing, is reserved for those who can afford rehabilitation and conceivably recover. Using these cases, I contribute to theories of social control and inequality in advanced liberal societies.

This article investigates “impaired insight,” a controversial psychiatric category describing a mad person unable to know his or her madness. Like “moral insanity” and other concepts before it, impaired insight offers a way to link the disparate logics of human responsibility in psychiatry and the law. I attribute its development to changes wrought by deinstitutionalization, the rise of antipsychotic medication, and patient incarceration in penal settings. In a system that aims to govern psychiatric patients through their freedom, the logic of impaired insight introduces a wrinkle: can a person make an informed choice to refuse treatment if madness itself impairs awareness of illness? Drawing on tools from the sociology of science, I trace the process by which researchers recast psychodynamic “denial” as a neurological and therefore non-volitional “impairment” in the 1990s. I then show how social movement actors mobilized the materialized form in the legal and policy fields in the 2000s, bringing insight science to bear upon the very questions of custodial management and patient rights that gave birth to it. At stake is this dilemma: how can societies that simultaneously privilege individual responsibility and somatic accounts of behavior govern those at the border of legal capacity, and with what justification?

Sociologists have long been concerned with the extent to which “civilizing processes” lead to the increasing salience of rationalized behavioral guidelines and corresponding internal controls, especially in social situations characterized by violence. Following Norbert Elias’s identification of a civilizing process in combat sports, sociologists have debated, though not empirically established, whether emerging “no-holds-barred” fight practices indicate a rupture in the historical civilization of leisure time violence. Using a critical case study of a “no-rules” weapons fighting group, where participants espouse libertarian values and compete in preparation for hypothetical self-defense encounters, I ask how the boundary between violence and social regulation is negotiated in an arena that putatively aims to remove the latter. Drawing on more than three years of ethnographic fieldwork, I specify the mechanisms that moderate action: (1) the cultivation of a code of honor and linked dispositions to replace codified rules; (2) the interactional hesitance that arises when participants lack clear rules or norms to coordinate action; and (3) the importation of external rule sets, such as self-defense law, to simulate the “real” world. Contrary to surface readings of “no-rules” discourse, I conclude that the activity is deeply embedded in larger societal norms of order. Participants’ ethos of honorable self-governance, “thresholds of repugnance” when exposed to serious injury, and aim of transforming emotive, violent reaction into reflective, instrumental action all indicate that the ostensibly unrestrained violence is, in Elias’s technical sense, precisely civilized. Los sociologos se han preocupado por el grado en que “los procesos de civilizacion” conducen al incremento de la importancia de las pautas de comportamiento reguladas y sus correspondientes controles internos, especialmente en situaciones sociales caracterizadas por la violencia. Siguiendo la identificacion teorica de Elias sobre el proceso civilizador en los deportes de combate, los sociologos han debatido teoricamente, aunque no empiricamente, si las practicas de lucha conocidas como “sin limites” indican una ruptura en la civilizacion historica de la violencia en actividades de ocio y tiempo libre. Utilizando el estudio de caso del grupo “pro-uso de armas “sin reglas” cuyos participantes defienden valores libertarios y compiten en la preparacion de encuentros en los que realizar peleas hipoteticas de autodefensa, el articulo investiga como se negocia el limite entre la violencia y la regulacion social en una arena que supuestamente funciona para eliminar este objetivo. Basandome en mas de tres anos de trabajo de campo etnografico, se pudo especificar los mecanismos de accion que regulan este entorno: 1) la existencia y el cultivo de un codigo de honor y unas practicas vinculadas a reemplazar reglas codificadas 2) la reticencia a la interaccion con otros cuando los participantes carecen de reglas o normas claras para coordinar la accion y 3) la incorporacion de reglas externas, tales como el derecho a la autodefensa, para simular el mundo “real”. Contrariamente a los estudios emergentes relacionados con el discurso “sin reglas”, la investigacion concluye que esta actividad esta profundamente arraigada en normas sociales de orden superior. La regla de “autogobierno basado en el honor' y los ‘umbrales de rechazo’ de los participantes cuando se exponen a lesiones graves, transforman la reaccion ante la violencia de emotiva a una accion reflexiva e instrumental lo que indica que la violencia aparentemente sin limites es, en el sentido tecnico de Elias, precisamente civilizada.