Paper short abstract:

This paper explores how community mental health patients understand and locate the cultivation of moral agency within and between sites of care. Focusing on patients with the dual diagnosis of substance use disorder and serious mental illness, I analyze the entanglement of medicated subjectivity and the pursuit of human flourishing.

Paper long abstract:

Where is the locus of moral agency in the space between the methadone clinic and the inpatient psychiatric ward? How do the increasing number of service users with the dual diagnosis of opioid dependency and psychotic mental illness understand this overdetermined relationship to their various medications as they move through ever-more labyrinthine networks of care? This paper seeks to answer these questions by exploring the practical and ethical entanglement of two ostensibly distinct regimes of mental and physical health within the space of a single life.

Drawing on fieldwork in the community mental health network of Dublin, Ireland, and following my interlocutor’s own thoughts on the matter, I analyze the moral dimensions of opioid use disorder as they are understood in the context of psychiatric dual diagnosis. I go on to examine how various apparatuses of psychiatric coercion and care apprehend and govern patients who are thought to be both addicted and mad, simultaneously enthralled by one form of the pharmakon and dangerously out of control when another form of medicine is absent or neglected. Most importantly, I ask: how are patients’ own engagements with the ethics of their care made possible and, perhaps more often, delimited by virtue of their proximity with substances that are understood to affect their will and capacity for self-governance? In the space of such a medicated subjectivity, I argue, a curious form of clinical authority about the intended and unintended effects of a polypharmaceutical approach to treating dual diagnoses takes shape.