UNIVERSITY OF CALIFORNIA, SAN DIEGO The Culture of Mental Health in a Changing Oaxaca A dissertation submitted in partial satisfaction of the requirements for the degree of Philosophy in Anthropology by Whitney L. Duncan Committee in charge: Professor Janis H. Jenkins, Chair Professor Wayne A. Cornelius Professor Thomas J. Csordas Professor John B. Haviland Professor Thomas L. Patterson 2012 Copyright Whitney L. Duncan, 2012 All rights reserved The dissertation of Whitney L. Duncan is approved, and it is acceptable in quality and form for publication on microfilm and electronically: _____________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Chair University of California, San Diego 2012 iii TABLE OF CONTENTS Signature Page…………………………………………………………………… iii Table of Contents………………………………………………………………... iv List of Figures……………………………………………………………………. viii List of Tables…………………………………………………………………….. ix Acknowledgements……………………………………………………………… x Vita………………………………………………………………………………. xiii Abstract of the Dissertation…………………………………………………….... xiv Chapter 1 Introduction: Oaxaca in the 21st Century……………………………. 1 Significance of Study……………………………………………………. 3 The Context……………………………………………………………… 6 Methods………………………………………………………………….. 21 Theoretical Orientations…………………………………………………. 32 Plan of the Dissertation………………………………………………….. 50 Chapter 2 Oaxaca’s Changing Culture of Mental Health……………………… 59 Centro de Atención y Formación Humanista…………………………… 62 Growth in Services: Theoretical Model…………………………………. 66 Current Landscape of Mental Health Services………………………….. 80 Conclusion………………………………………………………………. 98 Chapter 3 Historical Foundations……………………………………………… 100 Prehispanic Mesoamerican Medicine…………………………………… 101 Colonial Medicine and Psychiatry……………………………………… 110 iv Mexican Psychiatry since Independence……………………………….. 116 Contemporary Indigenous Medicine and Ethnopsychiatry…………….. 119 Conclusion……………………………………………………………… 130 Chapter 4 Managing Emotions, Taking Pills: Global and Local Discourse, Ideology, and Practice………………………………………………………….. 133 Introduction…………………………………………………………….. 133 Globalizing Health, Self, & Sentiment………………………………… 135 Psychological Globalization: Stress & the Management of Emotions… 147 Psychiatric Globalization: The Mexican Psychiatric Association Southern Regional Conference…………………………………………. 156 Globalizing Discourses and Ideologies…………………………………. 164 Conclusion………………………………………………………………. 178 Chapter 5 Creating Consciousness, Changing Culture: Oaxaca’s Mental Health Practitioners……………………………………………………………… 181 Magical Thinking: Confronting the Local………………………………. 181 The Conflicted Role of Culture…………………………………………. 187 Democratizing Health Services in Emerging Economies……………….. 190 Representations of Culture………………………………………………. 198 Psicoeducación…………………………………………………………… 220 Emotional Modernization and the Creation of Subjectivities……………. 230 Chapter 6 Gendered Trauma and its Effects: Domestic Violence and PTSD…... 240 Introduction………………………………………………………………. 240 Gender and Domestic Violence in Oaxaca………………………………. 242 PTSD and the Meanings of Violence…………………………………….. 256 v Gendered Trauma at the Psychiatric Hospital……………………………. 265 Discussion and Conclusions……………………………………………… 273 Chapter 7 Narrating Illness at the Psychiatric Hospital…………………………. 279 Introduction………………………………………………………………. 279 Hospital Psiquiátrico Cruz del Sur……………………………………….. 281 Self, Illness, and Social Suffering………………………………………… 287 Patient Characteristics……………………………………………………. 292 Case Studies: Negotiating Explanatory Frameworks…………………….. 308 Returned Migrants at the Psychiatric Hospital…………………………… 327 Discussion and Conclusions……………………………………………… 337 Chapter 8 Mental Health in Migrant Sending Communities…………………… 341 Introduction……………………………………………………………… 341 Background………………………………………………………………. 342 Practitioners Confront Migration………………………………………… 361 Migration, Mental Health, and Morality…………………………………. 390 Chapter 9 Transnationally Shaped Sentiments…………………………………. 394 Introduction………………………………………………………………. 394 The Critical Phenomenology of Illegality………………………………... 395 Transnational Families: When Children Leave………………………….. 399 ‘Yo Sentía Que el Sol Estaba Triste’…………………………………….. 406 Transnationally Shaped Sentiments and Oaxaca’s Culture of Mental Health…………………………………………………………………….. 417 Conclusion………………………………………………………………… 423 vi Conclusion………………………………………………………………………… 426 Concluding Case Study: Carmen & Mario………………………………... 428 References Cited…………………………………………………………………… 441 vii LIST OF FIGURES Figure 1.1: Psychologist Signs in Oaxaca City…………………………………. 22 Figure 1.2: Psychologist Sign in Juxtlahuaca, Mixteca Region……………….... 22 Figure 1.3: Neurotics Anonymous Sign, Teposcolula…………………………. 23 Figure 2.1: Theoretical Model: Change in Oaxaca’s Culture of Mental Health… 67 Figure 4.1: Stress and the Management of Emotions Poster……………………. 148 Figure 4.2: Mexican Psychiatric Association Meetings Entryway……………… 158 Figure 4.3: Valdoxa and General Conference Program Poster in Conference Entryway………………………………………………………………………… 158 Figure 4.4: Paxil CR Ad Poster in Conference Entryway……………………….. 159 Figure 4.5: moksha8’s website…………………………………………………... 162 Figure 4.6: Emotional Codependence (vivirlibre.org)…………………………… 168 Figure 5.1: Services a Psychologist Can Provide, mural in Teotitlán del Valle….. 222 Figure 5.2: Encuentro Familiar, La Merced………………………………………. 223 Figure 5.3: GAPS Flyer on Emotional Health……………………………………. 225 Figure 7.1: Cruz del Sur Façade………………………………………………….. 283 Figure 7.2: Cruz del Sur Courtyard………………………………………………. 285 Figure 7.3: Cruz del Sur Patient Gardens………………………………………... 286 Figure 7.4: Cruz del Sur Chapel…………………………………………………. 286 Figure 7.5: Myths and Realities about Mental Illness: Psicoeducación at Cruz del Sur……………………………………………………………………………. 297 Figure 7.6: The Brain and Schizophrenia, Cruz del Sur psicoeducación……….. 298 viii LIST OF TABLES Table 2.1: Theoretical Model: Growth of Mental Health Services…………….. 77 Table 5.1: Culture/Mental Health Discursive Opposition……………………… 208 Table 5.2: ‘Cultural’ vs. ‘Mental Health’ Practices……………………………. 211 Table 7.1: Age & Occupations of Sample……………………………………… 293 Table 7.2: Geographical Origins of Hospital Participants……………………... 294 Table 7.3: Participant Diagnoses in Order of Occurrence as reported by patients, including concurrent diagnoses…………………………………………………. 303 Table 7.4: Illness attributions, usually multiple………………………………… 306 Table 8.1: Practitioner Views on Migration’s Effects………………………… 380 ix ACKNOWLEDGEMENTS This project has benefitted from the support, guidance, feedback, and patience of so many people. First, I am immensely grateful to those in Oaxaca who opened their lives and homes to me, who displayed enthusiasm for the project, and who graciously shared their stories. I would like to specially thank A and M, whose courage humbles me and whose friendship I will always treasure. Many, many thanks also to the Cruz del Sur hospital patients who, often under painful circumstances, took time to speak with me. I am also deeply grateful to Servicios de Salud de Oaxaca, the many individual mental health practitioners who participated in the project, and the psychiatrists and administrators at Cruz del Sur—thank you for sharing your expertise. Fieldwork went smoothly in part due to the intrepid efforts of my research assistants in Oaxaca— Santiago, Pepe, Rebecca, Erica, and Jenny—whose observations, corrections, and transcriptions greatly improved my work and sharpened my perceptions. I am indebted to Paul Hebb and Karen Rasmussen for generously housing me and providing beautiful spaces in which to work. For friendship, moral support, and constant laughter, I thank Megan Martin, Shane Dillingham, and Karen Rasmussen. Fellow fieldworkers Shane Dillingham, Abigail Andrews, and Holly Worthen could always be counted on for stimulating exchanges academically and beyond. And to all the members of The Hub who made me feel welcome and who provided a workspace: mil gracias. There are many people I wish to thank at UCSD, particularly my doctoral chair, Janis Jenkins, who has provided immeasurable support throughout my graduate career x and who has believed in and greatly enriched this project from its inception. I am extremely grateful to have had you as a mentor. My other committee members—Tom Csordas, John Haviland, Wayne Cornelius, and Tom Patterson—have also offered guidance, critiques, and insights which have been invaluable to the dissertation and which will continue to guide my work as I move forward. My training as an anthropologist and social scientist was significantly enhanced through my participation in SWYEPT and MMFRP—I thank Janis Jenkins, Tom Csordas, Wayne Cornelius, and David Fitzgerald for those opportunities. My fellow grads at UCSD—particularly Charlotte van den Hout, Bridget Haas, Allen Tran, Ted Gideonse, Heather Spector Hallman, Jess Novak, David Keyes, and Nofit Itzhak—have been great friends and interlocutors throughout graduate school and the dissertation process. Special thanks to Bridget and Charlotte for your support and close chapter readings in the past few months. Last and definitely not least, I would like to thank my family. I am tremendously fortunate to have a clan of close family members who have always