Uncertain Adherence: Psychosis, Antipsychosis, and Medicated Subjectivity in Dublin, Ireland by Michael J. D’Arcy V A dissertation submitted in partial satisfaction of the requirements for the degree of Joint Doctor of Philosophy with the University of California, San Francisco in Medical Anthropology and the Designated Emphasis in Science and Technology Studies in the Graduate Division of the University of California, Berkeley Committee in charge: Professor Stefania Pandolfo, Chair Professor Nancy Scheper-Hughes Associate Professor Ian Whitmarsh Professor Massimo Mazzotti Fall 2018 Copyright (2018) by Michael J. D’Arcy V Abstract Uncertain Adherence: Psychosis, Antipsychosis, and Medicated Subjectivity in Dublin, Ireland By Michael J. D’Arcy V Doctor of Philosophy in Medical Anthropology University of California, Berkeley Professor Stefania Pandolfo, Chair This dissertation is an ethnographic exploration of what it means to seek and provide care in Dublin, Ireland’s community mental health network. Based on eighteen months of ethnographic research with both clinicians and patients, and situated at the theoretical intersection of science and technology studies and psychological anthropology, Uncertain Adherence examines the multiple logics of antipsychotic adherence, or the extent to which a mental health patient does or does not comply with their prescribed medicinal regimens. Ireland’s history as a colonial laboratory for early forms of experimentation in hospital care, as well as its contemporary status as an increasingly heterogeneous and cosmopolitan site of advances in cross-cultural psychiatry, mark it as an important locus for anthropological research into the aftermath of psychiatric deinstitutionalization and the development of more rigorous protocols for global mental health in the face of increasing immigration and cultural diversity. I argue that psychiatric discourse defines antipsychotic adherence as the condition of possibility for deinstitutionalized, patient-centered treatment, but ethnographic attention to patients’ own understandings of their medications and the clinical injunction to adhere reveals far greater complexity. Specifically, my ethnographic research sheds light on the ways in which patient attitudes toward the seemingly straightforward task of psychopharmaceutical adherence are entangled with the lived experience of psychosis and social marginality, as well as a host of culturally mediated interpretations of medicinal efficacy, institutional responsibility, and psychiatric rationality. To engage this complex scene, I explore the multi-sited nature of community mental healthcare in an inner-city, inpatient psychiatric hospital ward, its affiliated outpatient clinic, and a community mental health group run by and for people living with schizophrenia and other psychotic illnesses. Patients’ movements through these primary and various secondary therapeutic settings uncover the distribution of psychiatric logic throughout a network of new institutions of care. Reading across the ostensibly divergent theoretical traditions of science and technology studies and psychological anthropology, I analyze the sociohistorical construction of scientific knowledge about psychopharmaceutical efficacy and the 1 concept of patient insight, while also theorizing the vicissitudes of patient subjectivity. Patients’ strategic engagements with psychiatric resources and ideologies must be understood in relation to their tendencies to find other forms of support from religious groups, patients’ and immigrants’ rights organizations, and from clinicians working in Dublin’s burgeoning psychoanalytic community. By virtue of this dual analysis, my dissertation formalizes the entanglement of these multiple orders of scientific discourse and patient experience as a problem of epistemological difference in the space of an increasingly globalized model of mental health. My research thus reveals the disparities between the theory and practice of psychiatric approaches to ensuring patient buy-in to drug adherence, as well as the ways that patients’ understandings of their medications are informed by the shifting perspectives of illness and health, sanity and madness, and ever- increasing cultural diversity. In the practical encounter between patients and antipsychotic drugs, new forms of subjectivity take shape. 2 In memory of Patricia Brennan, who knew the breadth and the length and the height and the depth, and for all the others who have gone before. i Acknowledgments If in this sleep I speak it’s with a voice no longer personal (I want to say with voices) -Adrienne Rich, “Phantasia for Elvira Shatayev,” The Dream of a Common Language, 4. In many ways, this writing was a haunting. At times the language of this text—in essence, the language of others—moved through me with uncanny fluency. At times it failed me utterly. Though it was often frustrating, this is nevertheless fitting, I believe, given the degree to which this work seeks to address the limits of mutually intelligible experience and shared meaning. Furthermore, it is written in the margins of a complex and contested history with which I am still only beginning to grapple. If one of anthropology’s many and diverse programs is to explore and render explicit the hidden but nonetheless enduring problem of how to confront and understand difference while living in relation to others, then I don’t yet have any authoritative solutions to such quandaries, but I hope that I have learned to ask better questions over the course of this dissertation. I am grateful to a multitude of people for helping me along the way. I first came to anthropology as an undergraduate at the University of Chicago when I had the good fortune to meet Tanya Luhrmann and learn about her ethnographic exploration of the relationship between schizophrenia and homelessness. Under her guidance, and benefitting from the insights, encouragement, and fellowship offered to me by Greg Thompson, Erin Moore, and others, I found a desire to participate in the larger conversations that animate the discipline and, ultimately, something like a vocation. Each of them has my thanks for their part in welcoming me into the beautiful and often outlandish intellectual community that has become my home. In the Joint Program in Medical Anthropology at UC Berkeley and UC San Francisco, I am grateful to Mariane Ferme, Lawrence Cohen, Charles Hirschkind, Vincanne Adams, and Deborah Gordon for the rigor and imagination of their pedagogy. They introduced me to the fundamentals of the discipline of anthropology, and—along with Cori Hayden, Liu Xin, Stanley Brandes, and Cristiana Giordano—they taught me to think both carefully and expansively. They continue to honor me by including me in their ongoing conversations and by taking my own modest contributions to the discipline seriously. Katie Hendy, Liz Kelley, Saleem Al- Baholy, Xochitl Marsilli-Vargas, Peter Skafish, and Khashayar Beigi were early mentors who likewise brought me into the fold and taught me how to read my colleagues generously, how to argue, and how to understand my relationship to the history of anthropology as a perpetual student. I also owe a great debt to my cohort, with whom I was first formed as a scholar, and who tolerated my youthful enthusiasm and ignorance. I am especially grateful to Jerry Zee, Jason Price, Ian Steele, Ugo Edu, Mark Fleming, Rachel Ceasar, ii and Alissa Bernstein, whose strange and wonderful friendships have challenged and sustained me since our first meeting. Joining them in shaping both my person and my capacity to think with others are a host of other beloved friends and colleagues, especially Raphaëlle Rabanes, Stefanie Graeter, Marlee Tichenor, Sam Dubal, Emily Ng, Drew Halley, Rochelle Terman, Patricia Kubala, Ashwaq Hauter, Kamala Russell, Fatima Mojaddedi, Eric Taggart, Ashley Teodorson, Samuele Collu, Gabriel Coren, Melissa Salm, Milad Odabaei, Heather Mellquist, Erik Lehto, Angelo Caglioti, Nicholas D’Avella, Vivian Choi, Ned Garrett, and Kathleen Van Sickle. I cannot imagine my intellectual being without these interlocutors, and I am better for their abiding presence in my life. Words fail me when I attempt to express my thanks to my committee members. I feel that I first met Nancy Scheper-Hughes as a college student when, after picking up Saints and Scholars, I first began to explore the wider terrain of medical and psychological anthropology, as well as the possibility of conducting fieldwork in my ancestral homeland. Since my matriculation at Berkeley, she has been a counselor and a gadfly—reminding me of my scholarly and moral responsibility to Ireland as a field site and acting as an impromptu theologian and spiritual adviser, though I suspect she would reject such honorifics. Since our first meeting in the spring of my first year of graduate school, Ian Whitmarsh—my Trobriand Uncle—has pushed me to think more daringly and in stranger and more generative directions than I first imagined. His skepticism, humor, and intellectual openness have been indispensible to my own habit of thinking otherwise. Massimo Mazzotti, with the utmost beneficence and patience, oversaw my unorthodox and long-overdue education in the history and philosophy of science in the years following my fieldwork. His willingness to think with and through the conceptual particularities of my ethnographic concerns has deepened my belief in the possibility of a dialogue between scholars working in the tradition of Science and Technology Studies and Psychological