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UNIVERSITY of CALIFORNIA Los Angeles Psychiatric Care in The UNIVERSITY OF CALIFORNIA Los Angeles Psychiatric Care in the Hospital and the Home in Puebla, Mexico A dissertation submitted in partial satisfaction of the requirements for the degree Doctor of Philosophy in Anthropology by Kathryn Law Hale 2017 © Copyright by Kathryn Law Hale 2017 ABSTRACT OF THE DISSERTATION Psychiatric Care in the Hospital and the Home in Puebla, Mexico by Kathryn Law Hale Doctor of Philosophy in Anthropology University of California, Los Angeles, 2017 Professor Thomas S. Weisner, Chair Based on 15 months of fieldwork in the only public psychiatric hospital in the state, this dissertation uses extended participant-observation, interviews, questionnaires, and the analysis of audio-recorded clinical visits to examine the beliefs and practices surrounding psychiatric healthcare in Puebla, Mexico. Each chapter provides insight into how patients and practitioners negotiate medical care in a resource poor setting, using direct recordings of clinical discourse and interaction as supporting evidence. Chapter 1 characterizes the geographic and historical landscape of psychiatric healthcare in Mexico, and it juxtaposes the significant investment in infrastructure and tourism found in the globalizing context of Puebla with the uneven distribution of psychiatric care across the state. Chapter 2 discusses political and economic processes and characterizes the texture of multiparty interaction during psychiatric care in Mexico. It argues ii that although psychiatric training and psychotropic medications have ben largely developed outside of Mexico, psychiatric providers use local expectations regarding the co-presence and involvement of kinfolk to recruit kin as informal translators and medication administrators as well as providers of social support. Chapter 3 reviews audio-taped psychiatric consultations to demonstrate how professional understandings of the nature and course of mental illness are presented to psychiatric patients, and it challenges the notion that psychiatrists rely on medication management above psychotherapy or other treatment recommendations in areas faced with structural, organizational, and resource limitations. It also identifies a strong divergence between an American belief that psychiatric medication is taken “for life” and the grounded treatment timelines that recommend a medication be taken for nine to eighteen months before evaluating the tapering or cessation of the drug. Chapter 4 emphasizes the value of non- clinical language for the experientially-based amelioration of distress and presents the phrase “estar más tranquilo” as a way for patients to manage both their internal emotional volatility and the volatility of their immediate surroundings. Chapter 5 of the dissertation presents case studies of two patients, one of whom ended treatment early and another who successfully followed their treatment plan, in order to underscore different subjective experiences of clinical care and its results. The dissertation concludes by arguing that adaptation and tranquilidad may provide the potential for a shift in how we understand chronic mental illness, and calling for more research on the spectrum of experience with various mental illnesses. iii The dissertation of Kathryn Law Hale is approved. Elizabeth Ann Bromley Steven R. López Elinor Ochs Thomas S. Weisner, Committee Chair University of California, Los Angeles 2017 iv This dissertation is dedicated to my grandmother, the world traveler, Boo Law. v Table of Contents Abstract . ii List of Figures and Tables . ..vii Acknowledgements . .viii Vita . xiii CHAPTER ONE: The Landscape of Psychiatry in Mexico . 1 CHAPTER TWO: Family Life and Social Medicine: Discourses and Discontents Surrounding Puebla’s Psychiatric Care . 34 CHAPTER THREE: Explanatory Models Have Some Explaining to Do . .82 CHAPTER FOUR: Ecologies of Care and the Desire to be ‘Más Tranquilo’ . .125 CHAPTER FIVE: Conclusion . 155 Appendix . .168 References . .179 vi List of Figures Figure 1. Example of products manufactured and packaged by the Association for the Training of the Disabled (ACAMI) employees in partnership with Sun Pharma. 18 Figure 2.1. Walkway from parking lot to outpatient area of the hospital. .20 Figure 2.2. External view of the inpatient area of the hospital . 21 Figure 3. The geographic location of the state of Puebla . 25 List of Tables Table 1. Breakdown of educational attainment in patient study sample . 23 Table 2. Occupational status of in patient study sample . 24 Table 3. Breakdown of diagnoses assigned to returning patients in study sample. .87 vii Acknowledgements A Ph.D. is a humbling experience. During the journey, you learn not only academic theory and methods, but that your successes are never merely your own – your advisers, peers, research participants, friends and family help you cross the finish line and achieve higher goals than you ever could have alone. Such individuals keep you sane, keep you focused, and they shape who you become. It is a pleasure to have the opportunity to look back over my past experiences and recognize those who have nurtured me to this point in my journey. Early on in my academic career, I was lucky to meet several individuals who encouraged me to pursue doctoral training. I wish to thank Marshall Duke and Benjamin Freed for their generous mentorship and notes of encouragement during my undergraduate years at Emory University, as well as Philippe Rochat for directing a research program in Samoa and Vanuatu that launched my foray into cross-cultural studies. After college, I worked at Cedars-Sinai Medical Center for approximately two years. While employed there, all of the physicians and coworkers with whom I worked helped foster my love for research and taught me how to work with psychiatric populations. Deidre Edwards trained me in clinical interviewing techniques and the administration of psychiatric scales. Mark DeMars provided supervisory support and valuable life advice. Perhaps most importantly, Catherine Bresee took me (a recent college graduate with an undergraduate degree with cultural anthropology) under her wing and believed that I could master flow cytometry as well as clinical psychology, and I am grateful for her trust, training, and friendship during my time working there. During my time at UCLA, I am tremendously fortunate to have had the opportunity to study under the mentorship of Thomas Weisner, Elizabeth Bromley, Linda Garro, Steven López, and viii Elinor Ochs. Studying under such accomplished scholars has been a humbling and immensely rewarding experience, and their incisive comments have greatly improved the quality of both my writing and my research. Moreover, I have worked with Ellie, Tom, and Linda for the entire duration of my graduate career, and I will never be able to repay them for the countless hours they have given me through formal coursework, professional development workshops, and one- on-one meetings. I have internalized Tom’s call to distill the ‘golden threads’ of my work, I have marveled more than once at Linda’s insightful recommendations for literature to read or debates in which to steep myself, and I continue to look back on and cherish the inspired schematics that Ellie drew during the invigorating brainstorming sessions we have shared. There is a surplus of stellar professors and staff at UCLA whom I have been lucky enough to get to know or from whom I have taken formative coursework. Even so, there were a few who have made an indelible mark on my graduate training and demonstrated human kindness inside and outside of the classroom, and I wish to recognize them here: Jessica Cattelino, Douglas Hollan, Anne Peplau, Daniel Siegel, and Suzanne Wertheim. I also owe a big thank you to Ann Walters and Tracy Humbert for guiding me through applications and expectations over the years and for embodying calm and kindness irrespective of the many other students and responsibilities they juggled. Each of these individuals significantly lightened the load during difficult moments of grad school, and that is a superpower worth celebrating. Similarly, I am deeply grateful to el Hospital Psiquiátrico Dr. Rafael Serrano and its staff, as the present research would not have been possible without the help and hospitality of Dra. Carmen Lara Muñoz, Dra. María Teresa Báez Merlo, Dra. Silvia Herrera, Dr. José Aguilar Domínguez, Lulu, and the psychiatric residents working in la consulta externa. Thank you to Dra. Lara and Dr. López for facilitating access to my fieldsite in Puebla, and in the process ix opening the door to my most transformative experience of grad school. Thank you to my research participants, who shared their lives, their struggles, and their successes with me. Thank you to Maribel Fernández Moctezuma for our many coffee dates and for generously sharing your linguistic and cultural insights with me – you are an inspiration and taught me to nunca darse por vencida. Similarly, Dr. Aguilar taught me a great deal not only about the art and science of psychiatric care, but also the in’s and out’s of living in Puebla, down to the magical powers of Coca-Cola when cleaning off battery corrosion in order to jumpstart a car. I thank Dr. Aguilar for his generous mentorship and consider him an honorary member of my doctoral committee. There were also several people who always made me laugh and became faces I looked forward to seeing each week: Adriana, Gaby, Itzel, Laura, Laurita, Miguel, Rafael, and Raul, thank you for the love, laughter, and lessons in albur. Thank you to Gaby for
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