TRANSFORMING SUBJECTIVITIES: GLOBAL MENTAL HEALTH, BIOPOLITICS, & DEPRESSION IN CHILE BY COURTNEY A. CUTHBERTSON DISSERTATION Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Sociology in the Graduate College of the University of Illinois at Urbana-Champaign, 2014 Urbana, Illinois Doctoral Committee: Associate Professor Assata Zerai, Chair Associate Professor Behrooz Ghamari-Tabrizi Associate Professor Zsuzsa Gille Associate Professor Jonathan Inda Associate Professor Julie Dowling ABSTRACT As the leading cause of disability around the world (WHO 2012), depression has become a major public health concern. The global mental health movement has organized to increase access to mental health care within primary care and to protect the human rights of those who experience mental illnesses. Within this movement, the World Health Organization (WHO) MIND Project which operated in the early 2000s aimed to increase services and legal protections for people with mental illness, through collaboration with national governments and with the assertion that through such collaboration, global psychiatric knowledge would trickle down to the general population. Foucault (1978) has argued that in contemporary society, governance takes place through biopolitics as the “making live” of populations through construction of health problems as simultaneously political and economic ones. Rose (2007) posited that the outcome of living in such a society is the creation of individual-level biological citizenship, where people increasingly see themselves in biological ways. Biological citizenship is theorized as an active process of describing the self in biologically-colored languages while also making demands upon the state for the provision of health care. This dissertation project examined the potential transfer of psychiatric knowledge from the global organizational level to the level of individuals in Chile, a country claimed as a success of the global mental health movement. This project utilized qualitative, ethnographic methods over a six-month period in Santiago, Chile, to explore the biopolitical management of depression, including discourse analysis, observations, and interviews. Observations took place in the psychiatry departments of two public hospitals. Interviews were conducted with people undergoing treatment for depression at either hospital, care providers working in mental health, and a set of people outside of the medical realm who may or may not have had any experience ii with depression. Discourse analysis of texts from global and national levels revealed that the management of mental health, and depression specifically, occurred in ways congruent with biopolitical governance (Foucault 1978, Rabinow & Rose 2006). Observations and interviews showed that depression was seen in contradictory ways, both social and biological. While patients generally felt any of a myriad of interpersonal problems caused their depression, depression was explained as being seen as an illness similar to physical ailments, requiring biomedical intervention. Outsiders and providers more often relied on biological explanations for the mental illness, but all of the interview participants felt depression was on the rise. Many felt the increase in depression throughout the population was due to society becoming more fast-paced, competitive, and individualistic, with superficial communication and relationships between people. Such feelings of disconnect from the larger population being interpreted as depression represent the medicalization of anomie (Durkheim 1997), in line with biopolitical governance through the inspiration of self-regulation (with regards to pharmaceutical treatments) for the good of the whole. A vast majority of those interviewed were women, who often described their responsibilities as overwhelming them, leading to depression; one woman explained that continuing to hold responsibility over the household in addition to the pressures of the workplace (also called the stalled revolution; Hochschild and Machung 2012) was too much to bear. Through medicalizing women’s experiences, such feelings of being overwhelmed are constructed and handled as issues of individual biology rather than problems within the social structure. None of the patients or the outsiders made explicit statements that the state should be responsible for the care of depression, even when asked about health care. The findings from this research indicate the need to widen biological citizenship to include implied biological definitions and passive demands on the state, as a new gradational biological citizenship. iii ACKNOWLEDGEMENTS The development and execution of this project would not have been possible without the support and feedback I have received from many, many people. I would like to thank my advisor, Dr. Assata Zerai, and my committee, Dr. Behrooz Ghamari-Tabrizi, Dr. Zsuzsa Gille, Dr. Julie Dowling, and Dr. Jonathan Inda for the invaluable feedback they have given me on the many iterations of the project and the chapters of this dissertation. Additionally, I would like to acknowledge the Department of Sociology and the Bastian Transnational Fellowship for supporting this research. Outside of my committee, there are several people to thank. There are several people who supported the development of the project and the writing of this dissertation through providing beneficial comments and criticisms, including Soo Mee Kim, Sheri-Lynn Kurisu, Joanna Perez, Dr. Michael Kral and Cultural Studio, and Dr. Tim Liao and the Fall 2011 Publication Workshop. Thank you for challenging me. I would also like to thank those individuals who made this process possible with their emotional support and guidance through the process, including Dr. Anna Marshall, Shari Day, and my family, Ruth, Clay, and Drew. Thank you to my uncle, Dr. David Kenney, for support through my undergraduate and graduate training. To my spouse, Jennifer Carrera, I have eternal gratitude for your belief in me, and the countless hours spent helping me to make this project better. Lastly, I thank the hospital administrators, psychiatrists, and participants in this project for allowing me to learn about their lives and experiences. iv Table of Contents Chapter 1: Introduction ................................................................................................................... 1 Chapter 2: Methodology ............................................................................................................... 21 Chapter 3: Chile ............................................................................................................................ 37 Chapter 4: The Biopolitics of Politicized Psychiatric Knowledge ............................................... 55 Chapter 5: The Micropolitics and Experience of Depression ....................................................... 87 Chapter 6: On the Social Context of Depression ........................................................................ 132 Chapter 7: Biopolitics, Biological Citizenship, and Beyond ...................................................... 164 Chapter 8: Conclusion................................................................................................................. 184 References ................................................................................................................................... 192 Appendix A. ................................................................................................................................ 209 Appendix B. ................................................................................................................................ 211 Appendix C. ................................................................................................................................ 212 v CHAPTER 1: INTRODUCTION A slender 47-year-old woman sat in a blue plastic chair along the wall in the crowded office of a psychiatric in-patient ward in Santiago one chilly, rainy Thursday morning. She clasped her hands tightly together in her lap, looking down at them as she explained the suicide attempt that brought her to the hospital the night before. “I don’t want to kill myself,” she said to the eight psychiatrists and advanced medical students sitting around the room, “but neither do I want to be a slave to this family situation.” Sonia1 told us she was legally responsible for her three neurologically impaired brothers; although she had a successful career as a sociologist, she felt trapped and saddened by feeling she was isolated, on her own, and bearing too much responsibility. After she finished telling her story, the psychiatrists dismissed her from the room and promptly determined the diagnosis: depression. Sonia is one of over 450 million people globally who experience a mental illness within their lifetime (WHO 2009). In 2008 more than 121 million people were affected by depression (WHO 2009), and by 2012 that number had increased to over 350 million worldwide (WHO 2012). This dissertation project explores the construction and circulation of global psychiatric knowledge as governance through biopolitics, including how such knowledge may play a role in individual experiences of depression in Chile. Ultimately, this dissertation is concerned with addressing the nature of the governance mechanisms offered through the global mental health movement, as well as whether individuals come to see themselves through their