Psychiatric Selves: Managing Disorder in Community Mental Health A Dissertation SUBMITTED TO THE FACULTY OF THE UNIVERSITY OF MINNESOTA BY Thomas Doyle-Walton IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY Karen Ho, David Lipset August 2018 © Thomas Doyle-Walton 2018 Acknowledgements I am indebted to my long-suffering co-advisers, Karen Ho and David Lipset, for their generous support and seemingly endless reserves of patience over the course of many years. This may not be the project that either of them had in mind, but it is finally complete. David Valentine graciously agreed to serve on my dissertation committee, as did Todd Rockwood, who also provided a much-needed breath of fresh air during my time in the School of Public Health. This dissertation would not have come into being had I not been offered the opportunity to participate in the Department of Sociology’s Minnesota Exits and Entries Project. I am grateful to Arturo Baiocchi for introducing me to the project, not to mention his friendship during graduate school and our adventures in applied research. Chris Uggen, a distinguished scholar and strong advocate for graduate students, allowed an anthropologist to become part of his team. I thank him for the opportunity and feel lucky to have worked with him. The long-term friendship of Akshat Agarwal, Matthew Whitaker, Rashid Amin, Alex Dragonetti, and Chris Machak sustained me in various ways, as did the unstinting support of my family. Koa Mira was there to help me through challenges of all sorts. I can’t thank her enough. i Abstract This dissertation examines the aftermath of psychiatric emergency among a group of young adults who were hospitalized with severe symptoms of mental illness. I trace the experience of this cohort of young people over time as they prepare to leave psychiatric rehabilitation facilities in Minnesota and transition into a variety of independent community living arrangements. My aim in conducting this research was to understand how the encounter with psychiatric knowledge in rehabilitative settings causes people to reconsider the ways in which they engage in processes of self-fashioning and reconceptualize the possibilities for personhood as they make their way toward a future that they expect to be punctuated by the unpredictable occurrence of symptoms of chronic mental illness. I argue that community rehabilitation facilities function as key sites for psychiatric subjectification where the objective status of diagnostic categories and discourses of chronic risk are addressed through a series of illness management activities that emphasize ethical self-governance intended to produce a form of personhood characterized by independence, autonomy, productivity and self-determination; this is a fraught process that is unsettled by the divergence between diagnosis and lived experience. In addition, individualistic conceptualizations of community recovery obscure the challenges of living with mental illness inherent in the structurally-vulnerable socioeconomic positions that many participants occupy, and I find that the methods through which people conceive of meaningful ways of being are bound up with everyday struggles and negotiations over relatedness and social belonging in their local worlds. ii Table of Contents Chapter I. Introduction ........................................................................................................ 1 Key Issues .................................................................................................................................... 1 Setting the Scene .......................................................................................................................... 5 Orientations ................................................................................................................................ 14 Notes on Research Design and Method ..................................................................................... 25 Plan of the Dissertation .............................................................................................................. 32 Chapter II. Contemporary Psychiatric Logic and Community Mental Health Practice ... 38 Introduction ................................................................................................................................ 38 DSM-III and the Revolution in American Psychiatry ............................................................... 41 Psychopharmacology ................................................................................................................. 63 Community Mental Health ........................................................................................................ 68 Conclusion ................................................................................................................................. 81 Chapter III. The Work of Recovery .................................................................................. 83 Introduction ................................................................................................................................ 83 Andrew ....................................................................................................................................... 88 The Unmaking of the Self .......................................................................................................... 96 Piecing Together Diagnosis ..................................................................................................... 103 Mental Health Education and Self-Management ..................................................................... 125 Drugs for Life .......................................................................................................................... 137 Conclusion ............................................................................................................................... 146 Chapter IV. Structural Vulnerability, Relatedness and Personhood in the Community . 149 Introduction .............................................................................................................................. 149 Community, Local Ecologies of Care, and Structural Violence .............................................. 151 Departures ................................................................................................................................ 162 Waiting for Recovery ............................................................................................................... 179 Coercion ................................................................................................................................... 185 Work and Education ................................................................................................................ 193 Relatedness, Recovery, and Social Belonging ......................................................................... 200 Conclusion ............................................................................................................................... 218 Chapter V. Conclusion .................................................................................................... 222 Bibliography ................................................................................................................... 238 iii Chapter I. Introduction Key Issues This dissertation examines the aftermath of psychiatric emergency among a group of young adults who were hospitalized with severe symptoms of mental illness. I trace the experience of this cohort of young people over time as they prepare to leave psychiatric rehabilitation facilities in Minnesota and transition into a variety of independent community living arrangements. My aim in conducting this research was to understand how dominant psychiatric discourses and forms of knowledge are enacted on the ground in the context of the decentralized, small-scale settings where contemporary community mental health treatment modalities and recovery models are implemented. In addition, I wanted to understand how the encounter with psychiatric knowledge in rehabilitative settings causes people to reconsider the ways in which they engage in processes of self-fashioning and reconceptualize the possibilities for personhood as they make their way toward a future that they expect to be punctuated by the unpredictable occurrence of symptoms of chronic mental illness. My inquiry is structured around a set of key questions: • How does psychiatry categorize and explain those symptoms that it takes to be its objects, and how do the frameworks through which it does so come to bear on the delivery and receipt of mental health services in community treatment and rehabilitation settings? 1 • How are processes of psychiatric diagnosis and rehabilitation entangled with practices of self-making and the emergence of forms of personhood that people come to desire and hope to achieve? • What are the structural conditions that shape the communities in which participants grapple with the implications of a psychiatric diagnosis for the future that they want to inhabit? How do these structural conditions interact with the forms of relatedness and sociality that help to constitute participants’ local worlds to both produce and foreclose possibilities for psychiatric care and recovery? In this dissertation, I demonstrate how the convergence of a set of historical processes involving deinstitutionalization, the rise of biological