A review of The Culture of Mental Health in a Changing Oaxaca, by Whitney L. Duncan.
The globalization of a biomedical approach to mental health, together with the consequent pharmaceuticalization of individuals subjected to drug regimes, has enjoyed the attention of anthropologists in the last couple of decades. Particularly, anthropologists have focused their analytical lens on the effect that global political, monetary, and epistemological economies have in developing countries such as those in the Latin American region (see Adriana Petryna, Andrew Lakoff and Arthur Kleinman eds., Global Pharmaceuticals: Ethics, Markets, Practices. Durham, NC: Duke University Press, 2006 for a general overview on the role of pharmaceuticals in global market economies; and Andrew Lakoff, Pharmaceutical Reasons: Knowledge and Value in Global Psychiatry. Cambridge: Cambridge University Press, 2005 and João Guilherme Biehl, Will to Live: AIDS Therapies and the Politics of Survival. Princeton: Princeton University Press, 2007 for particular cases in Latin America). Whitney Duncan’s dissertation contributes to our understanding of how global mental health culture spreads to Oaxaca, Mexico; how practitioners function as mediators in this process, using a set of strategies that she calls psicoeducación; and how patients adopt this new mental health culture, changing their own personal and community’s understandings of disease, self, and social relations, and turning themselves into promoters of the modern mental health services offered within their communities. Particularly relevant in Duncan’s analysis is the role of psicoeducación in restructuring patients’ narratives of mental and emotional distress originally framed in traditional gender roles and social and familial relations. Her analysis shows that in contrast to other world regions, Oaxaca’s change in the culture of mental health has not entirely been led by biomedically grounded disease categories and their associated pharmaceuticalization. Rather, mental health patients in Oaxaca have appropriated and re-elaborated the global narrative on mental health using their own local culture.
Duncan’s dissertation developed from eighteen months of in-depth research in Oaxaca City and the Mixteca region in the state of Oaxaca in Mexico. She carried out qualitative and survey interviews of both patients and practitioners within Oaxaca’s public, private, and non-governmental mental health institutions; participant observation in mental health-related events and institutions. Duncan also analyzed the public media, advertisements, educational materials, and institutional documents. Her theoretical framework, explored in Chapter 1, sees globalizing mental health practice in Oaxaca as an “emotive institution,” following the work of anthropologist Geoffrey White. (See Geoffrey White, “Emotive Institutions” in Conerly Casey and Robert B. Edgerton eds., A Companion to Psychological Anthropology: Modernity and Psychocultural Change. London: Blackwell, pp. 241-254.) An “emotive institution” generates “discourse and ideology about self, emotion, and social relations, enables the ‘enactment or embodiment’ of particular means of interaction and being-in-the-world, and is itself shaped by broader ‘spheres of ideology and political arrangements’” (pp. 37-38). Whitney Duncan uses Chapter 3 to show that indigenous and medical models of and approaches to mental health evolved independently after the Spanish Empire arrived to the Americas in the mid-fifteenth century. While European physicians, first influenced by Catholic institutions during the colonial period and later by French positivistic science in the nineteenth and twentieth centuries, regarded indigenous medicine as belonging to the magical realm and as object of control and punishment, indigenous healers appropriated certain European medical practices, conceiving the latter as complementary, and developing a syncretic understanding of emotional well-being. Duncan’s dissertation shows that this trend persists in the twenty-first century.
The global culture of mental health penetrates Oaxaca through psychology and psychiatry, which reach Oaxacans through commercial for-profit means. By analyzing Dr. Alfonso Ruiz Soto’s “Semiology of Everyday Life” workshop, Duncan shows in Chapter 4 how psychologists popularize among the middle and upper-middle class the idea that individuals have a health need and a moral obligation to improve from their lives full of stress through self-imposed regimes. On the contrary, psychiatric globalization reaches Oaxacan practitioners through pharmaceutical companies, such as moksha8, which emphasize liberation of mental health distress through the consumption of pharmaceuticals. While the former has reached the general public, the latter is confined to the clinic. Responding to such asymmetry, Duncan’s ethnographies in Chapter 5 show how mental health practitioners are using local media, health institutions, development initiatives, schools, churches, and clinical practice — what Duncan calls psicoeducación — “to de-stigmatize and normalize mental health care, to portray it as important as any other type of care, and to encourage Oaxcanas to seek [modern institutional rather than traditional indigenous] services” (p. 220), stigmatizing indigenous culture. Through psicoeducación, practitioners create the psychological conditions for disciplining the self in modern Oaxaca. But to what extent practitioners achieved this?
The following chapters detail how this new culture of mental health shapes both patients’ and practitioners’ understandings of mental and emotional distress in connection with traditional social relations and structural problems such as migration and poverty. In Chapter 6, Whitney Duncan analyzes how women who suffer domestic violence are not diagnosed with Post-Traumatic Stress Disorder (PTSD), when this is regularly the case in the rest of the world. Her ethnographies show that, despite Oaxacan women’s awareness of domestic violence and their active search for psychological treatment as a consequence of institutional efforts to mitigate it, psychiatrists do not diagnose PTSD. Psychiatrists regard domestic violence as a problem too rooted in Oaxacan culture for women to express their symptoms in the terms required by international taxonomies of psychiatric diseases. With migration, the theme for Chapter 8, the result is the exact opposite. Practitioners and patients alike regard migration as a social threat that impacts the social, emotional, and psychological well-being of Oaxacans. In this case, practitioners regard the cultural change produced by both leaving and returning migrant populations as the direct cause of mental health disorders; for instance when it is framed in terms of “culture shock.” Paradoxically, migration, which impacts mostly the male population, also results in women’s empowerment, which may eventually produce women’s well-being and good mental health. In Chapter 7, Duncan analyzes the ethnographies of patients at Cruz del Sur Hospital. She finds that patients acknowledge the beneficial effect of medicines in their re-integration to society after suffering mental or emotional distress, but their former interpretation of this suffering does not change with the psicoeducación offered in the hospital. In Chapter 9, Duncan’s ethnographies provide evidence of how non-immigrant communities in Oaxaca experience emotional distress as a consequence of events that happen across the border. This phenomenon, which she conceptualizes as “transnationally shaped sentiments” (pp. 415-16) contributes to a growing desire for mental health services and culture in Oaxaca.
Duncan’s dissertation is an invaluable contribution to the anthropological studies of global mental health. Her work goes “well beyond the provision of treatment” (pp. 5 and 426), as she put it herself. The process of pharmaceuticalization is not driving the change in mental health culture in Oaxaca; Duncan’s contribution lies in demonstrating that Oaxacan practitioners, whether through global psychology or psychiatry, are “explicitly attempting to foment culture change and promote modern forms of subjectivity” (p. 426). But her detailed analysis also shows the contradictory complexity of disciplining the self through empowering the self; she provides ample evidence on the influence of local cultures in the adoption and reformulation of global discourses, ideologies, and practices. Furthermore, by incorporating migration as an analytical category, Duncan’s work links global mental health to both local structural problems, such as poverty and political upheavals, and across-the-border events that have an indirect yet significant impact on the local culture of mental health. Her dissertation is an excellent example of how to analyze global discourses and events through ethnographies, showing at the same time both the interconnection between the global and the local, as well as the particularities of the local.
Department of Anthropology, History, and Social Medicine
University of California, San Francisco
Practitioners from public and private mental health institutions and non-profit organizations
Patients from the Cruz del Sur psychiatric hospital
Oaxacans from San Miguel Tlacotepec, Ixpantepec Nieves, Santiago Juxtlahuaca, Huajuapan de Leon and all communities from the Mixteca region
Participant observation in the town, the city, mental health conferences, workshops and support groups
Public media materials and institutional documents
University of California, San Diego. 2012. 471 pp. Primary Advisor: Janis H. Jenkins.
Image: Sign for psychologist, Oaxaca City, Mexico. Photograph by author.