UC Berkeley

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 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.