Psychiatric Encounters: Madness and Modernity in Yucatan, Mexico

By Beatriz M. Reyes-Foster

Psychiatric Encounters presents an intimate portrait of a public inpatient psychiatric facility in the Southeastern state of Yucatan, Mexico. The book explores the experiences of patients and psychiatrists as they navigate the challenges of public psychiatric care in Mexico. While international reports condemning conditions in Mexican psychiatric institutions abound, Psychiatric Encounters considers the large- and small-scale obstacles to quality care encountered by doctors and patients alike as they struggle to live and act like human beings under inhumane conditions. Beatriz Mireya Reyes-Foster closely examines the impact of the Mexican state’s neoliberal health reforms on how patients access care and doctors perform their duties. Engaging with madness, modernity, and identity, Psychiatric Encounters considers the enduring role of colonialism in the context of Mexico's troubled contemporary mental health care institutions.  

• Language: English
• Publisher: Rutgers University Press
• Release date: Oct 30, 2018
• ISBN: 9780813594873

Book preview

ENCOUNTERS

1 • INTRODUCTION

Las Lomas at the Threshold of Modernity

[Las Lomas] is a medieval dungeon.… I would sooner lock my relative in a room than I would allow them to spend one second in your hospital.

—J. R., October 19, 2012

The truth is that colonization, in its very essence, already appeared to be a great purveyor of psychiatric hospitals.

—Frantz Fanon, The Wretched of the Earth

In the fall of 2012, after I returned from fieldwork in Mexico, I wrote the first version of what would eventually become the foundation of this book. It was a paper I would present at the 2012 meeting of the American Anthropological Association in San Francisco. On a whim, as I was finishing the paper, I googled the name Las Lomas. As the search results appeared, a headline grabbed my attention: Envejece Las Lomas, Las Lomas Ages. The brief story—233 words in total—was published on the website of a local paper with a daily print run of about 70,000 copies sold throughout the Yucatan Peninsula. It described the state psychiatric hospital’s crumbling infrastructure, noting that the hospital director had publicly announced the need for a new facility. The life cycle of this hospital has come to an end, the note read. There is an urgent need for a new construction with a different model and modern technology.

I scrolled down to the comments section and discovered only one, dated October 19 of the same year. Written anonymously by someone who went by the screen name J. R., the comment was prefaced with a statement: copied from an email sent to Juan Vasquez, former director of Las Lomas. The comment continued: Las Lomas is a prison, a medieval dungeon where people are locked away without the possibility of appeal, denied their liberty following an initial assessment made without seriousness by a recent graduate or student.… I would sooner lock a relative of mine in a room in my house before I would ever bring him to your ‘hospital.’ … You do not have the moral authority to lock people up nor tell them what to do or not do with their lives. You have failed. I thought about J. R.’s comments as I reflected on my most recent experience at Las Lomas—a three-month visit in 2012 during which I had plunged into the guts of this institution more deeply than in the six months of continuous fieldwork I had conducted in 2008 or research I would undertake later. Even as I was finishing a seven-page oral presentation, I had become convinced I would never turn my experiences into a book—writing about my work there had become too emotionally draining. My months inside Las Lomas left a lasting impression, one I carry with me to this day; a sensation of nausea is triggered when I think of the smell of the ward, or hear, in my mind, the sound of desperate cries through open windows. This was One Flew Over the Cuckoo’s Nest brought to horrible life.

The Las Lomas state psychiatric hospital is similar to many other Mexican public psychiatric hospitals. The international human rights organization Disability Rights International (DRI) has published several reports over the years outlining the horrific conditions of public psychiatric institutions in Mexico (MDRI 2000; DRI 2011, 2015), where people are routinely abandoned to unhygienic conditions, stripped of privacy and dignity, forced to wear uniforms, subjected to physical restraints, and deprived of food, water, and medical care. The most recent report, published in 2015, notes that despite previous reports and public acknowledgment by the Mexican state of the conditions of its psychiatric institutions, DRI investigations have continued to uncover a pattern of egregious and widespread human rights violations (2015, i). What I had encountered in my time conducting ethnographic fieldwork resonated with several of the findings in the DRI reports. During my time in the wards at Las Lomas, I witnessed patients restrained for extended periods of time, medicated against their will, and placed in isolation in a room with nothing but an ancient metal hospital bed, a black rubber mattress, and a broken toilet. Patients are forced to wear a uniform, allowed no personal property (not even reading material), and they are without access to a telephone or other means of communication. Conditions inside the wards were horrific: the buildings were literally crumbling around them, with paint peeling off the walls, which were scratched with graffiti and messages from patients who had passed through these rooms. The odors from the constantly broken toilets permeated the entire ward with the stench of human waste. Inside the acute wards, patients were locked in to their dormitories for up to twenty hours a day and allowed out only to consult with the attending psychiatrist, visit with their relatives in the ward vestibule, and eat (also in the ward vestibule). They were never allowed outdoors. When patients are committed—even if they enter the institution on a voluntary basis—they become wards of the state. They cannot leave voluntarily and are essentially at the mercy of the attending psychiatrist. Medieval dungeon, indeed.

Yet I also realized the dungeon masters were not evil people. They were, for the most part, hard-working professionals—psychiatrists, nurses, and social workers—even if they occasionally did not get along with one another. I was reminded of a phrase I saw in an unrelated book on birth in post–Soviet Russia (Rivkin-Fish 2005), a prelude borrowing the words of musician Boris Grebenshikov: Everything I do is an attempt to live like a human being, in conditions that are inhumane. The people I worked with at Las Lomas—patients and hospital employees alike—seemed to be striving to do just that, to live like human beings under inhumane conditions that seemed to stubbornly persist despite clear recognition by everyone on the ground that the current system simply was not working.

This book is an ethnography of a psychiatric facility in Yucatan, Mexico. Las Lomas, of course, is not its real name. It is a pseudonym chosen to protect, as best I can, the identities of the medical providers and patients who generously allowed me to bear witness to life in a place some would go on to describe as a hell on earth. Las Lomas is a public psychiatric hospital in the southeastern state of Yucatan in Mexico. The stories I will share may be difficult to read—some were extraordinarily difficult to write—but they represent a slice in time, a fraction of ethnographic material collected over several seasons of institutional fieldwork inside the hospital’s wards and more than a decade of ethnographic engagement in the region.

The purpose of this research was not to capture the visceral exposure of human suffering, nor to document a pornography of violence, but rather, initially, to understand how users of Mexico’s public mental health care services navigated these services. In 2008, my research was focused on the hospital’s suicide prevention program, which was part of my broader ethnographic work on suicide. However, as I spent more and more time at Las Lomas, other questions emerged. When I returned to the hospital in 2012, my interests focused on the medical interactions between patients and psychiatrists, residents, and other medical providers.

Nearly ten years after the inception of Seguro Popular, the national health care scheme that has come to insure millions of previously uninsured Mexicans, Las Lomas forms part of a vast nationwide network of medical institutions utilized by nearly 55 million people (INEGI 2016). Yet at the same time that Seguro Popular and medical reform promised access to quality medical care for all Mexicans, economists and politicians have fretted over the viability of its health institutions, particularly the Instituto Mexicano del Seguro Social (IMSS), colloquially referred to as el Seguro, the National Institute for Social Security, which provides health care and retirement benefits to 62 million privately employed citizens (Instituto Nacional De Estadística 2016). IMSS is beloved by some (Hayden 2007) but despised by others—Seguro? Seguro que te mueres!¹ (Surety? Surely you will die!) is a popular expression for my interlocutors when talking about el Seguro. The financial viability of IMSS had long been a source of concern in a neoliberal Mexico. In the thirteen years that I have been an active field researcher in Mexico, the neoliberal groundwork laid during President Carlos Salinas de Gortari’s sexenio in the 1980s has led to the steady privatization of various state enterprises and a definitive move toward free market economics, to the great benefit of some and the harm of others. Some argue that neoliberal economic reforms in the last thirty years have resulted in the emergence of a Mexican middle class and quite likely contributed to the dramatic decrease of migration to the United States (Duncan 2017). At the same time that neoliberal economic reforms have firmly taken root, Mexican state policy and public discourse continues to be dominated, as it has since the nineteenth century, by a concern of modernity. How do we make Mexico modern?

Yucatan ranks sixteenth out of thirty-two federative entities (thirty-one states and the Federal District of Mexico City) in poverty in Mexico, with just over 80 percent of the population categorized as living in some kind of economic distress.² Some 45.9 percent of the population is said to be living in poverty, with 10.7 percent considered to be in extreme poverty, 27.7 percent considered vulnerable to falling into poverty for lack of social resources, such as access to quality education, health care, or social security, and 7.0 percent vulnerable to falling into poverty because of low income (CONEVAL 2014). While Latin American intellectuals like Nestor García Canclini (1989) and his predecessors such as Octavio Paz ([1950] 1993) and José Vasconcelos ([1979] 1997) wrote of Mexican modernities, cosmic races, and hybrid cultures, the values they attached to modernity—progressive, technological, efficient—betray a vision of modernity congruent with the Global North.³ Although the way modernity itself has been defined has changed over time, concerns voiced in public opinion columns in 2016 echo those of the past. Despite reform, Mexico continues to be plagued by political corruption, economic disparities, and financial stagnation, all seen as emblematic obstacles to realizing this vision.

One Flew Over the Cuckoo’s Nest (Forman 1975) occupies a special place in the U.S. imagination as an epitome of the horrors of psychiatric institutionalization. Having grown up in the United States, this film became a point of reference as I began to process what I witnessed in the wards in Yucatan. In my interactions with people unaffiliated with the hospital, my disclosure of my project and my work inside the institution was invariably met with a grimace: "You’re working where?" Occasionally this was followed by gallows humor admonishing me to be careful, lest they decide to keep me. While One Flew Over the Cuckoo’s Nest does not have the same salience in Mexico, local imaginaries of the manicomio (asylum) and its inhabitants exist. These imaginaries can be summed up in a single word: locura (madness).

MADNESS

Eva was a recent chemistry graduate from the local state university. She had gotten a job as a laboratory technician at one of the university’s research laboratories. Her family—her mother and unwed siblings—lived in Chelem, a nearby beach community. Eva’s new job meant she could now live on her own and no longer had to make the forty-minute commute back to her hometown every day. It also meant her family now saw her as someone who could contribute financially to the household, even though her earnings were meager. Eva shared this view—she had made a promise to her father shortly before his death that she would complete her studies and become a professional in order to help pull her family out of poverty. However, things did not go as planned: shortly after Eva started working, her mother, now a widow, and one of her sons-in-law became embroiled in an ugly legal dispute that split the family into two sides. Soon, both sides were pressuring her to support one or the other. Her brother-in-law asked Eva to testify in court against her mother, something that greatly distressed her.

Soon, Eva began to research things obsessively on the Internet, as she was convinced that numbers and dates held hidden meanings. Although she considered herself a skeptical scientist, she began to think her sister had cursed her hand, causing her spasmic pain. The day she was scheduled to testify, her brother-in-law sent her a text message saying he was sending someone to pick her up. Eva panicked, suddenly fearful that the person who was coming was going to hurt her. She left her apartment and asked a friend to help her hide. Soon, her friend realized that something was very wrong. Eva was hearing voices and speaking incoherently. Her friend contacted Eva’s mother, who saw her daughter’s mental state and took her to Las Lomas, where she was involuntarily committed.

A few days after she was hospitalized, Eva sat in a consultation room inside the acute ward. Her attending psychiatrist, Dr. Maria Tun, had been closely monitoring her progress, and was pleased to see that many of Eva’s symptoms had remitted.

Can you tell us what happened? Dr. Tun asked Eva, a question she asked her each day.

Eva put her fingers over the bridge of her nose and squeezed her eyes shut. "Todo parecía locura [it was all like madness], she began, people I knew suddenly frightened me. Things I saw on the internet suddenly seemed connected to one another, like, dates and times and astrological events. I thought I was being watched. I thought my hand was cursed and my food was being poisoned."

Eva’s vivid description is a small window into the experience of psychosis. The way she begins her story is meaningful: todo parecía locura (it all seemed like madness). Madness, for Eva, signified a frightening state of blurred boundaries between reality and fantasy, what Janis Jenkins (2015) calls the edge of experience.

Madness, writes Tanya Luhrmann, is terrifying (Luhrmann 2016). It blurs the defining features of personhood, reminding us that the foundations of our being are built on sand (270). The suffering of people who are seen as mad is a stark reminder of the fragility of the human psyche. Las Lomas frightens because of the people it houses, people broadly conceived in Mexican society as los locos (the mad). Madness troubles us, and it troubles most Mexicans, because it so easily distorts what we believe makes us human. For Eva, the fragility of her own sanity—her rapid transformation from an educated young scientist to a frightened, delusional human being—illustrates how madness is simultaneously alien to our everyday experience yet closer than any of us care to admit.

Mental illness, particularly what some call madness (those forms of severe mental illness that necessitate confinement in a psychiatric institution) is as stigmatized in Mexico as it is in the United States—although, as I will discuss, the etiology of severe mental illness and other kinds of mental distress is understood and addressed differently on the local level. In this book, I frequently use the word madness to describe the symptoms and experiences of the people I interacted with. I do this because madness is a more open-ended term than mental illness, schizophrenia, or psychosis. It is a kind of catchall term that describes a swath of symptoms, from delusions to hallucinations to crippling melancholy. It provides us with continuity: when I write of madness I write of it the same way as do some of my intellectual interlocutors—Fanon ([1952] 2008, [1961] 2004), Luhrmann (2016), Ríos Molina (2009). The word madness (locura in Spanish) resists the sanitizing effects of medicalization and burrows in its contrarian roots, showing the messiness of human suffering that accompanies it. As I discuss later in this chapter, what makes a person mad or loco in this context is not a medical diagnosis but socially determined; the term is both troubling and flexible.

While Yucatan has frequently been portrayed by regional specialists as a world apart [from the rest of Mexico] (Moseley and Terry 1980; Terry et al. 2010), a culturally distinct area with ties closer to the Caribbean and Europe than to central Mexico, it remains firmly part of the Mexican state, intertwined within the nation’s own historical narrative. The history of psychiatry in Yucatan and Mexico is characterized by cycles where a new method supplants an old one in the name of modernity (Sacristán 2005). Before Las Lomas, people with mental illness were housed at the old Hospital Leandro León Ayala, usually referred to as the Asilo Ayala, a beautiful building that today houses Bellas Artes, the state school of fine arts. Inaugurated on February 6, 1906, the old Asilo Ayala and the former penitentiary and still-operating Hospital O’Horan were commissioned by President Porfirio Diaz, whose thirty-five-year dictatorship is today remembered as El Porfiriato (the Porfirate or Porfirian period, roughly from 1876–1911). Porfirian development policy was inspired by a Comptian-influenced positivist philosophy and an Americanized Spencerism (Priego 2012): science was upheld as the key to modernization, yet the elite readily accepted the racist idea—based on U.S.-generated notions of race—that Mexico’s large indigenous population was preventing it from evolving into a modern state. Modernity came to be equated with whiteness (Echeverría 2010). The racist view that the majority of Mexico’s population was simply too uncivilized to handle liberal democratic governance served as justification for the lengthy Porfirian dictatorship, which went against the tenets of French Liberalism, which had formed the basis of Mexican governance since the