Social route: Peruvian psychiatrists and the politics of mental health reform
Claux, Juan Alberto
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This thesis is about the prospect of change in the Peruvian mental health services system as seen through the lens of public psychiatry. It is based on the depiction of the work of psychiatrists in two of Lima’s mental hospitals -Hospital Valdizán and Instituto Noguchi- and the projects of mental health services reform that I found in both of these institutions and an advocacy group sponsored by the Pan American Health Organisation. Ethnographic fieldwork was conducted from April 2012 to July 2013. I portray the current paradigm of care that dominates the public psychiatric sphere by describing the practice of specialists in outpatient consultations and hospitalisation wards. What I call the empirical model of psychiatry is an objectivistic, pharmaceuticalized, and top-down practice that finds its most augmented version in the wards. It loses sight of such therapeutic mandates as cultivating rapport, giving voice, and providing social support, elements that can be encountered in alternative paradigms of care that hold a marginal position in today’s mental health system, such as the community mental health model that was developed in the 1980s at Instituto Noguchi and has progressively faded into near oblivion. The multiple inadequacies of treatment reviewed in this thesis, which are fuelled by a historical relegation of mental health policy in the country, speak of a psychiatry that is far from effectively improving the lives of service users. This was the greatest blind spot revealed by the mental health reform agenda; the need to improve psychiatry as a therapeutic practice was largely absent from reform discourse. Another important issue encountered was the failure of initiatives focused on training primary healthcare professionals in detecting and treating mental health problems (task-sharing). I argue that sustainable task-sharing strategies, added to comprehensive and locally-sensitive models of mental health services, should be explored. Finally, there is a paradox to be solved in relation to mental health governance in Peru. Psychiatry has hegemony; it owns the national institute of mental health and presides over the national mental health direction at the Ministry of Health. However, as a profession it has remained alienated from public health matters, absorbed in the daily practice of public hospitals and private practices. Mental health governance, then, needs to be balanced with the contribution of other professions and this is where the social route of the mental health system gains significance: anthropology has great potential to help develop a richer understanding of people’s mental health and craft effective services in socially unequal and multicultural societies.