Mental Health, Suspicion, and Care in a Peruvian Community

This dissertation ethnographically examines Peru’s transition from a mental health care model based in psychiatric hospitals and asylums to Community Mental Health (CMH). This project explores how a multiplicity of actors, including psychiatrists, health providers, community workers, and residents, envision and enact CMH and “community care.” It argues that CMH and the process of psychiatric deinstitutionalization transform communities. Since its enactment in 2016, CMH—and its process of psychiatric deinstitutionalization—has been an important reform regarding the provision of mental healthcare and has made visible the tensions regarding different conceptions of madness and community care between health providers and ordinary residents. The long-term fieldwork for this dissertation was conducted between 2021 and 2022 in a place I call “Ciudad Norte,” an impoverished and underserved community at the margins of Lima, Peru. The COVID-19 pandemic and its subsequent waves impacted brief portions of this fieldwork, requiring some conversations to be held over Zoom or over the phone. Prior to the reform, the state’s budget for mental health was relatively small; most of the budget was spent on Peru’s main psychiatric hospitals. Now, CMH has its own budget and is supported by Peru’s 2018 Mental Health Law, which requires every psychiatric hospital to form a deinstitutionalization committee. The goal of these committees is to locate family members of those institutionalized so that they may return to their communities. My dissertation examines what happens when formerly institutionalized individuals are “returned” to their families and communities. It centers on the experiences and perspectives of Ciudad Norte residents regarding the proximity to severe mental illness, notions of care, community, and madness, and the enactment of a social and moral community. While the CMH reform was intended to resolve some of the issues regarding the provision of mental health to those in need, it has also generated unexpected consequences. Residents conceive of the reform as “the mad no longer contained in the asylum,” and instead housing them in their otherwise-sane community. Neighbors fear proximity to the potentially mad. There exists a climate of deep and mutual suspicion that, in conjunction with other historical processes such as the years of political violence (1980-2000) and the Fujimori dictatorship (1990-2000), taints social relationships between neighbors. This dissertation engages with the multiple conflicts and tensions emergent in the transition to CMH and the process of deinstitutionalization, and demonstrates that the effects of these processes go beyond the realm of “mental health.”