Rainforest Asylum

The Enduring Legacy of Colonial Psychiatric Care in Malaysia

Sara Ashencaen Crabtree

• Publisher: Whiting & Birch Ltd
• Year: 2015
• eBook ISBN: 9781861770813
• Edition: 1
• Topic: Social Sciences
• Subtopic: Cultural & Social Anthropology
• Index: Social Sciences

The author argues that psychiatric services in Malaysia retain many of the premises of colonial psychiatry, while little influenced by more recent concepts such as service-user empowerment. Also present in Malaysian health services are features unique to this region (such as the continuing popularity of traditional healing practices) which are not congruent with the colonial premises.

1

Introduction

In 1996, fresh from university studies, I was delighted to leave a wintry Britain to take up my first academic post in Malaysia – a compellingly fascinating region. My first experience of Malaysia was the congested capital city of Kuala Lumpur, where bristling, hyper-modern skyscrapers towered over the more sedate, colonial villas and municipal landmarks, thus defying many of my more outdated notions of the city. Finally, I arrived in Sarawak, East Malaysia, which I found both beautiful and sufficiently steeped in a polymorphous and multifaceted heritage to satisfy my romantic instincts and where I lived very happily for the next five years. Settling in at the local university I subsequently learned probably as much from my friendly, multicultural Malaysian students as I taught them of the social sciences.

At some point during those first exciting, confusing and frenetic months of orientation I became aware of the existence of a discreetly located psychiatric hospital built some sixty or so years earlier. I had long been interested in mental health issues and resolved to learn more about mental health provision in this area at the first opportunity. As I settled into my new life, it became apparent that the hospital had been virtually untouched by previous external research, and yet appeared to offer an intriguing picture of post-colonial psychiatric care that invited closer attention.

After making some initial overtures to the hospital authorities, I was eventually sufficiently privileged to be permitted to carry out a series of research studies at the hospital, which for the purposes of confidentiality, whilst trying to remain true to the appellations of many psychiatric hospitals in Malaysia, I have duly called ‘Hospital Tranquillity’. This book, the culmination of my research studies there, represents a pioneering experience for me in view of the dearth of research activities taking place on such topics regionally.

Moreover, the few studies undertaken on mental health issues in Malaysia have mostly been scientifically based. Therefore, being quantitative in methodology, they have not focused upon subjective experiences, particularly those of psychiatric patients, which incontestably formed a serious deficit in our understanding of mental health phenomena. A gap in the literature, therefore, was evident. Thus the study, after duly negotiating logistical problems and the potential quagmires of ethics committees, commenced in 1997. Reaching a zenith in the new millennium, it was periodically dusted down in the intervening years. Now fully revived and revised, this ethnography offers an account of the lives of both patients and staff in a post-colonial psychiatric institution in Malaysia. In so doing it has drawn from a particularly influential well of knowledge – the surge of interest by historians in colonial psychiatry – which has illuminated many of the phenomena noted in this study; and which may be seen to make its own tangential contribution to our dislocated understandings of historically situated care.

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The aim of the ethnographic approach, which is the chosen form of methodology used here, links the narratives of participants to the overarching theme relating to the embedded nature of the colonial paradigms of the asylum, which, it is argued, are implicitly enacted at Hospital Tranquillity. Ethnography enables the researcher to engage closely with a complex social situation. It is the pursuit of understanding of the ‘culture’ of the setting through an analysis of the conditions of individuals therein, premised upon and grounded in their experiences and perspectives. Accordingly, the concept of ‘culture’ defines how participants view their world, and interact with and from within it, using a phenomenological view. Here it serves to define the categories of participants: as ‘patients’ or ‘staff’ with implicit and explicit social guidelines that prescribe expected conduct for each group. Naturally, however, individuals frequently do not react or behave in the way that might be predicted from their acculturation (Helman, 1990). Consequently, the descriptions of participants across the institutional strata are noted in reference to their experiences of hospital life, albeit often from very different perspectives. The strong resonance between narratives and theory therefore seeks to lend a muscular and vigorous credibility to a critical discussion of postcolonial psychiatric services in contemporary Malaysia.

Furthermore, as will be discussed in more detail in Chapter Two, this study does not attempt to camouflage or obviate the mediating influences of my cultural background, but instead openly exploits this as a prism through which to interpret findings and my role as a researcher. My position as a British, white and female researcher therefore creates an interesting resonance in research undertaken in a developing country with a British colonial heritage, and is explored in greater depth.

Finally, I would add that, as this is a study of a unique phenomenon, it would be unwise to make gross generalisations across all psychiatric institutions in Malaysia or to assume that one psychiatric hospital is exactly the same as another (Brewer, 2000; Hammersley, 1990b). As will be seen however, the narratives of participants do raise important questions for contemporary services in this region, and serve to increase our awareness and comprehension of the development of mental health services in other postcolonial nations. Those services considered here are grounded in the historical context of colonialism in Malaya and its relationship with the advancing profession of psychiatry practised on subject nations. That many of these traditional, and often very oppressive, practices and attitudes can still be found in current service delivery is at least disquieting and demands closer scrutiny. Yet, the insights provided by analyses of colonial psychiatry suggest that there are some close parallels to be drawn in the evolutions of psychiatry between Malaysia and Britain in particular, and also across the other nations of the Commonwealth.

A guide to terms and semantics

After grappling with the ethics of what constitutes confidentiality issues in research and to whom or how this should be extended, as well as for whose interests, I have decided on a compromise in which both the names of all participants have been carefully disguised, as has the name of the hospital. The geographical location of the hospital is implied but not specified, as clarification of the role the hospital plays in the wider, multicultural community is essential to our understanding of its local and regional importance.

Furthermore, I regularly refer to people admitted to the hospital as ‘patients’ rather than using the more progressive and popular term ‘service user’. This latter term has become ubiquitous in the UK, for example, where it is strongly associated with consumer choice towards psychiatric services (including the issue of the right to refusal of services). It emphasises individual rights and empowerment and stands in contrast to the more passive term of ‘patient’. Therefore, my reasons for not using the term ‘service user’ are conscious and pointed, and first of all relate to the fact that primarily the term is in rare currency in Malaysia. It is also one that is not used by informants at the study site, and I consider it more in keeping with an ethnographic approach not to impose titles relating specifically to the context, but which are nonetheless unfamiliar to it. The term ‘patient’ by contrast is one generally utilised by parties employed, admitted or visiting the hospital, and is therefore the one I have adopted throughout this study.

In addition, the hospital is occasionally referred to as an ‘asylum’ by some participants. This term however carries very powerful connotations, as, for example, has been used to notable effect by Erving Goffman in describing the almost complete lack of autonomy characteristic of the ‘total institution’ in which all normal functions of life are carried out in a regimented fashion under a single supervisory authority (Goffman, 1991). Some of the findings discussed in the study depict institutional practices at Hospital Tranquillity, which are commensurate with Goffman’s terminology and illustrative examples. I have therefore appropriated the term ‘asylum’ and use it in a deconstructive manner to describe certain aspects of hospital policy and episodes of patient care, which I feel comply rather more with a highly custodial and disempowering environment for patients and for staff, than with the practices compatible with Western contemporary consumer ideology. However, equally I recognise that the term ‘asylum’ also corresponds to the notion of a haven, which holds historical resonances to the establishment of such institutions, as explored in more detail in Chapter Three. Additionally, in Chapter Four, the first of the chapters on fieldwork, this tension is explored in more detail in relation to participant experiences of the psychiatric institution as both imprisoning and as acting as a refuge. Finally, in relation to the process of fieldwork, I refer to those interviewed as both ‘respondent’ and ‘participant’. I am conscious that I use these terms according to subtle nuances, in that ‘respondent’ tends to indicate to me a more formalised interview relationship than that implied by the latter term. Nonetheless, for the reader’s benefit I would conclude by saying that in effect these terms are used more or less synonymously.

The social and historical background to the study

The city where the study took place is relatively small and prosperous, with a largely white-collar workforce mainly employed in Government administration, served by a large population of shopkeepers and commercial workers (Hew, 1999). It is a rapidly changing city in a region long wealthy in natural resources, but these have been regularly exploited, causing the dispossession of many indigenous groups. For the most part the region’s resources are harvested by the less well-off and comparatively over-populated Peninsula. This is not to say that the new opportunities and prosperity have not succeeded in filtering down to many people. Nonetheless, for the social scientist it is not necessary to be equipped for a lengthy expedition to find many examples of hard-core poverty, literally on the ample, polished doorstep of the city.

The Chinese presence in the city is evident, where streets are dominated by Chinese food outlets and ornamented by colourful Buddhist temples. However, the attempt to alter the Chinese ethnic flavour of the city is accelerating, where, for example, many of the old colonial street names of long dead British administrators, along with prominent ethnic Chinese personalities, are gradually being replaced with those that reinforce a focus on the country’s prevailing power balance.

Briefly, the historical background to modern Malaysia effectively starts in 1957 when Malaya gained its independence from Britain. In 1963 the two States of East Malaysia, Sarawak and Sabah, joined with Malaya to form the Federation of Malaysia. Since then political lines have been drawn in the enshrinement of pro-discriminatory policies towards Malays and indigenous peoples in the country’s constitution, whereby these groups are welded together under the title bumiputera, literally ‘sons of the soil’.

The New Economic Policy in 1971 continues to be regarded as a contentious political strategy. As Cleary and Eaton (1992: 93) point out, ‘positive discrimination …. has meant that there is considerable economic self-interest attached to classification methods’. This has fuelled, one might add, considerable resentment amongst non-bumiputera citizens, as well as proving an expensive expedient in many ways for the country as a whole (Kheng, 2003). Yet, it is also argued that even among the identified bumiputera inequalities exist between the ‘birthright’ Malay bumiputera and those among the indigenes who have acquired this status through religious conversion to Islam (Baba, 2010). Not surprisingly, the affirmative action policy was the basis of the conflict between the newly founded Malaysia and Chinese-dominated Singapore, resulting in the latter’s expulsion from the Federation in 1965.

The effect of this is that the bumiputera have been able to purchase land at a favourable price in all areas. The Chinese and other non-indigenous groups, however, have not been allowed this latitude, and are concentrated in urban areas. This consequently has an influence on the demographic population of consumers of psychiatric services that are predominantly urban based, and which forms an important context to the discourses of patient ‘race’ or ethnicity, discussed at greater length in Chapter Eight.

Popularly psychiatric hospitals and asylums have often been regarded as deplorable institutions, redolent of abuse, neglect, abandonment and at best unmitigated tedium and rigid routine. In fiction Kesey’s sensationalised novel One Flew Over the Cuckoo’s Nest depicted medical treatment, specifically ECT (electro-convulsive therapy) as brutal, punitive and ultimately destructive of individual autonomy (Kesey, 1962). However, Goffman’s (1968, 1991, 1993) far more sober, academic study also depicts the psychiatric institution as fundamentally dehumanising.

In some regions of the world, psychiatric services have supplied a notoriously poor service, such as, for example, the ‘chaotic and miserable’ environment of Greece’s psychiatric community on the island of Leros (Strutti and Rauber, 1994: 309). This hit the headlines in the 1980s with photographs of naked, disorientated patients of indeterminate sex in many cases, being hosed down with cold water, like so much cattle, by indifferent and demoralised staff. Leros seemed to typify the worst conditions of asylum care of an earlier age and maybe even of other developing countries, as asserted in the following statement.

Mental hospitals in the Third World are fairly dreadful places, and there are many in which custodial care is the only intention, ECT the usual treatment, staff brutality is commonplace, all patients compulsorily detained and few ever discharged (Rack, 1982: 171).

Large scale reform of psychiatric services have in fact taken place, such as that under Franco Basaglia, who spearheaded the attack on the abusive systems of psychiatric institutions in Europe, resulting in legal changes in Italy in the late seventies. While following on from this in latter years British service users, for instance, have succeeded in speaking out about the brutalities and repressions of institutional care (Laing, 1996; Sainsbury Centre for Mental Health, 1998).

Additionally, in the West a feminist body of critique has built up to explore the particular significance of psychiatry in relation to women service users. This argues that women are exposed in great numbers world-wide to a male-dominated medical hierarchy that replicates the patriarchal oppression of society within the stigmatising and controlling confines of psychiatric services (Chesler, 1996; Russell, 1995; Showalter, 1985). Although the United Nations have acknowledged that women suffer massively from the trauma of violence and oppression, little has specifically been written concerning the position of women in psychiatric services beyond the ethnocentric focus of the West although certainly this is a subject that deserves greater academic focus (Wetzel, 2000). Consequently, in considering psychiatric care in developing regions, the condition of women is frequently subsumed by the generic plight of patients per se, rather than subjected to gender differentials. In this study, there has been an endeavour to amply the otherwise relatively muted voices of Malaysian women, predominantly, as patients; however, there has also been a concerted attempt to apply a gender-based analysis to the lives of psychiatric staff, both nurses and the rare female doctor as well.

Although psychiatry is a relatively new profession and, as can be seen, has been besmirched by negative stereotypes, the institutional environment in which psychiatry has been practiced has often been viewed with enormous social stigma accompanied by social anxieties. As argued here, the exporting of the asylum model to the colonies, such as colonial Malaya, did not appear to evolve a new approach to care, but merely engaged in transferring not only contemporary skills and knowledge of the time, but social attitudes as well. This then is the background to the study of the hospital which, being built at the end of the colonial era, has seen many changes in the care of psychiatric patients. It continues to be an important example of institutional responses to social and political developments towards mental illness and the welfare of those who use the services.

Organisation and navigation

The final section of this chapter seeks to assist the reader in their navigation of the text. Accordingly, Chapter Two focuses upon the use of ethnographic methodology and methods underpinning this study. The logistics of field work are additionally discussed in respect to the crucial forging of relationships with participants, and finally, ethical considerations in fieldwork.

Chapter Three critically scopes the literature devoted to the historical background of evolving psychiatric services in the West, colonial territories in the Indian subcontinent and elsewhere, and subsequently Malaya and Borneo.

The findings of the study commence in Chapter Four, by locating Hospital Tranquillity within a historical, geographical, social and cultural context. Following this, a discussion of the routines, rituals and the socialisation process of life in the ward environment is offered.

Chapter Five concentrates on the hierarchical socialisation of individuals and relationships between patients. This concludes with an examination of the nature and utilisation of patient labour structured on stereotypical gender divisions.

In Chapter Six methods of patient control are reviewed, such as treatment programmes that include electro-convulsive therapy. The chapter concludes with a ‘service user’ view of how medication is used at the hospital.

Subsequently Chapter Seven considers how women patients are subject to stringent control in terms of freedom of movement consistent with patriarchal stereotypic notions of gender and mental illness.

The following chapters are devoted to issues of staffing. The conditions of work at the hospital are considered in Chapter Eight, where professional practice and career opportunities are viewed against a backdrop of the national policy debate on service delivery. In Chapter Nine, staff strategies of control and containment of patients are explored, along with staff perceptions of risk and violence in working with psychiatric patients.

Finally, Chapter Ten draws the findings together in a concluding discussion.

2

Fieldwork and field relationships

Social science studies that engage directly with the issue of culture, both as conceptual and overlapping social construction, as well as ‘culture’ enacted as a unfamiliar and factual reality, such as is the case here, have typically been classified as essentially anthropological in essence. Classic anthropological ethnographies have almost invariably taken place in locations far removed from the home environment of the researcher, such as those of Malinowski in New Guinea (1922) or Mead in Samoa (1943). These locations have often been perceived as exotic or in some other sense removed from the familiar. Nancy Scheper-Hughes, for instance, leaves the United States of America and chooses rural Ireland, which appears to represent a sharp contrast to her own cultural background; subsequently writing an account of anomie, social and, arguably, cultural stagnation and mental illness (Scheper-Hughes, 1982). Sue Estroff, by contrast, emphasises that her ethnographic study of mental illness in Wisconsin takes place in her own hometown. Although this was a study from home, she conveys the polarisation between the underground existence of a deeply marginalised group of people and the privileges of the comfortable, conventional living standards that she is familiar with (Estroff, 1985). Scheper-Hughes also offered an account of neonatal mortality in impoverished communities in Brazil. This locat...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Preface
• Acknowledgements
• 1. Introduction
• 2. Fieldwork and field relationships
• 3. Psychiatry and the colonial enterprise in historical Malaya and Borneo
• 4. The transformation to patient-hood
• 5. Ward relationships: Power and reciprocation
• 6. Healing, medication and resistance
• 7. Mad, wanton women and the feminine ideal
• 8. Strategies of containment on the ward
• 9. Towards community psychiatry
• 10. Reflections and conclusions
• References
• Index