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