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