Sentosa: a Feminist Ethnography of a Psychiatric Hospital in Sarawak, East Malaysia

SENTOSA: A FEMINIST ETHNOGRAPHY OF A PSYCHIATRIC HOSPITAL IN SARAWAK, EAST MALAYSIA SARA ASHENCAEN CRABTREE A thesis submitted in partial fulfilment of the requirements of the University of Hertfordshire for the degree of Doctor in Philosophy The programme of research was carried out in the Department of Health and Social Care, Faculty of Health and Human Sciences, University of Hertfordshire. November 2002 I ABSTRACT This doctoral thesis is a feminist ethnographic study of psychiatric patients in the State of Sarawak, East Malaysia. The study took place at a psychiatric hospital located in the capital city of Kuching, commencing in 1997. Although Hospital Sentosa is a small institution it is the only psychiatric institution in the State and therefore constitutes an important mental health resource in this region. This ethnographic study primarily concentrateson the lives of women patients in keeping with my chosen methodological approach and seeks to explore the 'culture' of the hospital setting through facets such as daily interactions, activities and relationships. The feminist approach has not however precluded the accounts of male patients whose experiences are utilised in a comparative exercise with those of women counterparts. In addition the views of staff of both sexes and all ranks are considered in relation to their attitudes towards the care of psychiatric patients and the broader area of work-related concerns including collegial support and occupational hazards. In keeping with an ethnographic approach themes developed in the thesis are drawn through an analysis of findings as noted by observation methods as well as through interviews with participants. Furthermore a self-reflexive approach has been an important aspect of analysis commensurate with feminist methodology, in which my role as a researcher is considered in relation to issues of culture, gender and class as well as some of the difficulties of research in a post-colonial and unfamiliar cultural context. Although some avenues of inquiry in the study have not easily lent themselves to an analysis of gender, this thesis primarily argues that the hospital reproduces oppressive policies and practices that impact with greater severity on women patients. Oppressive practices in relation to gender and ethnicity at the hospital are viewed against a backdrop of contemporary psychiatric care as enacted on wards. It is argued that these practices can be viewed in turn as being, for the most part, historically premised upon imported British models of care replicated through colonialism in Malaya and by extension at a later period in the multicultural State of Sarawak. UNIVERSITYOf HERTFA-GUIRE u HATFIECDNbl, PUS M IRATFIELDAL10 9AD i --A MB Z\ö _11 f4c&Sýack IW- oo3 -7 ACKNOWLEDGEMENTS I have several people to thank for helping me to achieve the completion of this doctoral thesis, many of whom cannot be mentioned by name for reasons Of confidentiality. Of those who can, I would first of all like to thank the two branches of my supervisory team based at the University of Hertfordshire, UK and in Sarawak respectively. Many thanks are due to my supervisor Dr Roger Green who despite all the problems of long- distance supervision has helped to keep me on track throughout this research project. Thanks also are due to Soo Lee, Manjit Rostom and Jim Roche of the University of Hertfordshire, the latter of whom strongly but humorously advised me to 'put some walls' around my original proposal. I hope that this final study of a somewhat enclosed psychiatric institution has justified his good advice. Many thanks are also due to my local Malaysian supervisor Dr Lau Kim Kali whose opennessto the study and generosity with his very limited time literally made this study possible. Thanks also are due to my local advisor Mick Bowman of the Sarawak Mental Health Association, whose experience, knowledge and insights into psychiatric care in this region were of enormous help on numerous occasions. I would like to mention with gratitude my three final-year social work students Chan Soak Fong, Pek Wooi Ling and Jessing Ak Awos for their translation skills and for prompting further insights through their intelligent questions and keen interest in the subject matter. Many thanks are heaped upon my two friends and colleagues at the University Malaysia Sarawak for their invaluable help at critical points in the project. Gabriel Chong must be mentioned for his tireless and uncomplaining assistance in sorting out most of my computer problems throughout this project, of which there were very many. Additionally Dr Hew Cheng Sim for her generous loan of relevant literature, when the literary well in Malaysia looked as though it had run dry. While a further thank you is due to my former Dean Dr Abdul Rashid Abdullah of the University Malaysia Sarawak for providing an academic environment personally conducive to research, as well as for his earlier efforts in helping me secure grants from my employing university which enabled me to build on my knowledge of mental illness in this region. Of those whose names cannot be mentioned, I would like to thank everyone who participated in this project, with enormous thanks to the patient informants at Hospital Sentosa who treated my often rather incomprehensible presence and inquiries with generosity, wit and welcome. In addition, many members of staff of all ranks and specialities and external service providers made a very important contribution to my understanding of the hospital and mental health services and policies in general. Finally, I would like to express my most heartfelt appreciation of my husband Jack Crabtree for his consistent support, faith and encouragementas well as devoted childminding of our baby daughter Isabel throughout a difficult time. Not to forget his invaluable and polished editing skills throughout this thesis, which by now he is as intimately familiar with as I am. iii CONTENTS Chapter One. An Introduction to the Study 1.1 Introduction 1 1.2 The aims and limitations of the study 1 1.3 Personal, professional and political commitments 4 1.4 The social and historical background to the study 9 1.5 Terms and semantics 11 1.6 Organisation of the thesis 13 Chapter Two. Psychiatry and the Colonial Enterprise in Historical Malaya and Borneo 2.1 Introduction 16 2.2 Psychiatry as an emerging profession 17 2.2.1 The historical development of the asylum in the eighteenth and nineteenth century 18 2.3 Psychiatry and colonialism 22 2.3.1 Colonial interest in anthropology and psychiatry; the arbitration of deviancy 24 2.3.2 Critiques of colonialism in modem psychiatry 27 2.4 Benevolent medicine and colonial propaganda in Malaya and Borneo 31 2.4.1 Psychiatry in colonial Malaya 32 2.4.2 Migration, gender and asylum admissions 33 2.4.3 Migration, ethnicity and mental illness 39 2.4.4 Care regimes in the therapeutic asylum in Malaya 41 2.5 Borneo: disease, disasters, colonial rule and colonial medicine 44 2.5.1 Imperialism and the propaganda of European medicine 45 2.5.2 Anxiety and isolation: stress in local populations in Borneo 46 2.6 The demise of the 'therapeutic' asylum in pre and post-war Malaya 50 2.6.1 Post-war modernisation in the Federation of Malaysia 51 iv Chapter Three. A Feminist Methodology: Personal dilemmas and challenges 3.1 Introduction 55 3.2 Anthropology, ethnography and feminism 56 3.2.1 Postmodernism.and ethnographic authority 59 3.3 Feminist ethnography as situated objectivity 62 3.3.1 The feminist consciousnessand dissent 65 3.4 The researcher in the field: methodological and ethical considerations 70 3.4.1 Epistemological considerations 70 3.4.2 Representation and appropriation 74 3.4.3 Feminist politics and accountability 79 Chapter Four. Commencing Fieldwork 4.1 Introduction 86 4.2 Accessing the site 87 4.2.1 Choosing the location 87 4.2.2 Gatekeepers and participants 89 4.2.3 The selection of wards 96 4.3 Data collection and the ethnographic process 97 4.3.1 The research design 97 4.3.2 The use of critical observation 100 4.3.3 Interviewing participants 104 4.3.4 Rapport, reciprocation and power in the interview situation 109 4.3.5 Documentation and statistical information 114 4.3.6 The process of analysis 116 4.4 Language and linguistic barriers 122 4.5 Some ethical considerations 126 V Chapter Five. The Transformation to Patient-hood 5.1 Introduction 130 5.2 The ideal asylum: physical boundaries and demarcatedvalues 130 5.3 Categorising patients: the 'salvageable' and the 'irredeemable' 133 5.4 The cycle of patient-hood through admission and dischargesprocedures 138 5.4.1 Life problems and hospitalisation 141 5.4.2 Discharge procedures: custodianship and gender 149 5.5 Ward existence and the process of socialisation 151 5.5.1 A 'typical' day: life on the wards 155 5.5.2 Uniforms as symbols of identity 159 Chapter Six. Roles and Relationships: Power, dominance and reciprocation 6.1 Introduction 164 6.2 Reciprocal relationships 165 6.2.1 The conditions for friendship 165 6.2.2 'Sharing' networks among patients 168 6.2.3 Profiteering in the marketplace 171 6.3 Dominant relationships 175 6.3.1 Achieving prominent status 178 6.4 Familial relationships and the connection with patient labour 185 6.4.1 Patient exploitation through 'therapeutic' work and gender disparities 188 Chapter Seven. Control of Patients Through Regimes of Care 7.1 Introduction 193 7.2 Medication, 'compliance' and resistance 193 7.2.1 The 'compliant' patient 194 7.2.2 Resistance through 'non-compliance' 197 7.3 ECT as an instrument of control 201 7.4 Open and locked wards: gender norms and physical control 207 vi 7.4.1 Reinforcing the virtue of feminine passivity 211 7.4.2 The female sex object in suspension 219 7.4.3 The viability of a lesbian alternative 222 Chapter Eight.

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