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THE INFLUENCE OF BURMESE BUDDHIST UNDERSTANDINGS

OF SUFFERING ON THE SUBJECTIVE EXPERIENCE AND

SOCIAL OF

by

SARAH ELIZABETH ADLER

Submitted in partial fulfillment of the requirements

For the degree of Doctor of

Dissertation Adviser: Dr. Melvyn C. Goldstein

Department of

CASE WESTERN RESERVE UNIVERSITY

January 2008 CASE WESTERN RESERVE UNIVERSITY

SCHOOL OF GRADUATE STUDIES

We hereby approve the thesis/dissertation of

______

candidate for the ______degree *.

(signed)______(chair of the committee)

______

______

______

______

______

(date) ______

*We also certify that written approval has been obtained for any proprietary material contained therein. TABLE OF CONTENTS Page

List of Tables v Acknowledgements vi Abstract vii

I. Introduction 1

A. Models and Meaning of Therapeutic Efficacy 2

B. The Role of in Addressing Health Concerns 6

C. Suffering: Connecting Religion and Illness Experience 10

D. The Definition and Cultural Construction of Suffering 13

E. Religion and Suffering in the Context of Schizophrenia 18

F. , Suffering, and Healing 22

G. Summary of Objectives and Outline of the Dissertation 28

II. Research Design and Methods 30

A. Development of Topic and Perspective 30

B. Research Site 33 1. Country Profile 33 2. Mental Health Hospital 37 3. Outpatient Clinics 45 4. Community 48

C. Research Participants 49 1. Patient subset (n=40; 20 inpatients, 20 outpatients) 52 2. Family member subset (n=20) 56 3. Healer subset (n=40) 57 4. Survey respondents (n=142) 59

D. Interpretation and Analysis 60 1. Data Collection 60 a. Structured Interviews 62 b. Semi-Structured Interviews 66 c. Ethnographic Participant Observation 67

ii Page d. Brief Survey 68 2. Data Analysis and Interpretation 69

III. Mental Health Sectors in Burma 72

A. Psychiatry in Burma 73 1. and Western Medicine in Burma (1554-1942) 73 2. World War II and the Japanese Occupation (1942-1945) 79 3. Independence and the Birth of Burmese Psychiatry (1945-1962) 81 4. The State Mental Hospital and The Years (1962-1988) 84 5. Contemporary Psychiatry in Burma (1988-present) 87

B. Religious Healing in Burma 92 1. Buddhism and Healing 93 2. Healing Methods 97

C. Traditional Healing in Burma 103 1. Indigenous Medicine 104 2. 109

D. Summary 110

IV. Explanatory Models of Schizophrenia 112

A. General Explanatory Models of Schizophrenia 112 1. Illness Definition, Symptoms, and Epidemiology 112 2. Etiology and Onset 116 3. Course and Outcome 117 4. Treatment 120

B. Explanatory Models of Schizophrenia Held by Burmese Buddhist Respondents 122 1. Illness Definition 122 2. Illness Etiology 126 3. Illness Onset 130 4. Course and Outcome 133 5. Treatment 138

C. Summary 146

V. The Disconnect between Patient Respondent’s Experiences and Non-Patient Respondent’s Perceptions of Suffering and Schizophrenia 147

A. Burmese Buddhist Perceptions of Suffering and Schizophrenia 147

iii Page B. Experiences of Suffering among Burmese Buddhists with Schizophrenia 157

C. Burmese Buddhist Means of Managing Suffering 167

D. Suffering, Feeling, and Affect among Burmese Buddhists 178 1. Burmese Buddhist Cultural Norms for Expressing Suffering 179 2. Respondent’s Expressions of Suffering 180 3. The Problems of Expressing Suffering for People with Schizophrenia 186

B. Summary 190

VI. The Role of Suffering in Burmese Buddhist Identity and its Impact on the Experience and of Schizophrenia 192

A. Features of Human Identity among Burmese Buddhists 194

B. The Impact of Dehumanization on the Experience of Schizophrenia 204 1. Buddhism, Stigma, and Social Interactions with the Mentally Ill 204 2. Dehumanization and the Ambivalent Role of Buddhism in the Treatment of Schizophrenia 210

C. Summary 220

VII. Conclusions 222

A. Summary of the Dissertation 222

B. The Role of Subjective Experience 229

C. The Meaning and Function of Feeling and Affect 232

D. Human Identity and the Authenticity of Suffering 234

E. Concluding Reflections 237

References 241

iv List of Tables Page Table 2.1. Unit (ward) Descriptions at the Yangon Mental Health Hospital, October 2002 39

Table 2.2. Socio-demographic Data of Research Participants 51

Table 2.3. Sites of Outpatient Recruitment 55

Table 2.4. Description of Family Member Respondents 56

Table 2.5. Description of Healer Types 58

Table 2.6. Axis I Diagnoses of Patient Participants 65

Table 3.1. Consultant Posted to Burma’s State/Division Hospitals and Clinics 89

Table 4.1. Patient and Family Member Respondent’s Illness Definitions 123

Table 4.2. Patient and Family Member Explanations for Patients’ Illness 127

Table 4.3. Healers Who Treat Mental Illness According to Survey Respondents 141

Table 4.4. Healers Who Patients Consulted 142

Table 5.1. Is suffering an inevitable feature of life? 148

Table 5.2. Do the mentally ill suffer? (In-depth Interview Respondents) 150

Table 5.3. Do the mentally ill suffer? (Survey Respondents) 150

Table 5.4. Non-patient responses by patient category 154

Table 5.5. Non-patient responses by healer type 155

Table 5.6. Non-patient responses by socio-demographic characteristics 156

Table 5.7. Do you suffer more than, less than, or the same as people with no mental illness? 157

Table 5.8. How do you cope with your suffering? 168

Table 5.9. Can you tell if someone else is suffering? 179

Table 5.10. Can others tell if you are suffering? 181

v Acknowledgements

This dissertation fieldwork and write-up was supported by a Ruth L. Kirschstein National Service Award granted through the National Institute of Mental Health (No. 1F31MH67479) and a Phi Beta Kappa Grant for Student Research granted through the Case Western Reserve University chapter of the Phi Beta Kappa Society. I would like to thank the Ministry of Health for granting me permission to conduct research at the Yangon Mental Health Hospital, several psychiatric outpatient departments, and the medical school library. I would also like to thank the staff of these institutions for their generous assistance. I would also like to acknowledge the many psychiatrists, particularly my supervisors, with whom I worked. Their support and guidance helped make this fieldwork possible. In addition, I owe special thanks to my interpreter whose companionship, dedication, and unsurpassable skills greatly enriched many aspects of this fieldwork. My field assistants also deserve recognition for their valuable contributions. In particular, I owe an enormous debt of gratitude to the many patients, family members, and healers who bravely shared their stories with me. This dissertation is dedicated to them. I would especially like to thank my dissertation committee, Profs. Melvyn Goldstein, Atwood Gaines, Charlotte Ikels, and James Overholser for their support when I most needed it. In particular, my advisor, Professor Goldstein, has been scientific mentor, sage, and friend—I cannot thank him enough for all he has done for me. I would also like to thank Kathleen Dowdell and Barbara Reebel for their help throughout the years. In addition, I would like to thank Dr. Janis Jenkins for giving me the opportunity to work on the SEACORA project. Several friends also deserve acknowledgment: Page B., Sarah R., Valerie V., Nance C., and several Burmese friends, who must go unnamed, for the insight and laughter they brought to my time in Burma. Kathryn McGowan, Elisabeth Ihler, Nina Aranoff, and Holly Augusta for the friendship and lively conversations that made graduate school all that it should be. Kathy, in particular, deserves a medal for her unwavering help and encouragement. In addition to the support of academic colleagues and friends, this dissertation would not have been possible without the support of my family, particularly my husband, Stuart Adler. Saya cinta padamu.

vi

The Influence of Burmese Buddhist Understandings of Suffering on the Subjective Experience and Social Perceptions of Schizophrenia

Abstract

by

SARAH ELIZABETH ADLER

Medical anthropologists have argued that therapeutic efficacy goes beyond addressing clinical aspects of illness and disease. This is particularly true for chronic or persistent illnesses where religion has been shown to play a central role in how people conceptualize and manage their health concerns. A unifying theme within this literature is that illness suffering involves more than specific symptoms, but also existential crisis, loss of control over fate, social stigma, erosion of social support, and socio-economic hardship. A comprehensive understanding of treatment efficacy, and religion’s many possible roles in it, however, remains elusive.

Of particular recent interest is the role religion may play in the lives of people with schizophrenia. Schizophrenia constitutes one of the most severe psychiatric illnesses, and epitomizes many non-symptomatic sources of suffering. Recent studies show that patients with schizophrenia are especially likely to turn to religion after the onset of their illness. Studies also show that in less industrialized countries, where religious healing is often a more prevalent and highly utilized form of treatment for schizophrenia, patients appear to have a better outcome. However, no complete ethnographic studies have fully elucidated the roles played by specific in the lives of people with schizophrenia, particularly in terms of how religious understandings

vii of suffering influence the subjective experience of the illness, as well as the actions and perceptions of family members, healers, and the community at large.

In order to address this gap in our understanding of severe mental illness, an ethnographic study was conducted on the influence Burmese Buddhism understandings of suffering had on the subjective experience and social perceptions of schizophrenia.

More than any other religion, Buddhism promotes the inevitability and of suffering as a central theme. It was hypothesized that Buddhism would play a central and uniquely beneficial role in the lives of the severely mentally ill. However, this expectation was not entirely met. This thesis delves into the roles of Buddhism in the lives of people with schizophrenia: its positive role in addressing patients’ illness symptoms and suffering, as well as its negative role in prejudicial perceptions of the mentally ill.

viii CHAPTER ONE INTRODUCTION

Medical anthropologists have long argued that therapeutic efficacy goes beyond addressing clinical aspects of illness and disease. This is particularly true for chronic or persistent illnesses where religion and religious healing have been shown to play a central role in how people conceptualize and manage their health concerns. A unifying theme within this literature is that illness suffering involves more than specific symptoms, but also existential crisis, loss of control over fate, social stigma, erosion of social support, socio-economic hardship, and the extended suffering of families and communities.

Although many of these non-clinical aspects of illness suffering have been studied, a comprehensive understanding of treatment efficacy, and religion’s many possible roles in it, remains elusive.

Of particular recent interest is the role religion may play in the lives of people with severe mental illness, such as schizophrenia. Schizophrenia constitutes one of the most severe and debilitating psychiatric illnesses, and epitomizes many non-symptomatic sources of suffering listed above, including low quality of life, impaired social and occupational functioning, social stigma and isolation, high rates of suicide, and vulnerability to other adverse life events. Recent studies in the psychiatric literature show that patients with schizophrenia are especially likely to turn to religion after the onset of their illness. Cross-cultural psychiatric studies also show that in less industrialized countries, where religious healing is often a more prevalent and highly utilized form of treatment for schizophrenia, patients appear to have a better outcome. However, no complete ethnographic studies have attempted to fully elucidate the roles played by

1 specific religions in the lives of people with schizophrenia, particularly in terms of how religious understandings of suffering influence both the subjective experience of the illness, as well as the actions and perceptions of family members, healers, and the community at large.

In order to address this gap in our understanding of severe mental illness, an ethnographic field study was conducted on the influence Burmese Buddhism understandings of suffering had on the subjective experience and social perceptions of schizophrenia. More than any other religion, Buddhism promotes the inevitability and transcendence of suffering as a central theme. As such, it was hypothesized that

Buddhism would play a central and uniquely beneficial role in the lives of the severely mentally ill and their communities. However, this expectation was not entirely met. This thesis delves into the multiple roles of Buddhism in the lives of people with schizophrenia: its positive role in addressing patients’ illness symptoms and existential concerns, as well as the negative role it plays in shaping prejudicial perceptions of the mentally ill.

A. Models and Meaning of Therapeutic Efficacy

In their articulation of the therapeutic process, Csordas and Kleinman (1996:9) write that “therapeutic outcome refers to the disposition of participants at a designated point of the therapeutic process, with respect to both their expressed (high or low) satisfaction and to change (positive and negative) in symptoms, pathology, or functioning.” They point out that outcome is a complex phenomenon to study due to the large number of factors involved, as well as the different ways it is conceptualized. For

2 example, they observe that successful outcome is defined in biomedical terms by the elimination of a disease or disorder, while in sociological terms it is the termination of the

“sick role” (Parsons 1958 cited in ibid.). In contrast, anthropologists define outcome more broadly, linking it to cultural context, the meaning attributed to therapeutic change, and the role that cultural representation and collective experience play in altering individual states.

Medical anthropologists have struggled with how to determine therapeutic outcome in a meaningful way, particularly within contexts of or religious healing.

Csordas and Lewton (1998:493) remind us “the obvious and inevitable question that arises in any consideration of religious healing is ‘does it work?’” Answering this question becomes particularly complex given the diverse ways in which efficacy is interpreted across cultures. For example, Laderman (1991:81) describes instances in which healers whose treatments promote symptomatic relief, rather than a definitive cure, are still considered to be efficacious. Others have shown that resolving a patient’s psychosocial issues (Kleinman 1980) or enhancing spiritual well- (Glik 1986, 1990;

Levin and Coreil 1986) in addition to addressing core illness symptoms are central to the therapeutic process. Hoskins (1996) shows that the ultimate goal of Kodi (Sumbanese) curing rites is to repair social relations and “heal the group” so that even a treatment that ends in a patient’s death may still be thought of as successful and satisfying. Based on such ethnographic examples, many anthropologists have suggested that the definition of

“cure” be expanded from its narrow of restoring health, to the larger goal of repairing identity and social relations (Conner 1982; Heinz 1988; Hoskins 1996;

Laderman 1991).

3 In order to understand its cultural relevance and meaning, anthropologists have grouped examples of therapeutic efficacy from diverse healing systems into various models or approaches, which have been summarized by Csordas and Kleinman (1996) in their description of the therapeutic process, and also by Csordas and Lewton (1998) in their review of religious healing. Together these models generally attribute therapeutic efficacy to one of four types, yet the authors specify that they are not necessarily mutually exclusive categories. The first type locates the seat of efficacy in the characteristics, knowledge, responsiveness, and abilities of the healer. The second type attributes efficacy to therapeutic procedure, or the actions taken to achieve a particular health aim. Many studies of this type emphasize the performative aspects of healing as essential for persuading others of their legitimacy and efficacy. For example,

Turner (2000/1964) notes that “the diagnosticians are diviners, and their therapists are in effect masters of ceremonies” (also see Csordas 1994, 1996; Kapferer 1979; Laderman and Roseman 1996; Roseman 1991, 1996; Schieffelin 1985). The third type emphasizes the efficacy of various psychological mechanisms that transform the meaning of a patient’s illness experience. These mechanisms might include suggestion, , trance, or dissociation, which give rise to meaningful changes in self, bodily, and sensory experiences and perceptions. For example, Desjarlais’ (1996) examination of healing rites of the Yolmo Sherpas revealed that shamans transform patients’ bodily experiences by altering and enhancing their feelings and (also see Barrett and Lucas 1993;

Bharathi 1993; Boddy 1989; Crapanzano 1973; Katz 1982; Lebra 1982). The fourth type attributes efficacy to the engagement of social elements, including social support and solidarity, and the resolution of interpersonal or social conflict. Examples include

4 Janzen’s work (1978, 1987) on therapy management, or the participation of a patient’s wider community in the healing process, and Suwanlert’s research (1976) that showed that phi bob possession in Northern was viewed as a socially acceptable means of resolving interpersonal conflict.

There are few studies that address therapeutic efficacy as a central concern or give a comprehensive account of its meaning within or across cultural contexts. Csordas and

Kleinman (1996) particularly note that anthropologists have tended to examine the meaning of efficacy from the point of of healers, so that less is known from the perspective of patients, their families, or their social milieu. Some anthropologists have attempted to correct these gaps by suggesting alternative theories of efficacy, particularly in the context of religious healing (e.g., Csordas 1983, 1988, 1994; Dow 1986; Kirmayer

1993; Lyon 1990; Prince 1975, 1982; Scheff 1979), or by describing how patients themselves conceptualize treatment effect (Finkler 1985; Kleinman and Sung 1979;

Kleinman and Gale 1982). Perhaps most comprehensive is the model suggested by

Csordas (1983, 1988, 1994) based on his studies of ritual healing among Catholic charismatics, in which he describes four elements critical for assessing therapeutic efficacy:

The disposition of participants within the healing process vis-à-vis social networks and symbolic resources; concrete experience of the as empowerment, transcendence, or otherness; the negotiation of possibilities or elaboration of alternatives for the suffering person’s behavior, emotion or cognition; and the actualization of change understood in terms of what counts as significant change for participants (Csordas and Lewton 1998:496).

Csordas explains that this model emphasizes experiential specificity and incremental change rather than global and non-specific effects of treatment.

5 A consistent feature among the approaches to therapeutic efficacy described above is that across a diverse range of cultural and healing contexts, anthropological research shows that notions of efficacy are based upon the general expectation and hope that therapeutic transactions will also address wider personal, social, and existential or spiritual concerns.

B. The Role of Religion in Addressing Health Concerns

The study of religion in the context of health and illness has a long within anthropology, medicine, and psychiatry. In their comprehensive review of religious healing, Csordas and Lewton (1998) trace the relationship between anthropology and psychiatry back to the work of the French , whose contemporary work on psychological healing included descriptions of miraculous recoveries instituted by religious, magical, and folk therapies. The majority of other early cross-cultural studies of health and illness had a similar interface with religion or religious healing (e.g.,

Frank and Frank 1991 [first published in 1961]; Kiev 1964; Opler 1959). Indeed, Csordas and Lewton (1998:436) observe “the single most common feature of healing forms treated is that they are in some way religious in nature.”

The primacy of religion in therapeutic modalities around the world is unsurprising given that many sicknesses are believed to be of religious, magical, or supernatural causation. What may be the earliest records of medical history—The Assyrian Tablets from 2500 BCE—describe the cause and treatment of illness as supernaturally based

(Ehrenwald 1956:27). Medical anthropologists have shown that health beliefs continue to play a large role in utilization patterns (e.g., Rosenstock 1966; Sargent 1982).

6 For example, religious healers are often associated with particular kinds of illnesses believed to be beyond the expertise of biomedical practitioners. One of the most well documented such examples involves the treatment of spirit possession, which requires the intervention of shamans, exorcists, or other possession experts (Bourguignon 1976;

Crapanzano and Garrison 1977; Firth 1967; Golomb 1985; Greenwood 1992; Heinz

1988; Lewis 1978, 1986; Spiro 1967; Tambiah 1970; Taussig 1987). In addition to conceptions of etiology, beliefs surrounding illness type and course also determine the frequency with which religious healers are consulted. For example, anthropological research shows that in certain contexts religious healers are frequently sought in cases of chronic illnesses, whereas biomedical healers are more often consulted for acute illness

(du Toit and Abdalla 1985; Fabrega and Silver 1973; Janzen 1989; Kleinman 1980; Lazar

1985; Sullivan 1989).

Many comparative anthropological studies have shown that religious healers are frequently perceived as more likely to address the ecumenical concerns described above than their biomedical counterparts. Moreover, religious healing systems tend to encompass a wide circle of experience (subjective, social, and collective) in the therapeutic process, which enhances perceptions of efficacy. For example, in a study of black folk healers in the , Snow (1978:102) argued that religious healers were more likely than “orthodox healers” to address these broader issues because they recognized that “health problems are inextricably entwined with other matters of daily life, lack of money, loss of a job, envious neighbors, a straying spouse.” DuToit and

Abdalla (1985:2) made a similar observation in their finding that South African biomedicine tended to view patients in terms of pathology, whereas local religious

7 healing systems perceived them as a “total person with a social-familial context who needs to be restored to a healthy state.” Likewise, Kleinman (1980) found in Taiwan that only a small percentage of patients were satisfied with their interactions with Western doctors, whereas a much larger percentage reported satisfaction from their health transactions with local shamans; patients explained that shamans spent more time with them and gave more meaningful explanations.

These findings help explain why religious healers are often preferred over biomedical healers. For example, Garrison (1977) reported that individuals sought out

Spiritism after being dissatisfied with the biomedical treatment they had received.

Comas-Diaz (1981) observed that Puerto Ricans consulted religious healers for problems concerned with daily life and only utilized psychiatrists as either a last resort or a source of medicine. W.H. Rivers (2000/1924), psychiatrist and anthropologist, also described this pattern of resort when he reported that he was the thirteenth healer to be consulted for his assistant’s pneumonia.

Transcultural and ethnopsychiatric studies have also highlighted the importance of religion and religious healing in the context of mental illness. While this is a vast literature, it is fair to say that a great deal of research within this category has examined how indigenous notions of mental disorder are informed by local religious and supernatural ideology. For example, psychotic illness is often conceptualized as spirit possession and treated accordingly (as described above); for Buddhists illness is often explained in terms of karma, or cause and effect (Bowker 1970; Keyes 1983; Nuckolls

1992; Rahula 1974; Spiro 1982). Another well-studied area in this literature is the religious healers themselves, their methods, and how they are applied to the treatment of

8 mental illness. For example, a large number of studies (particularly early studies) analyzed religious healing in terms of its similarities with (Comas-Diaz

1981; Frank and Frank 1991; Garrison 1977; Greenfield 1992; Harwood 1987; Koss

1987; Koss-Chioino 1992; Morales-Dorta 1976). Many other studies of mental illness and religious healing have illustrated through specific illness examples how self and personhood are culturally constructed and mediate illness experience (e.g., Connor 1982;

Gaines 1982a; Kapferer 1979; Kenny 1986; Lebra 1982; Marsella 1980; Wikan 1990).

In recent years there has been a surge of interest in religion within psychiatry and leading to an increase in clinical studies of the role religious beliefs, practices, and healing play in the course, outcome, and treatment of mental illness (see

Bhugra 1996). These studies have tended to focus on the effects of religion on general mental health status, or affective disorders secondary to medical illness among patient populations in the United States or Western Europe. For example, religious beliefs and practices are often associated with greater psychosocial well-being by fostering hope, optimism, and purpose and meaning (Farakhan et al. 1984; Kass et al. 1991; Loewenthal

1995; Witter et al. 1985). Many studies also suggest that religiosity and religious intervention predict faster recovery from depression (Azhar and Varma 1995; Braam et al. 1997; Griffith and Bility 1996; Koenig et al. 1992; Koenig et al. 1998; Koenig and

Larson 2001; Pressman et al. 1990; Propst 1980; Propst et al. 1992; Razali et al. 1998) and enhance social support (Ellison and George 1994; Idler and Kasl 1997; Koenig et al.

1997; Koenig and Larson 2001). Although this body of literature generally shows that religion can play a positive role in mental illness, some studies also note that religion, in general, can induce feelings of guilt and shame, and may also lead to increased social

9 isolation and prejudice (Pruyser 1977; Sorenson et al. 1995). A drawback to these studies is their functionalist orientation to religion (see Csordas and Kleinman 1996), which precludes the importance of meaning and experience in recovery from illness.

C. Suffering: Connecting Religion and Illness Experience

A unifying theme within the literature on therapeutic efficacy, , and religious healing is suffering. This theme emerges in two primary ways.

First, suffering is an integral element of illness experience. Second, religious beliefs, practices, and forms of healing provide a framework by which individuals and society interpret and address suffering in general, and illness suffering, in particular.

Researchers have identified suffering as a primary element of illness and disease.

Indeed, anthropologists have argued that the definition of disease as an entity is problematic, suggesting that it be reinterpreted as a means by which healers and patients interpret certain forms of suffering (Kleinman 1980, 1983) or as “a manifestation of a deeper disorder involving the total condition of the individual” (Bakan 1968:13). Csordas

(1992:159) suggests, “the substrate [of illness and disease] is the phenomenology of affliction.” In his compelling examination of the religious, clinical, and phenomenological meanings of demonic oppression, he writes (ibid.:125): “To say that an individual is afflicted by “demonic oppression” or “psychopathology” is to give a cultural account of an existential circumstance: a person is suffering.” What these authors imply is that illness is an explanatory model for suffering, rather than vice versa, and thus suffering should be at the of any anthropological study of illness and disease. This focus is echoed in David Bakan’s (1968:3) study of the psychology of suffering, where

10 he argued “disease is certainly one of the most conspicuous manifestations of suffering and thus invites itself as our starting point.”

A benefit of this shift in focus is that it has allowed anthropologists to naturally incorporate profound (and inseparable) illness issues transcending painful illness symptoms, such as questions of identity, social relationships and support, and orientation to the future. For example, Bulka (1977) shows that illness suffering is associated with unchangeable fate, emotionally painful experiences (such as death), and frustrated attempts to find existential meaning. Cassell (1991) identifies social isolation, powerlessness, helplessness, hopelessness, physical agony, fear, loss of work or career, and death as profound manifestations of suffering in the context of illness. Kleinman’s work (1986, 1988a) describes how illness involves profound life changes and impaired social support. Bakan (1968) reviews several studies of numerous diseases illustrating how they disrupted social relations, further intensifying patients’ suffering. Kahn and

Steeves (1996) found that patients undergoing a bone marrow transplant reported experiencing three primary types of suffering: loss of time, which caused patients to believe that their futures and lives were no longer their own; fundamental changes in their social relationships; and changes in their conceptualizations of their own bodies. Similar findings were reported in an ethnographic nursing home study of Jewish elders, who attributed their suffering to physical decline, constriction of their social world, and a disconnection with the present due to estrangement from the modern world, as well as from the future because they believed their death was imminent (Spross 1996).

These findings are in parallel with the observation that therapeutic efficacy involves more than treating illness symptoms, and also includes addressing suffering

11 related to dramatic changes in one’s existential, bodily, social, and temporal experiences.

Cassell (1991:33) elaborates:

Suffering occurs when an impending destruction of the person is perceived; it continues until the threat of disintegration has passed or until the integrity of the person can be restored in some other manner. It follows, then, that although it often occurs in the presence of acute pain, shortness of breath or other bodily symptoms, suffering extends beyond the physical.

These findings suggest “the caring environment in which processes of suffering occur can influence a person’s suffering, positively and negatively” (Kahn and Steeves 1996:27). In cases of persistent or chronic illness, it is possible that more suffering is incurred due to the long-term impact on self-concepts, family support, social networks, and socio- economic status (Cassell 1991; Kleinman 1988a).

The therapeutic efficacy associated with religious experience and healing may stem from the framework that religion provides for understanding and alleviating suffering. As Bowker (1970:1) 1 explains, “religions give suffering a place of central importance or consideration—indeed, it is often said that suffering is an important cause of religion, since the promises held out by religion represent a way in which men can feel reassured in the face of catastrophe or death.” For this , religious healers are often utilized as an alternative to Western biomedical treatments because they are perceived as more effectively addressing illness in the context of suffering (Csordas 1994; Fletcher and Kirmayer 1997; Garrison 1977; Good 1994; Jenkins 1988a; Kleinman 1980, 1986,

1988a; Low 1994; Perera 2001). Kleinman (1988a) explains: “Whereas virtually all healing perspectives across cultures, like religious and moral perspectives, orient sick

1 Bowker (ibid.) has produced the most comprehensive description of religious understandings of suffering and illustrates through detailed comparisons how many religions have distinct frameworks for conceptualizing suffering. The historian Joseph Amato (1990) similarly traces the religious roots of suffering in Western society.

12 persons and their circle to the problem of bafflement [why do I suffer?], the narrow biomedical model eschews this aspect of suffering . . .” Keyes (1985:167-69) further elaborates on the relative merits of religious and biomedical approaches to suffering:

An illness perspective constitutes, at best, only a partial way of viewing the experience of pain and affliction. Even when an illness has been interpreted as a particular disease, the prescribed treatment may prove to be ineffectual and the affliction thus persists or leads to death. Even if an effective treatment can be found, any powerfully painful experience may still lead the afflicted person, or those for whom the affliction is also of concern to bring to consciousness the question of why it is that humans must suffer. The break one makes from the commonsensical world when one becomes aware, as every person does at different points in his or her life, that one is a being who cannot escape suffering through means at the disposal of mere mortals, typically leads one to turn toward a mode of practical understanding quite different from that which serves to restore him or her to health. Such a mode of understanding comes from adopting a religious perspective on the world. This perspective, drawn from distinctive texts and often communicated through rituals, serves to situate problems of suffering within a cosmic framework and to orient those who know suffering toward a course of action that conduces not to the control but to the transcendence of suffering. . . Western medical practice is perhaps unique in its effort to interpret illness without reference to the problem of suffering.

D. The Definition and Cultural Construction of Suffering

Although suffering has become a major topic of interest within anthropology, medicine, and the , few scholars articulate what suffering actually means. It is understandable that authors have discussed suffering under the assumption that their readers already have some understanding of what it means. After all, who hasn’t suffered? This in the universality of suffering suggests that the referent for understanding the suffering of others begins and ends with our own experiences and our ability to empathize. It is this assumption that suffering is not only a commonly held experience, but also a natural (and thus acultural) feature of the human condition that

13 helps explain why the term is rarely pinned down and defined, and, in cases when it is defined, is often done so using culturally specific criteria.

The word “suffering” itself bears a very specific cultural imprint. The English word “suffering” comes from the Latin su (to be under) and ferre (to bear), which together imply being weighed down underneath something (Amato 1990). Popular lexicons of the echo these linguistic origins by defining suffering as

“the bearing or undergoing of pain, distress, or tribulation” (O.E.D. online) or “an instance of pain or distress” (American Heritage Dictionary 2000). Anthropological definitions of suffering frequently embody these Western conceptions of distress. For example, Connolly’s (1996:251-2) definition of suffering is almost identical to that found in the O.E.D. (“to bear, endure or undergo, to submit to something injurious, to become disorganized”). Similarly, other definitions embody specific cultural values by stating that suffering is a “disvalued” state (e.g., Kleinman 1986; Nuckolls 1992; Shweder et al.

1997). Other definitions are based upon specific cultural notions of personhood; they presuppose a separation between mind and body2, primarily by making a distinction between somatic pain and psychological, existential, and spiritual suffering (e.g., Young

1997). Still other definitions of suffering neglect the social dimension of suffering (e.g.,

Kahn and Steeves 1996:5). More comprehensive definitions recognize that suffering is a pervasive phenomenon, which not only affects the whole person, but also shapes and is shaped by a host of other socio-cultural factors (e.g., Cassell 1991; Kleinman 1995).

2 David Morris (1991:9) refers to this separation as “the myth of two pains.” According to Morris, this myth is based on the prevailing notion that pain comes divided into distinct categories: mental and physical. He explains (1991:9): “You feel physical pain if your arm breaks, and you feel mental pain if your heart breaks.”

14 Other work goes beyond defining suffering and attempts to identify a general framework for understanding how it is conceptualized and interpreted. For example,

Kleinman and Kleinman (1995:101) suggest that suffering is “a universal aspect of human experience in which individuals and groups have to undergo or bear certain burdens, troubles, and serious wounds to the body and spirit that can be grouped into a variety of forms.” These forms are contingent misfortunes (e.g., acute illness), routinized forms of suffering (e.g., chronic illness), and suffering from extreme conditions (e.g., war). Shapiro (1996) suggests that there is a four-dimensional framework to suffering: intensity, quality, impact, and time. Ferrell (1996) draws on the work of the phenomenologist Merleau-Ponty to suggest that suffering has a basic structure, which can be understood in terms of four aspects that reveal the fundamental nature of the sufferer’s lifeworld: the lived body, temporality, lived human relations, and lived space. Freud

(cited in Loewy 1991) similarly attributed suffering to the body, social relations, and the external world.

Ethnographic research has fleshed out the framework of suffering by providing specific examples that illustrate how cultural factors influence how suffering is explained, expressed, and managed. For example, Shweder et al. (1997) identify several “causal ontologies3” of suffering, showing that ideas regarding suffering causation are shaped by cultural notions of normality, blame, and responsibility (also see Das 1997), and control over past and future events. Anthropologists have also shown that culturally sanctioned modes of expression dictate whether, and in what form, suffering will be expressed. For

3 The causal include: biomedical, interpersonal, sociopolitical, psychological, astrophysical, environmental, and moral (ibid.) Also see Nuckolls (1992) who briefly describes causal ontologies.

15 example, many studies show that distress is communicated by means of “idioms of distress” (Nichter 1981; Rasmussen 1992), such as nerves or nervios (Guarnaccia 1996;

Jenkins and Cofresi 1998; Low 1994), or somatization (Gaines and Farmer 1986;

Kleinman 1980, 1986, 1995a; T.-Y. Lin 1989; Kleinman and Good 1985; Good 1977).

Anthropological research has also illustrated that culture shapes the ways in which people cope with and interpret their suffering, highlighting, in particular, the subjective and intersubjective dimensions of suffering (Das 1984; Good et al. 1992; Fletcher 1997;

Hollan 1994; Jenkins and Cofresi 1998; Kirmayer 1994; Kleinman 1986, 1988a, 1988b;

Kleinman and Kleinman 1997a; Kleinman, Das, and Lock 1997; McKevitt 1991).

Out of this body of work has grown increasing attention to the social production4 and moral dimensions of suffering5 (Das et al. 2001; Farmer 1997; French 1994;

Gumende 1973; Kleinman 1986; 1995b; Kleinman, Das, and Lock 1997). In his discussion of suffering and structural violence, for example, the medical anthropologist and physician Paul Farmer argues that markers of discrimination particularly shape how individuals experience and perceive suffering, as well as which groups are likely to suffer in the first place (1997:278-9):

Any distinguishing characteristic, whether social or biological, can serve as pretext for discrimination, and thus as a cause of suffering . . . The capacity to suffer is, clearly, part of being human. But not all suffering is equal, in spite of pernicious and often self-serving identity politics that suggest otherwise.

4 Kleinman (1997) describes this element of social suffering as a process which “ruins the collective and the intersubjective connections of experience and gravely damages subjectivity…[I]t results from what political, economic, and institutional power does to people, and, reciprocally, from how these forms of power themselves influence responses to social problems.” 5 This issue has often been cast in terms of the “problem of suffering” or theodicy, that is, understanding how suffering and evil can co-exist with a benevolent higher being (Gachter 1998). Bowker (1970) describes the problem of suffering as “problems of suffering” because it is approached differently depending on its given context.

16

Other authors similarly show that particular socio-cultural factors, such as gender

(Bendelow 1998; Notermans and Tophoff 1967; Ortner 1996), race and ethnicity (Morris

1991), socioeconomic class (Zborowski 1969), age (Notermans and Tophoff 1967;

Shapiro 1996), and religion (Amato 1990) are used not only to produce suffering, but also to legitimize prejudicial perceptions of who suffers, what kind of suffering they experience, whether that suffering is attended to or neglected, and how much value is placed on particular kinds of suffering and sufferers (also see Gaines and Farmer 1986;

Spellman 1997). This literature has been especially important for revealing how cultural perceptions and values of suffering can shape human identity, and vice versa. In his compelling and thorough review of pain, David Morris (1991:40) describes several historical examples that illustrate how cultural interpretations of human identity shape and are shaped by perceptions of suffering:

The distant past is not only a source of examples demonstrating beliefs that the pain of some particular group—blacks, Indians, women, madmen, children— either does not exist or (much the same thing) does not matter. The barbarous medical experiments carried out by Nazi doctors assumed that the pain their victims felt simply did not count. In wartime, torture is justified on various pragmatic or tactical grounds, but ultimately it reflects the belief that the pain of the enemy has no status in or . The enemy is the Other, and the Other does not feel pain as we do.

As these examples illustrate, the failure to acknowledge an individual’s or group’s suffering is a profound means of dehumanization.

In her psychology dissertation on suffering in adult life, Nancy Grevengoed

(1989) collapses many of the themes described above into three “propositions,” which, in turn, constitute the “arena of suffering.” The first proposition describes the cause or onset of suffering. The onset of suffering occurs in with events that threaten or

17 damage personal integrity; events broadly defined as experiences that severely attack fundamental concerns of meaning, control, identity, and connectedness. Second, the experience of suffering is marked by a pervasive and distressing cluster of cognitive, affective, somatic, and behavioral manifestations that consistently reflect an on fundamental concerns of meaning, control, identity, and connectedness. Third, in the response to suffering, during the aftermath of suffering, one’s views of self, others, and the world consistently undergo a process of change as suffering individuals attempt to integrate the experience into their lives.

Drawing on previous anthropological studies and, in particular, Grevengoed’s comprehensive definition, the following definition of suffering is proposed, which will be applied for the remainder of this dissertation:

Suffering is a pervasive, unwanted, and distressing experience that fundamentally alters one’s sense of self, others, and the world.

Such a definition recognizes the overwhelming and multi-faceted dimensions of suffering, yet leaves room for culturally sanctioned interpretations of the significance and manifestation of such an experience. In addition, Burmese Buddhist’s understandings of suffering are conceptualized as explanatory models, drawing on Kleinman’s (1980) elaboration of explanatory models of illness and Grevengoed’s (1989) articulation of the

“arena of suffering.”

E. Religion and Suffering in the Context of Schizophrenia

Schizophrenic disorders are the most severe and debilitating of psychiatric illnesses, with an international prevalence of about 1% (Cornblatt et al. 1999). People with schizophrenia also suffer from persistent illness symptoms, such as hallucinations,

18 paranoia, and delusions, despite recent strides made in developing new antipsychotic medications. Individuals with schizophrenia report that the subjective experience of schizophrenia is one dominated by feelings of fear, helplessness, anxiety, and distress, interwined with the themes of lack of control, failure, isolation, and loss (Baker 1996;

Corin et al. 2004; Maclane 1964; McGorry 1991a, 1991b; Searles 1988/1961; Sechehaye

1994/1951; Shaw et al.1997; Strauss and Carpenter 1981). Indeed, psychotic illnesses, such as schizophrenia, have been described as one of the most severe stressors to which one can be subjected—both for the person afflicted and the caregiver (Lundy 1992). The suffering caused by schizophrenia can be so severe that the illness itself may be traumatizing, causing many individuals with schizophrenia to develop Posttraumatic

Stress Disorder (Hough et al. 1996; McGorry 1991a; Mueser and Rosenberg 2003; Shaw et al. 1997; Stampfer 1990; Williams-Keeler et al. 1994; Wilson 1988).

Studies worldwide also show that having such severe mental illness exacerbates other forms of suffering, including severe social stigma (Kleinman and Kleinman 1997a;

Penn and Martin 1998), low socio-economic status (Cohen 1993; Fox 1990; Warner

1994/1985), low quality of life (Browne 1996; Katschnig 2000), high rates of suicide

(Allebeck 1989; Brown 1997), impaired functioning (Cornblatt et al.1999; Laliberte-

Rudman 2000), and heightened vulnerability to other adverse life events (Heila et al.1999; McFarlane 1995). People with severe mental illness may also be more at risk for exposure to trauma than other populations (Marsella et al. 1996) and studies show a strong correlation between previous psychiatric disorder and posttraumatic psychopathology (Davidson et al. 1991, Kinzie et al. 1989; McFarlane 1995; Offringa and Goff 1995; Smith et al. 1990).

19 A growing number of clinicians and researchers argue that understanding subjective experiences of schizophrenia with an eye to their cultural context is critical for helping explain illness course, outcome, and treatment efficacy (e.g., Awad and Hogan

1994; Jenkins and Barrett 2004). Although medical anthropologists have established the importance of culture in shaping the experience of mental illness (e.g., Janzen 1987;

Kleinman 1980, 1988b; Obeyesekere 1985), research on schizophrenia (in both the health and social ) has shifted considerably in the direction of exploring biological, rather than cultural, models of illness. One consequence of this shift has been that experiential aspects—such as suffering—of schizophrenia, and mental illness in general, have been considered to be less important in shaping the course of illness than biochemical processes. Given that many anthropological studies indicate that suffering, and all of the cultural meaning it embodies, plays an important role in shaping one’s sense of self and identity, illness experience, and health seeking behavior (e.g., Kleinman

1986, 1995a), it would appear that further examination of this feature of subjective experience might provide critical understanding for the treatment of a wide range of illnesses. Cassell (1991:46) underscores the importance of attending to illness suffering:

If suffering occurs when there is a threat to the integrity of the person or a loss of a part of the person, then suffering will continue if the person cannot be made whole again. Little is known about this aspect of suffering.

Given the many ways in which individuals with schizophrenia suffer—due to illness symptoms, social stigma, and life stressors—this severe mental illness provides a pertinent context in which to study the impact of suffering on illness experience.

Although anthropological studies illustrate the centrality of suffering in illness experience and the importance of religion and religious healing for addressing that

20 suffering, little is known about the role that religion plays among people with severe mental illness, such as schizophrenia. Findings show that religious beliefs and practices increase with the onset of psychotic illness (Kirov et al. 1998). Severity of psychiatric symptoms is also associated with increased religiosity (Tepper et al. 2001). For example, patients with psychotic illness tend to be more religious than those with depression or anxiety (Kroll 1989; Neeleman and Lewis 1994).

In various cross-cultural settings, psychotic illness is often interpreted within a religious or supernatural framework (Corin et al. 2004; Csordas 1992; Diaz et al. 2004;

Good and Subandi 2004; Lucas 2004), as mentioned previously, and therefore falls under the therapeutic purview of religious healers (Janzen 1989; Langness 1976; Spiro 1967;

Turner 2000/1964). Whether through their interactions with religious healers or through their own spiritual practices, religion appears to play a beneficial role in the lives of those suffering from schizophrenia. For example, increase in religious activities has been associated with improved outcome of schizophrenia (Schofield et al. 1954; Verghese et al. 1989). Others have shown that religion plays a central role in how persons with schizophrenia reconstruct their sense of self and recovery (Adler and Jenkins 2001; Mohr and Huguelet 2004). However, these studies do not clearly delineate how religion and religious understandings of suffering influence the subjective experience and social perceptions of schizophrenia.

Despite the important ways in which religion can help the mentally ill address and interpret their health concerns, it is a factor that is rarely addressed by Western clinicians and researchers (Crossley 1995; Huguelet 2006; Larson et al. 1986; Mohr et al. 2006;

Neeleman and Persaud 1995). One explanation for this neglect is that the religious

21 of patients with severe mental illness is often interpreted as delusional, rather than as an important and meaningful feature of their life and illness experience (O’Connor and

Vandenberg 2005; Sanderson et al. 1999). The link among religion, suffering, and severe mental illness has also been neglected within anthropology. Understanding the potential benefits of religious experience and healing for people with schizophrenia may be of particular importance given the diverse ways in which those with this illness suffer. It also might help explain differences in the course and outcome of schizophrenia across cultural contexts.

F. Buddhism, Suffering, and Healing

Buddhism, more than any other religion, emphasizes the importance of suffering, and regards it as a universal and defining condition of human experience; for a Buddhist, one’s past, present, and future lives are predicated upon the existence of suffering and the ultimate goal of eliminating that suffering (Bowker 1970; Keyes 1977; Pruett 1987;

Rahula 1974; Thera 1998/1949). Indeed, a Buddhist’s experience of suffering and illness can only be understood when contextualized within its religious framework (Kitagawa

1989; Obeyeskere 1968, 1985; Tambiah 1970, 1977). As a result of this emphasis and its fundamental goal of transcending and eliminating suffering, Buddhism might be expected to be especially helpful in addressing illness-related suffering. What is unclear, however, is the overall influence Buddhism has on the lives of people with schizophrenia.

Theravada Buddhism, a distinct school of Buddhism that is observed in ,

Thailand, , , and parts of , is also practiced by 89% of Burma’s population (Keawkungwal 1989). Buddhism originated in the 6th century in

22 and had a firm foothold in Burma by the (Spiro 1982; Swearer 1995).

Although Burmese Buddhists practice Theravada Buddhism, theirs is a particular blend of Buddhism and spirit () (Nash 1966a; Spiro 1982; Swearer 1995).

In the world of Buddhism, “suffering” is generally translated into as dukkha and Burmese as dokkha6; however, scholars of Buddhism have pointed out that

“dissatisfaction”, “unsatisfactoriness”, or “troubled” might be more accurate English translations (e.g., Rahula 1974). The literal translation of dukkha connotes the action of a wheel rubbing against its hub ( 2003:2). A discussion of some key

Buddhist concepts helps elaborate upon the meaning of suffering as it is understood among Burmese Buddhists.

The philosophical core of Buddhism can be found in what are called the Four

Noble Truths as outlined by the Buddha; it is within the Noble Truths that the role of suffering in Theravada Buddhism is articulated. The First Noble Truth teaches that dukkha is a central feature of human experience. While the experience of dukkha is one of suffering, the states of , satisfaction, and comfort are associated with dukkha because they are impermanent and eventually will become painful. Buddhist scholar

Donald Lopez (2001: 46) explains:

6 In Burma, the Pali canon is the primary vehicle for the transmission of Theravada Buddhism. The began to incorporate Pali-derived vocabulary in the 11th century. Although proficiency in Pali is primarily the domain of the (monastic order of Buddhist ) and Buddhist scholars, the general population often draws on certain Pali terms in everyday discussions of Buddhism, (e.g., dukkha, nibbana and kamma) in addition to their Burmese equivalents (dokkha, neiban and kan). In this dissertation, I will use Pali or Burmese, depending on the term utilized by the person or text I am quoting. For Burmese terms, I refer to the Peacock Burmese-English Dictionary (2004) by Aung Soe Min and Nance Cunningham. Yangon.

23 The Buddha identified the obvious sufferings that humans undergo: birth, ageing, sickness, death, losing friends, gaining enemies, not finding what one wishes for, encountering what one does not wish for. But he is also said to have identified a more subtle form of pain: pleasure. He observed that a painful experience will remain painful unless one acts to counteract the pain, but a pleasurable experience will naturally become painful eventually. . . Pleasure is therefore compared to the relief felt when a heavy burden is shifted from one shoulder to another. After a while, the other shoulder will begin to hurt, at which point the burden will be shifted back.

Dukkha not only describes the general state of existence for all sentient , but also refers to specific aspects of suffering. As Obeyesekere (1985:144) explains, “The

Buddhist term dukkha also has a variety of meanings ranging from ordinary sorrow to suffering in its doctrinal sense.” There are three primary categories of dukkha, each of which is related, respectively, to the life cycle, the notion of (annica), and the doctrine of no-self () (Rahula 1974). The first category involves ordinary suffering (dukkha dukkha), particularly that arising from the universal life cycle experiences of birth, aging, sickness, unfulfilled wishes and death. The second form of suffering (viparinama dukkha) is produced by change and impermanence—it is in this sense that happiness is associated with suffering: when a person experiences a pleasant sensation, such as happiness, becomes attached to that experience and wishes it to remain; however, according to Buddhism such sensations, like all things, are impermanent and inevitably change, and thus eventually become suffering. The third kind of suffering (samkhara dukkha) is associated with the illusion that there is an enduring self or . In his doctrine of anatta, or no-self7, the Buddha taught that people

7 Inherent in the idea of anatta is the notion that existence is not defined by a single component. Theravada Buddhism teaches that what people often consider to be the “self” is actually composed of Five Aggregates, which are themselves impermanent forces that are constantly changing. These Five Aggregates include: the Aggregates of Matter,

24 commonly cling to the idea of an enduring self for psychological comfort but in doing so only enhance the degree to which they experience dukkha. The concept of annata is further illustrated in the following saying: “Mere suffering exists, but no sufferer can be found. The deeds are, but no doer is found” (Rahula 1974:26).

These aspects of suffering are associated with Theravada Buddhist conceptualizations of reality. Two versions of reality (or truths) exist—ultimate and conventional. The ultimate version of reality reflects a Buddhist ideal in which doctrinal concepts, such as annata and dukkha, represent what is actually real. Conventional reality, on the other hand, reflects the experiences that constitute ordinary day-to-day life of the common person, that is, that each person has a “self” and that there is a difference between happiness and suffering, as well as good and evil (Rahula 1974). These differences are reflected in different kinds of suffering. Ultimate suffering is the existential distress associated with samsara and the absence of enlightenment. Ordinary suffering is manifested in everyday life events such as illness, poverty, and political oppression. In other words, there is both the immediate, lived experience of the ordinary suffering associated with being ill—“I feel ill”—and the more conceptual experience of ultimate suffering because of being human—“I know that I suffer because I still experience , the illusion of self, and have yet to attain nibbana.” This distinction is important for understanding Burmese Buddhist’s beliefs about who suffers. For the remainder of this dissertation these distinctions of suffering will be drawn upon, in conjunction with Obeyeskere’s categorization presented earlier, referring to suffering as either “ordinary” or “existential.”

Sensations, Perceptions, Mental Formations (volitional activities), and Consciousness (Rahula 1974).

25 The Second Noble Truth describes the cause of dukkha, or essentially why people suffer (as opposed to the First Noble Truth that explains the nature of suffering, or how people suffer). The Buddha taught that dukkha was a universal experience caused by desires and attachments, which prevent one from escaping the cycle of (samsara).

Kamma, or the law of cause and effect, is an important determinant of one’s place within the cycle of rebirth and thus acts as a source of suffering; although good kamma might ensure a better rebirth, it still maintains one’s place within samsara and, ipso facto, the continuation of suffering (Keyes 1977). The Third Noble Truth teaches that dukkha can be eliminated once one has been liberated from samsara by reaching nibbana

(enlightenment). This liberation is achieved by extinguishing all of one’s desires and cravings, attachment to existence and the illusion of self, and, ultimately, dukkha.

The Fourth Noble Truth describes the means by which one can end one’s dukkha: the (also referred to as the Middle Path) is a prescribed path of moderation that leads to the quenching of all cravings and nibbana. Lopez (2001:56) describes this path as a prescription for suffering: “Once the prognosis is made, the physician [Buddha] must prescribe the cure, the course of action that will lead from sickness to health. The fourth and final truth of the path is said to be the Buddha’s prescription.” The Noble Eightfold Path consists of eight components, which are contained within three broad categories--ethical conduct (right speech, right action, right livelihood), mental discipline (right effort, right , right concentration), and wisdom (right thought, right understanding). Altogether, these aspects of the Middle Path prescribe a code of correct behavior, thought, and worldview to apply to one’s daily life.

26 There have been several anthropological studies of Buddhist interpretations of and approaches to illness and disease. Kitagawa (1989), in particular, gives a detailed description of Buddhist medical history, explaining how Buddhism and Buddhist healers conceptualize and address both health and illness (also see Clifford 1984; Csordas and

Lewton 1998; Golomb 1985; Granoff 1998; Salgado 1997; Weisberg 1984). Many of these studies articulate Buddhist healing as a pluralistic form that encompasses both doctrinal and popular (including Ayurveda, astrology, and supernatural beliefs) traditions

(Jaspan 1969; Nash 1966b; Spiro 1967; Westermeyer 1990). For example, Birnbaum

(1989) describes how Chinese Buddhist monks and utilize Ayurvedic techniques, exorcism, , personal remedial action, and purification to treat illness. Other studies focus on the therapeutic efficacy of specific Buddhist practices and rituals as a means of addressing illness (e.g., Desjarlais 1992, 1996; Heinz 1988; Kapferer 1979;

Lebra 1976; Yalman 1964). For example, Tambiah (1977) describes how healing in

Thailand was effected through meditation or through the therapeutic intervention of a meditation teacher. Within this literature a large number of studies emphasize the psychotherapeutic and social functions of Buddhist forms of healing (de Silva 1991,

1996; Kalab 1990; Keawkungwal 1989; Peters 1981; Yamanaka 1985).

The importance of suffering to Buddhism is also underscored as an important element of healing among Buddhist patients and healers. For example, in a study of meditation and spirit possession among Buddhists in Sri Lanka, Obeyeskere (1989:140-1) notes that meditators did not define their illness as such, but rather in terms of existential suffering:

They had defined despair as a problem of human impermanence and suffering as Buddhists see it . . . even when the movement to adopt meditation was a response

27 to a specific event such as bereavement or loss, the event was immediately perceived in more general terms as epitomizing the human condition. Such generalization can occur because Sinhalas are Buddhists and they have myth models . . . which permit spontaneous and immediate generalization.

Obeyesekere (1985) and Keyes (1985) similarly highlight the centrality of suffering to

(Sri Lankan and Thai) Buddhist’s interpretation of depression. For example, in describing a Thai woman’s prolonged grief over the death of her husband Keyes (ibid.:168) argues that her depression can only be interpreted in a way that incorporates “the Buddhist message that the underlying character of human experience is “suffering” (dukkha).” He then elaborates (ibid.:171) upon the importance of Buddhist notions of suffering for the understanding of illness: “The continued salience of Buddhist ideas for the interpretation and treatment of mental illness serves to provide a means whereby modern Thai can confront not only problems of illness but also problems of suffering.” In her interviews with Burmese psychiatric patients, Skidmore (1999) also found that the meaning of illness, distress, and recovery were embedded within a religious framework. To date no studies have been done that specifically examine the role Buddhism plays in the lives of people with schizophrenia.

G. Summary of Objectives and Outline of the Dissertation

The ethnographic study on which this dissertation is based explored how Buddhist understandings of suffering affect the ways in which schizophrenia is experienced, perceived, and coped. It also investigated how suffering is culturally constructed among

Burmese Buddhists, as well as what the cultural norms are for expressing and managing that suffering. These issues were examined from the perspective of both patients and non- patients in order to compare their interpretations of suffering, and examine the role

28 religion plays in influencing both sides of treatment—patient’s and caregiver’s. By further developing anthropological understanding of the relationship between religion and severe mental illness, this dissertation presents new ethnographic data on the ways culture affects illness experience, perceptions of therapeutic efficacy, and the construction of human identity. The importance of Buddhism to Burmese culture and the importance of suffering to Buddhism made Burma an ideal context in which to explore the issues set forth in this dissertation.

The findings of this research are presented and discussed in subsequent chapters of this dissertation. Chapter 2 describes the ethnographic community in which the dissertation fieldwork was conducted, and the methods used for the dissertation research and analysis. Chapter 3 describes the range of health sectors in Burma—psychiatric, religious, and traditional—paying particular attention to how these sectors have been shaped by historical and political events. Chapter 4 reviews general explanatory models of schizophrenia, including those employed by Burmese Buddhists. Chapter 5 presents results concerning patient’s experiences and non-patient’s perceptions of suffering in the context of schizophrenia. Chapter 6 examines how Burmese Buddhist constructions of human identity influence perceptions of suffering regarding the mentally ill. It also discusses how prejudicial perceptions of the mentally ill are reflected in the social interactions between patients and non-patients in Burma, as well as perceptions of treatment efficacy. Chapter 7 summarizes the dissertation’s conclusions and how they relate to the broader context of suffering, mental illness, health seeking behavior, and human identity.

29 CHAPTER TWO RESEARCH DESIGN AND METHODS

This chapter describes the theoretical and methodological background of this dissertation and presents an introduction to the ethnographic sites and communities in which the fieldwork took place. It will also discuss the research sites, the general characteristics of the research participants, and the nature of the research relationships and interactions in order to orient the reader to the environment and social context that shaped the fieldwork. In doing so, the reader is provided with a comprehensive picture of this cross-cultural research experience and the factors that influenced its development and implementation.

In order to achieve the aims of this dissertation, I conducted in-depth qualitative interviews with a total of 100 patients, family members, and healers over a period of twelve months in Burma. As my fieldwork proceeded and themes in the data began to emerge, I expanded the sample of research participants to include 142 survey respondents from the general Burmese Buddhist population. These interviews were complemented by ethnographic data gathered through participant observation in a wide range of religious, social, and health care settings to produce a comprehensive picture of Buddhism, mental health care, and daily life in Burma. These interactions and the data they generated helped define and explain the central issues of this dissertation.

A. Development of Topic and Perspective

The dissertation research began in the spring of 2002 when I spent two months in

Burma continuing Burmese language training, reconnecting with research contacts,

30 conducting further preliminary research, and obtaining the necessary permits for long- term research there. Further language training was carried out in the summer of 2002 at the Southeast Asian Studies Summer Institute in Madison, Wisconsin. The majority of the dissertation research took place between the fall of 2002 and the summer of 2003.

Additional fieldwork was conducted early in 2004 for five weeks in order to conduct follow-up interviews and fill in some remaining gaps in the data. Altogether twelve months were spent in Burma conducting fieldwork for this dissertation.

The connection between mental illness and suffering in this dissertation are predicated on preliminary research that I conducted in the United States and Southeast

Asia. In 1998, I had the opportunity to join a research project1 that focused on documenting the subjective experience of schizophrenic disorders treated with antipsychotic drugs, and to identify cultural and psycho-social factors mediating recovery. The research site for this study was a local outpatient clinic where some of the first atypical antipsychotic medications in the United States had been prescribed. Over the next three years, I spent several hours each week at this clinic observing group therapy sessions, “hanging out” with patients in the waiting room or at clinic social gatherings, and conducting in-depth qualitative interviews with outpatients with schizophrenia. It was during this fieldwork that the link between suffering and schizophrenia emerged: patients stated repeatedly that suffering was an overwhelming feature of their daily experience and that (Judeo-Christian) religious understandings of

1 This project was NIMH-funded study MH-60232, “Schizophrenia Experience and the Culture of Recovery through Atypical Antipsychotics” (SEACORA), Principal Investigator Janis H. Jenkins, PhD.

31 that suffering helped them to find meaning and recovery in their lives (Adler and Jenkins

2001).

This connection between suffering and schizophrenia emerged in another religious context during two months of preliminary fieldwork in Burma and Thailand in

19992. In Burma, I interviewed a number of healers from a variety of professional backgrounds and other key informants in order to determine the range of therapeutic options available for treating severe mental illness. In addition, I conducted in-depth interviews with patients at the Yangon Psychiatric Hospital (now known as the Yangon

Mental Health Hospital [YMHH]) and gathered demographic data and illness . I also conducted brief interviews and participant observation and gathered detailed ethnographic fieldnotes in clinics and hospitals, teaching facilities, health-related non- governmental organizations, , meditation centers, as well as the Buddhist

Infirmary for the Aged in central Burma. Building upon this preliminary research in

Burma, I interviewed Burmese refugees living in Thailand with schizophrenia in order to better understand how the immigrant experience affected the experience of illness and suffering. During this period of preliminary fieldwork, an extensive research network was established, thereby making it possible to pursue future fieldwork in Burma.

2 This fieldwork was made possible by the Eva L. Pancoast Memorial Fellowship.

32 B. Research Site

1. Country Profile

Burma3 lies on the Southeast Asian mainland bordered by , ,

India, Lao, and Thailand. Geographically it is quite diverse, consisting of the mountainous in the north (including ’s highest

Hkakabo Razi), the hilly Shan plateau in the east, the central dry zone, the southwestern

Irrawaddy delta, and the tropical jungle in the south along the Thai border. The country is divided into seven states and seven divisions, which are further subdivided into districts, townships, wards, and village tracts.

The most recent census reports estimate the population of Burma is approximately

50 million, with over 70% of its population living in rural areas. Ethnically, Burma is diverse with 135 ethnic groups residing within its borders: over 69% of the population is ethnic Bamar; other major ethnic groups include Chin, Kachin, Karen, Mon, Rachine,

3 In 1989, the military junta changed the country’s name (as well as the names of several cities and towns, including the change of “Rangoon” to “Yangon”) from the “Union of Burma” to the “Union of Myanmar.” This change has been explained as an attempt to eradicate all (British) colonial associations (Carey 1997), as well as to affect written and spoken references to Burma in non-Burmese languages (Houtman 1999). Although Myanmar is a more ethnically inclusive name for the country, its associations with the government have made it unpopular with those who disagree with its policies. For example, many political entities (the U.S. Department of State among them) and activists around the world do not recognize the country as Myanmar, continuing to refer to it as Burma (Rotberg 1998). As anthropologist Monique Skidmore (1999:22-23) points out, however, “whilst not agreeing with the undemocratic manner in which the names have been changed, it is important to emphasize that Burmans now live under a military regime who have created a Union of Myanmar, however repressive and terrifying.” This dissertation utilizes the “old names”—Burma, Rangoon, etc.—but when citing any narrative from respondents will maintain their own usage, which often includes the “new names” of Myanmar and Yangon. (As Houtman (1999:15) points out, “Burmese citizens speaking in Burmese, who continue to refer to both Myanma as well as Bama [this not unlike formal reference in the English language to ‘The ’ while informally using ‘Holland’].”)

33 and Shan (United Nations Population Fund [UNFPA] 2005; United States Department of

State 2006). Although the national language is Burmese, English is widely used among professionals and by those educated before the 1960s4.

Burma has a rich history and mythic past involving tribal and monarchic rule5.

The British expansion into Asia in the early 19th century greatly altered the historical course of Burma. As a result of the First Anglo-Burmese war (1824-26), Great Britain took control over parts of western and southern Burma (Steinberg 2001). The Second

Anglo-Burmese War was fought in 1852 and resulted in most of Lower Burma coming under British control. In 1885, after the Third Anglo-Burmese war, the British abolished the Burmese monarchy (based in ) and claimed Upper Burma for its expanding empire (Aung-Thwin 1985). Although Burma was given limited self-rule by Britain in

1923 and formally separated from India in 1935 (Britain had declared Burma a province of India in 1886), the country effectually remained under British rule until World War II

(Allen 1984; Tarling 1999). This period of British rule was influential on various levels, not least of which on its educational and health care systems. In Chapter 3, this British influence in Burma will be examined in greater detail, showing how these effects linger today.

World War II brought about chaos in Burma. As Burma gained more self-reliance in the political realm, leaders focused on independence from the British as their ultimate goal. At the same time, the Japanese were attempting to trump Europe’s weakening grip

4 The use of English among the older, professional classes is a remnant of the educational system established by the British in Burma. During the British colonial period in Burma (1885-1948), English became the primary medium of university and medical school instruction, and many Burmese attended school abroad at this time. 5 For a detailed discussion of Burmese history, see Harvey (1967), U Thant Myint (2001), and Tarling (1999).

34 throughout the Asian mainland (Allen 1984). In 1941, a group from Burma called the 30

Comrades, including their leader , went to to receive military training to help free Burma from the British. By March 7, 1942 the British had evacuated Rangoon.

Despite their previous cooperation with the 30 Comrades, however, the Japanese invaded and established control over much of Burma. By May of 1942, Japanese control extended as far north as Mandalay. Although the Japanese established an independent government under U in 1943, Burma remained virtually occupied with very little real control in the hands of the Burmese. The country subsequently entered a period of severe shortages and the Burmese soon realized that life might have been better under British control6 (Tarling 1999).

Allied troops (with the help of Aung San) gained control of Rangoon in May

1945. Between 1945 and 1948, the British attempted to implement their postwar strategy of giving Burma self-government while maintaining it within the British Commonwealth.

However, popular support of Aung San’s Anti-Fascist People’s Freedom League undermined British authority. This unified effort led to the signing of the famous

Panglong Agreement7 in 1947, which paved the way for Burma’s official independence from Britain on January 4, 1948. Aung San and several of his colleagues were

6 This feeling exists today, particularly by people who were living during the British colonial period. They claim that everything from the country’s basic human rights, infrastructure, and education were better under the British. For this reason, the government has labeled opposition parties (such as the NLD) that tend to endorse this position as “neo-colonialists.” 7 The Panglong Agreement dictated that upon independence from the British each ethnic group would be unified under the Union of the Burma, qualifying that after seven years certain groups could secede and establish self rule (Universities Historical Research Centre 1999; Tarling 1999).

35 assassinated soon after the Panglong Agreement and never lived to see Burma become an independent nation (Tarling 1999).

General Aung San was succeeded by U8 Nu, a devout Buddhist and socialist, whose weak leadership and exclusive social policies9 helped pave the way for the military coup that would unseat him. In 1962, the military, under the command of General Ne

Win, seized control of the government. The country existed under increasing isolation and oppression during Ne Win’s dictatorship until 1988 when he putatively transferred power to the State Law and Order Restoration Council (SLORC)10 in response to mass pro-democracy uprisings. In 1990, due to mounting public pressure, SLORC held multi- party elections during which the National League for Democracy (NLD) won by nearly

90%. The SLORC, however, refused to acknowledge these results and instead killed, exiled, or imprisoned many NLD members. It was at this time that SLORC placed Daw

Aung San Suu Kyi (popularly referred to as “The Lady” in Burma)—General Aung San’s daughter and prominent NLD member—under house arrest. Her continued struggle for achieving human rights in Burma was recognized by the 1991 Nobel Peace Prize. To this day, the Lady continues to be under house arrest.

Burma’s isolationist policy is evident throughout the country today. For example, large signs are posted throughout Rangoon printed with the “People’s ,” the title of the Burmese government’s mission statement:

8 In Burmese, are used to denote age and status relationships: “U” is used for someone who is male and older, “Maung” for one who is younger, and “Ko” for someone who is of equal age; “Daw” for someone who is female and older, and “Ma” for someone who is younger or of equal age. 9 made it a priority to combine government policy with Buddhist doctrine, which made many belonging to the non-Buddhist minority uneasy (Tarling 1992). 10 In 1996 SLORC changed its name to the State Peace and Development Council (SPDC) (Carey 1997; Matthews 1999).

36 Oppose those relying on external elements, acting as stooges, holding negative views. Oppose those trying to jeopardize stability of the State and progress of the nation. Oppose foreign nations interfering in internal affairs of the State. Crush all internal and external destructive elements as the common enemy.

The signs, which are printed in both Burmese and English, are a ubiquitous feature of the country’s public spaces, as well as its textbooks and newspapers. The attitude reflected in the “People’s Desire” is manifested in a climate of censorship and surveillance. For example, it is not uncommon for the government to restrict contact with foreigners and place both visitors and citizens under military intelligence (MI) surveillance (Selth

1996)11. My own research and frame of mind were affected by this climate of distrust, in spite of the many welcoming people I encountered and befriended, and the generous access I was granted to carry out my work.

2. Yangon Mental Health Hospital

This dissertation research took place primarily at the Yangon Mental Health

Hospital (YMHH). I chose the YMHH as the research site in 1998 during a preliminary research trip when I established contacts and rapport with patients, healers, and others involved with mental health services in Burma. During this period of exploratory fieldwork, Burmese psychiatrists and I agreed that the YMHH was an ideal setting for in- depth research, as it constituted the largest and most accessible patient population in

Burma12.

11 In 2006, fearing lax security and competition for his position, Burma’s President, General Than Shwe, ordered a major restructuring of the Burmese military and its powers, and also relocated the capital from Rangoon to a more remote location. 12 There are only two psychiatric hospitals in Burma (one in Rangoon and one in Mandalay), of which YMHH is by far the largest.

37 The YMHH is a 1,000-bed hospital on the outskirts of Rangoon, in East Dagon

Township, Ywathargyi. The psychiatric hospital, commonly referred to as ayu taun or the crazy prison, was recently relocated from its former location downtown Rangoon near the airport13. The hospital is now located about 25 miles outside of Rangoon and was built in a rural farming area. This relocation has had a significant impact on inpatient lives, hospital resources, and the quality of hospital care, resulting in fewer family visits to the hospital, doctors working fewer hours due to transportation difficulties14, and chronic shortages of water, electricity15, and medical supplies.

The hospital is quite a large building and is surrounded by a large fence. There was construction around the hospital during the whole of my fieldwork. Many trees have been planted, but it will be several years before they offer much shade. As one approaches the hospital entrance, male patients appear looking out the grated wall of their wards. The women are housed in a compound in the back. At the entrance of the hospital is a sign reading: “To all Patients. Warm Welcome. Treat them well.” Outside of the entrance sits the hospital’s small fleet of trishaws (a three-wheeled bicycle taxi). Within

13The army took the site over due to its strategic location and the unpopularity of its former tenants. Locals joke that the government had to turn the patients out to make room for even crazier residents. 14 At the old hospital, doctors typically worked until four or five p.m.; they now leave the hospital at one or two p.m., depending on when they can get a ride. They often carpool, borrow a friend’s car, take a taxi or several buses (there are no direct bus lines from Rangoon, and the bus trip takes over an hour). However, taxis can be difficult to take because the trip is so far and drivers rarely have a return fare. Because doctors make little money at their government day jobs (9000 to 13,000 kyat per month—roughly 9 to13 dollars), most supplement their incomes with private practice. The doctors therefore needed to leave the hospital in time to see their private patients. Although each doctor has a room in the YMHH staff quarters, they rarely make use of them; these quarters are primarily used by nurses and orderlies who cannot afford the commute from Rangoon. 15 Electricity is rationed at the hospital, as it is in all government offices. Exceptions are made during the hot season (so that fans can be used) and for electroconvulsive shock therapy (ECT) treatments.

38 the hospital compound there is also a small pharmacy, as well as a few canteens where patients’ family members and hospital staff often take their meals.

On average, there are 650 patients in residence at YMHH at any given time, nearly half of whom have been diagnosed with schizophrenia or an other psychotic disorder (see Table 2.1).

Table 2.1. Unit (ward) descriptions at the Yangon Mental Health Hospital, October 2002 Total Female Male Psychotic (N=657) (N=214) (N=253) (N=429) Unit I (Professor’s Unit) 134 0 134 54 Unit IIa (Lecturer’s Unit) 101 0 101 29 Unit IIb (Forensic 40 0 40 25 section) Unit III 115 0 115 38 Unit IV 160 146 0 69 Unit V (Narcotics) 39 0 39 Unknown* Unit VI 68 68 0 38 *The number of psychotic patients in the narcotics unit is unknown because I did not include this unit in my random sample.

There are twice as many men in residence as women16. The hospital consists of one large main building with four smaller buildings in the back, which are connected by a walkway. Under construction was a fifth building, which will be a . Along the walkway hospital workers wash patients’ longgyis and lay them out to dry on the grass, trishaws transport family members between units, and women set up baskets of food and clothing to sell. These women have quite a monopoly over business, as the nearest market is many miles away, too far for most staff and family members to travel.

16 Doctors explained this gender difference by claiming that women are easier to take care of at home and thus less likely to be sent to the hospital. Forster (1927) made a similar observation in her report on mental hospitals in Burma.

39 In the main building are three separate male wards, lecture rooms, a small library17, a kitchen, a medical records room, the emergency ward, and several staff offices. The other buildings consist of two women’s wards, another male ward that also houses the forensic patients (female forensic patients—mentally ill persons who have committed a crime—are not housed separately from the other women because they are not considered to be a threat), and a narcotic ward, which is exclusively male. Each unit is further subdivided by room type: paid rooms, free rooms, and locked wards. The paid rooms run the spectrum from fully private rooms to large rooms shared with tens of other patients. Private rooms cum bathrooms cost 1000 kyat per day (a little over one dollar at the time). Patients in these rooms are provided food and drink by their families, who either bring food or purchase it from one of the local canteens. These patients also have several personal possessions in their rooms, including their own dishes, water jugs, towels, and books. Semi-private rooms are similarly configured but for two people and cost 500 kyat per day. The next room type holds 10-30 people and costs 200 kyat per day

(some patients live for free in these rooms once age or poor health makes living in the poorer wards more difficult). Patients in these rooms have a metal bed with mattress, as well as a few personal items. They share a communal bathroom. Some of these patients are able to provide their own food some of the time, but several partake of the meals provided by the hospital, which usually consist of rice and vegetable curry (unless a donor has provided a more substantial meal of egg or meat curry). Fewer of these patients

17 The library is a small dusty room filled with very old journals covered in cobwebs. Most of the journals were American or British psychiatry journals dating back to the U Nu years when doctors were able to access information from outside of the country more easily.

40 had family members who visit them, and those who do only receive visits every few weeks or so.

The free rooms are subsidized by the government and house up to 50 people.

Patients in these rooms also share a communal bathroom and eat hospital meals. They sleep on reed mats on the floor and have few, if any, personal possessions (the often go

“missing”). These patients tend to be visibly thinner, have more sores and medication side effects, and have fewer teeth than patients living in the paid wards. Some of these patients are not mentally ill, but have no where else to go. As one psychiatrist said to me,

“The hospital is just like a hotel. We keep them even though they have no mental illness.”

The locked wards consist of small, barred cells each with a wooden bed and small bathroom. Most of them have two people in each room who, in the majority of cases, have been isolated for being “unsettled” (usually experiencing an acute psychotic episode), are malnourished or weak, have tried to escape, or were violent.

There is very little privacy at the hospital: the doors remain open, and the curtained windows (no glass, just bars) catch the breeze of the fan so that one can usually see inside. When there is electricity to power the fans, they tend to drown out the voices of patients and doctors, creating some degree of privacy by of making their words difficult to discern by those waiting in the hallways. These halls are filled with chairs, which always seem occupied by waiting patients and family members.

The hospital staff is, not uncommonly, very hierarchical. The largest office on the top floor of the hospital belongs to the hospital’s medical superintendent (MS). The MS in charge was initially a general doctor who specialized in administration, who, after his retirement, was replaced by a senior psychiatrist. Next on the hierarchy are the Deputy

41 Superintendent, the Professor (head of the university’s psychiatry department),

Lecturer/Consultant psychiatrists, Consultant psychiatrists and Assistant Surgeons18.

Following the doctors come the nurses, of which there are about 70 working at YMHH.

The Matron, distinguished from the other nursing staff by her sky blue longgyi (a tube- like sarong), is essentially the hospital administrator. A head nurse, referred to as “Sister” or “Brother,” runs each unit: sisters can be identified by their green longgyis, while brothers have no particular uniform regardless of position. Experienced staff nurses wear dark blue longgyis, and those fresh out of nursing school are referred to as “training nurses” and wear red longgyis. All female nurses wear white nursing caps. Emergency

Medical Officers (EMO), or nurse’s aids, are hired through the Department of Labor and have little formal training, but spend more time with patients than any other staff person and wear purple longgyis. Other hospital staff includes a clinical psychologist19, general workers (laborers), cook staff, two social workers20, two occupational therapists, and a sports director (representatives from the latter two groups did not come to the hospital during the entire period of this dissertation research). At the old hospital, there was also an art and music therapist, but this program has not yet been reinstituted. There were four psychiatry residents during my fieldwork who were at YMHH each Monday,

Wednesday, and Thursday. (General medical students come to the hospital for a two week rotation each year.)

18 These titles are based upon the British medical system. 19 The clinical psychologist works primarily with male patients from the narcotic unit. She leads a weekly relaxation group with them but spends the majority of her time administering psychological tests to patients to help determine their work status. 20 These social workers worked primarily with high functioning male patients who needed help negotiating leave from work, pensions, etc.

42 The MS assigned two psychiatrists to supervise and assist this dissertation research at YMHH: the Professor and a senior psychiatrist who ran Units IV and VI (the women’s wards). I was encouraged to spend the majority of my time in the women’s wards—although I also spent much time in the other units (except the narcotic unit) — thus the senior psychiatrist was the supervisor with whom I had the most contact. My role at YMHH was similar to that of a psychiatry resident, which helped normalize my presence there and integrate me into the hospital’s routine. The psychiatrists asked me for my input at case conferences and invited me to attend special lectures. The patients referred to me as sayama (a term of respect for a woman who has some sort of special knowledge, often a teacher) and the nurses referred to me as “staff,” a title that gave me unrestricted access throughout the hospital, including to all charts and patients. This freedom also extended to Institute Medicine (1), the largest medical school in Burma, where my primary supervisor was the Professor of Psychiatry (he has since retired). Due to the cooperation of the medical school and the school librarian, I was given access to the medical school’s library and its related to schizophrenia and other mental health issues.

A typical day at YMHH began with ward rounds. In Unit IV ward rounds progressed from the paid rooms to the free Rooms (this unit is made up of six separate buildings built around a grassy courtyard; only five are in use and one is the locked ward building). During rounds the head psychiatrist interviewed the patient, often taking her hand, asking if she was all right and if she needed anything while a nurse took notes in the patient’s chart. Patients were asked to hold out their arms so the doctors could detect if they had any tremors (a side effect of antipsychotic medications), and medication

43 adjustments were made if necessary. Often a family member would also be present and would help answer the doctor’s questions. On a few occasions, another patient helped answer. As we proceeded from the private rooms to the less private rooms, the staff paid less and less attention to the patients. By the time we reached the free wards, the staff

(three psychiatrists, one psychiatry resident, the Sister, two training nurses, an EMO) would just peek inside the large room to make sure everyone was basically okay before wandering to the next building. At first I thought this was for my benefit (trying to avoid showing me the poorer rooms and patients), but eventually learned that this was the normal way of doing things.

After morning rounds, we would normally head back to the building where the staff offices were. On Tuesday and Wednesday, new patients were admitted to Units IV and VI, respectively21. There the doctors would see inpatients who needed special attention, process new patients, discharge patients, as well as see outpatients. ECT was scheduled on Mondays, Wednesdays and Fridays. On Monday mornings, there was a hospital wide case conference where a case was presented and discussed. On Fridays, the doctors held “sitting” or “table” rounds, which were a time to discuss patients (that is, diagnostic and treatment problems) in a less formal context than the case conference.

Staff meetings occurred every other week, which were the only hospital activity that I did not participate in. The hospital also hosted lecture series for medical, nursing, and social work students, many of which I did attend.

21 The only difference between Units IV and VI was that the latter had more “settled” (calm, relatively symptom-free) patients, thus receiving less attention from the psychiatrists. Unit VI was also a newer building and lacked many of the facilities that the other units had. For example, they did not have toilet until the end of 2003.

44 There is not much for patients to do during the day. Except for patients in the private rooms, most patients are locked inside of their rooms during the day. As one patient explained when I asked at what times the doors were opened each day:

When we eat. They open it up once in the morning [for bathing] and once in the evening [for ]. They let us through, but they won’t to patients who are likely to run away. They can’t risk their jobs, you see. They’ll lose their jobs if the patients escape, that’s why they’re closed.

All of the rooms have barred windows, and many of the patients gathered around them to peer through the open spaces. A few afternoons a week they were allowed out for exercise, which primarily involved picking the grass around the compound. Higher functioning patients were allowed to help around the wards, cleaning, running errands, even helping with other patients (including holding them down during ECT treatments)22.

Some of these patients were also allowed to participate in religious festivals, including walks (under escort) to local monasteries (also see Forster 1927). Patients were released in the evenings for group and, of course, for mealtimes. They were also allowed out for interviews or “hanging out” with me.

3. Outpatient Clinics

There are six government psychiatric clinics in Rangoon, as well as three privately run clinics. In addition, most psychiatrists see patients out of their homes. The government outpatient departments are typically attached to a larger general hospital and patients are seen just once or twice a week. These include: Yangon General Hospital

22 Skidmore (1999) reports that at the previous Yangon Psychiatric Hospital patients also maintained vegetable gardens and a small number of livestock.

45 (YGH)23, East Rangoon General Hospital, West Rangoon General Hospital, Thingangyon

Sampya Hospital, Insein Hospital (which has a daily inpatient and outpatient department), and North Okkalapa General Hospital (a teaching hospital affiliated with

Rangoon’s other medical school, Institute Medicine (2) that has a daily outpatient and inpatient clinic). I attended the outpatient clinics at Yangon General Hospital and West

Rangoon General Hospital nearly every week during my fieldwork. I also attended Insein

Hospital’s outpatient clinic on one occasion, but it was clear that my presence made the doctor there nervous so I did not return.

Most of the patients seen in the psychiatric outpatient departments are referred from other units within the hospital, or live nearby. Like other government hospitals, the treatment is free but medications must be purchased outside from a pharmacy. On average, twenty patients are seen during each clinic. (The number of psychotic patients who come to these outpatient departments is relatively few.) The fact that this is a small number is reflected in the YGH waiting room, which the psychiatric clinic shares with the endocrine and metabolic wards: the psychiatric side of the waiting room is relatively empty and calm, while the other side is teeming with lines of anxious families. Many patients who receive a diagnosis of schizophrenia or other psychotic disorder are immediately referred to YMHH.

23 Yangon General Hospital is a large colonial building and was built in 1899. The psychiatric unit was added in 1965 (Mandalay General Hospital was the next hospital to acquire a psychiatric unit in 1969). There are actually two psychiatric outpatient departments at this hospital. One is held in the pain clinic, which is attached to the neurosurgical unit in one of the hospital’s newer buildings (it was formerly run by a neuropsychiatrist working at this neuro-surgical unit). The other department is held across the street in the original hospital building, next to the trauma centre and the pharmacy. It consists of a long, narrow room broken up into three five foot by five foot compartments, each with a bench, a table at which the doctor sits and writes, an exam table, and several unused cabinets.

46 There are three private psychiatric clinics in Rangoon, one of which is primarily for narcotic patients. One clinic is run by a semi-retired psychiatrist whose clientele tend to be from socio-economic levels higher those patients seen in other psychiatric treatment settings in Burma. Patients are seen there twenty four hours a day; it has the reputation of being the biggest and best place to go for psychiatric issues24. The other clinic opened quite recently (during this fieldwork) and both in and outpatients are seen there. I spent a great deal of time at the latter two clinics. I attended the opening of the newer clinic, spent time in the waiting areas with patients, observed doctors’ clinical visits with patients, and conducted interviews on site with patients recruited at these clinics.

I also attended many of the psychiatrists’ private practices. These outpatient practices are generally run out of the doctor’s homes. Patients usually come with their families and the doctor reviews their case and refills their medication prescriptions.

Doctors are able to spend more time with the patient in these private settings, and tend to be on familiar terms with the family. Families pay what they can depending on their circumstances, but the general fee for an office visit was usually 500 kyat (about 50 cents), or more if medications were included.

24 For those who can afford it, better “outpatient” care is sought abroad. General Ne Win was known to consult a psychiatrist and went so far as to take a trip to where he consulted Dr. Hans Hoff. Dr. Hoff later came to Burma to treat Ne Win. Although the reason for these consultations remains a mystery to the general public, there are numerous stories describing his erratic and strange behavior. One of the most infamous occasions took place at the Inya Lake Hotel where he entered the banquet room followed by a group of soldiers and proceeded to destroy a drum set with his golf club, which he then used to beat the drummer (Sargent 1994:200).

47 4. Community

The ethnographic community in which this dissertation fieldwork took place was not limited to clinical contexts. It also included Buddhist monasteries and where

I learned about vipassana (insight) meditation and other important features of Burmese

Buddhism; the Theravada Buddhist Mission University where I made use of its extensive library and had many helpful discussions with its students and teachers; indigenous medicine offices where I learned more about herbal treatments and the Ayurvedic medical system that is the foundation for traditional Burmese medicine; astrologer’s booths where I observed palm and chart readings; as well as many conversations with friends, colleagues, staff of non-governmental organizations, and diplomats about features of Burmese daily life.

This ethnographic community also surfaced in more unlikely places. There are relatively few foreigners who visit or live in Burma, so those, like myself, who are there for long periods of time tend to be recognized around town. I rarely had to tell taxi and trishaw drivers my home address, for example, because they often already knew. They also knew that I frequented many of the hospitals, with a particular, incomprehensible penchant for the ayu taun. The people at the photocopy shop became familiar with my research by virtue of reading so many copies of my interview guides; and my favorite shopkeepers recommended snacks that they thought inpatients would especially appreciate. This community-at-large not only expressed interest in my goings-on, but also provided further information about social attitudes towards mental illness and the institutions that treat it.

48 C. Research Participants

This research involved the participation of three distinct groups of informants, all of whom included Burmese Buddhist women and men: patients (n=40), patient family members (n=20), and healers (n=40). A fourth group was added in the middle of the fieldwork to include survey respondents culled from the general population of Rangoon and its vicinity (n=142). The socio-demographic characteristics of all research participants are summarized below in Table 2.2. There was a fairly even representation of gender across all categories of respondents: 50% of inpatients and outpatients, 40% of healers, 65% of family members, and 44% of survey respondents were women; 50% of inpatients and outpatients, 60% of healers, 30% of family members, and 66% of survey respondents were men. The average age in years for inpatients was 41.00 (SD 12.06), outpatients 35.15 (SD 9.97), healers 54.95 (SD 14.10), family members 53.85 (SD13.33), and survey respondents 36.19 (SD 14.63). Most inpatients (80%) and outpatients (75%) were unmarried, while only 20% of healers and 10% of family members were single. The majority of healers (75%) and family members (70%) were married; only 10% of inpatients and 25% of outpatients were married. The marital status of survey respondents was not gathered. The majority of inpatients (70%) did not graduate from high school;

40% outpatients did not have a high school degree either, but 55% also had some college education. The majority of healers (67.5%) had attended college or had professional training, whereas 30% of family members had a high school degree and 35% had attended college. Half of survey respondents (50%) also had some college education, while 24% had a high school degree. These various education levels were reflected in respondents’ occupational backgrounds. Few inpatients and outpatients were currently

49 employed; those with an employment history had typically worked in manual or service oriented jobs (80% and 90%, respectively). All of the healer respondents clearly belonged to higher occupational levels. Family members and survey respondents represented various occupational levels: 45% of family members and 30.3% of survey respondents had professional or managerial backgrounds, while 55% of family members and 56.3% of survey respondents had semi-skilled or unskilled jobs.

50 Table 2.2. Socio-demographic Data of Research Participants (n=242)

Inpatients Outpatients Healers Family Survey (N=20) (N=20) (N=40) Members Respondents (N=20) (N=142) N % N % N % N % N % Gender -Female 10 50 10 50 16 40 14 70 63 44 -Male 10 50 10 50 24 60 6 30 79 56 Age -18 to 30 5 25 7 35 2 5.0 2 10 61 43 - 31 to 50 12 60 13 65 13 32.5 5 25 56 39 - 51 to 70 3 15 0 0 19 47.5 11 55 21 15 - 71 to 90 0 0 0 0 6 15.0 2 10 4 3 Marital Status -Married 2 10 5 25 30 75.0 14 70 n/a -Single 16 80 14 70 8 20.0 2 10 -Separated/ 2 10 1 5 1 2.5 2 10 Divorced -Widowed 0 0 0 0 1 2.5 2 10 Education - <10th 14 70 8 40 9 22.5 3 15 32 22.0 - 10th graduate 1 5 1 5 1 2.5 6 30 34 24.0 - Some college 1 5 6 30 1 2.5 3 15 25 18.0 - College grad 2 10 5 25 5 12.5 4 20 38 27.0 - < College 0 0 0 0 21 52.5 0 0 7 5.0 - Monastic 1 5 0 0 1 2.5 0 0 4 3.0 - None 1 5 0 0 2 5.0 4 20 1 0.5 -Missing 0 0 0 0 0 0 0 0 1 0.5 Occupation25 - Professional 0 0 2 10 23 57.5 2 10 14 9.9 -Managerial/ 4 20 0 0 17 42.5 7 35 25 17.6 Admin. - Service/ 7 35 6 30 0 0 3 15 42 29.6 Manual - Unskilled/ 9 45 12 60 0 0 8 40 31 21.8 None - Missing 0 0 0 0 0 0 0 0 30 21.1

As most of the fieldwork took place in Rangoon, the majority of patient, family member, and healer respondents lived in an urban context. However, 40% of these

25 Occupation categories were created based on the Hollingshead Index of Social Position (Hollingshead and Redlich 1958).

51 respondents were originally from other regions of Burma (mostly smaller cities and towns, although a few were from villages). Forty percent (n=8) of inpatients (prior to their hospitalization) and 25% (n=5) of outpatients lived outside of Rangoon during the period of fieldwork (they or their families commuted from nearby towns to receive medical care in the city). Thirty-five percent (n=7) of family members and 50% (n=20) of healers were originally from elsewhere in Burma; 15% (3) of family members and 22.5%

(n=9) of healers lived outside of Rangoon during the fieldwork. All of the survey respondents (n=142) were located in Rangoon and no further information about their living situation was acquired. Despite the higher than expected number of respondents from outside of Rangoon, this sample is largely drawn from urban or semi-urban areas.

All research participants were volunteers and informed of their right to withdraw from the study at any time. Each participant received an information sheet in Burmese or

English about the study, were asked if they understood it, and if they had any questions about the research. With the exception of the survey respondents (who gave oral consent), study participants signed an informed consent form and received a copy to keep. They were also compensated with small gifts of food, clothing, or money.

Depending on the preference of participants, interviews were conducted at the clinic from which they were recruited, their homes, my interpreter’s home, or my apartment.

1. Patient subset (n=40; 20 inpatients, 20 outpatients)

Inpatients were recruited through the YMHH medical records. Medical charts for each patient currently in residence at the hospital were examined and a numerical identity code was entered into a database for those with a clinical diagnosis of schizophrenia or

52 other psychotic disorder26. At the time, there were 261 charts recording these diagnoses.

A random sample of patients with these diagnoses was then generated for each unit at the hospital (excluding the narcotics unit). Based on the following inclusion criteria, ten males and ten females were selected, making sure that each unit was represented

(including one forensic patient). The inclusion criteria were that patients 1) had a diagnosis of schizophrenia or other psychotic disorder27; 2) were Burmese Buddhist; 3)

26 All patients with a psychotic disorder were included in the random sample in order to include local manifestations of psychotic illness that were not necessarily recognized according to international diagnostic criteria of schizophrenia. 27 Cross-cultural research of severe mental illness has generally followed one of two prevailing models: (1) an ethnopsychiatric (or psychiatric anthropological) approach that seeks to understand indigenous beliefs and practices related to psychiatric disturbances, and (2) cross-cultural (or transcultural) psychiatric approach that seeks to apply its own conceptions of diagnosis and treatment in other contexts, that is, by documenting (Western) psychiatric maladies in other (non-Western) contexts. While the latter approach has yielded some important data, its interpretation of that data is limited without consideration of their local significance (Hopper 1991; Karno and Jenkins 1993). With the aim of incorporating ethnopsychiatric and transcultural techniques in this dissertation, two definitions of schizophrenia are utilized in this dissertation. The first is anthropologist Robert Edgerton’s (1976:63) definition of mental illness: As a working definition, one may speak of mental illness when a person’s thoughts, emotions, or behaviors appear to others in his society to be unreasonable or irrational, or when his ability to cope with the demands of life is impaired. The second is the Diagnostic and Statistical Manual’s IV (DSM-IV-TR) definition of schizophrenia (APA 2000): A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): (1) delusions (2) hallucinations (3) disorganized speech (4) grossly disorganized or catatonic behavior (5) negative symptoms (affective flattening, alogia, or avolition) Note: Only one of these symptoms is required if the delusions are bizarre or the hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other. B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when

53 were currently seeking treatment at YMHH; 4) were willing and able to provide informed consent, and were sufficiently stable to participate in the study; and 5) were at least 18 years of age. Some patients were excluded immediately because they had been discharged (n=2), were deceased (n=1), or deaf (1).

I then met with patients in numerical order according to the random sample. This initial meeting served to introduce patients to the research and me, determine if they wanted to participate, and if they were capable of participating and giving a meaningful consent. A total of 25 inpatients were excluded after it was determined that they were not oriented well enough to participate (n=21)28, they did not meet diagnostic criteria for schizophrenia or another psychotic disorder (n=1), were not Buddhist (the chart had mislabeled the patient’s religion) (n=1), or they refused to participate (n=2). My YMHH supervisor accompanied me during these initial meetings with patients, as well as during the clinical interviews. The majority of inpatients (80%, n=16) lived in the free rooms;

10% (n=2) of inpatients lived in private rooms for 500 kyat/day, and 10% (n=2) lived in semi-private rooms for 200 kyat/day.

the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement. C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6- month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). 28 Of these 21 inpatients, 8 were excluded because of low Mini Mental State Exam Scores (a score of 20 was required to participate in the research). The remaining 13 inpatients were incapable of giving informed consent and were thus excluded before completing any structured interviews. These inpatients were unable to indicate that they understood the nature of the research, and generally did not give any response to interviewer’s questions. Some of these inpatients did not appear to know their own name or personal history.

54 Outpatients were recruited from a variety of clinical settings. I had initially intended to recruit all outpatients from YMHH, but after its relocation most people started seeking more local outpatient care. I therefore recruited patients from government hospitals, private clinics, and psychiatrists’ private practices (see Table 2.3). I would sit in during patients’ visits with their psychiatrist; if someone with a diagnosis of a psychotic disorder arrived, the doctor would explain my research to him or her and ask if they would like to participate. If he or she was interested, I went through the same routine as described above with inpatients. A total of six outpatients were excluded after it was determined that they were not oriented well enough to participate based on low Mini

Mental State Exam scores (n=1), they did not meet diagnostic criteria for schizophrenia or another psychotic disorder (n=2), or failed to complete the interviews (n=3) 29. The majority of outpatient respondents (85%, n=17) lived with their family; 10% (n=2) of outpatients lived alone and 5% (n=1) lived in a .

Table 2.3. Sites of Outpatient Recruitment (n=20)

Female Male Total (N=10) (N=10) (N=20) N % N % N % Government 3 30 6 60 9 45 outpatient departments Private clinics 2 20 2 20 4 20

Private practice 5 50 2 20 7 35

Total 10 100 10 100 20 100

29 One outpatient left Rangoon and could not complete subsequent interviews, another failed to appear at an interview and was not at the address he provided, and another outpatient withdrew from the research claiming that the interviews were too long for him.

55 2. Family member subset (n=20)

Family members were selected in collaboration with patients according to (1) which family member had the most “face-to face” contact with the patient and was most involved with the patient’s care, and (2) which family member the patient felt was most appropriate for me to interview. As anticipated the majority (65%) of these caretakers were female (see Table 2.4). This finding is consistent with cross-cultural studies showing that although other family members care for ill kin, they have less frequent contact than women (mothers, sisters, daughters, etc.) (Jenkins and Schumacher 1999).

Table 2.4. Description of Family Member Respondents (n=20)

Female Male Total (N=13) (N=7) (N=20) N % N % N % Parent 5 25.0 4 20.0 9 45.0 Sibling 4 20.0 0 0 4 20.0 Aunt/Uncle 0 0 1 5.0 1 5.0 In-law 1 5.0 0 0 1 5.0 Spouse 3 15.0 1 5.0 4 20.0 Cousin 0 0 1 5.0 1 5.0 Total 13 65.0 7 35.0 20 100

Family members were contacted through and with the permission of the patient. I had originally planned to contact inpatient family members during their visits to the hospital, but since few of them actually came to the hospital I visited them instead. If the family had a telephone, my supervisor from YMHH would call to alert the family about me and my visit, otherwise she would accompany me. Since a family member accompanied most outpatients, he or she was approached during clinic visits once the patient had given permission to do so. I was unable to interview family members for half

56 of the patient (in and outpatients) participants. Some patients had no family or did not know where their family could be located (n=8); other family members lived too far away to visit during the timeframe of fieldwork (n=5), some were too physically unwell to participate (n=3), and some refused to participate (n=4).

3. Healer subset (n=40)

Healers were recruited at YMHH and other local healing sites. All healers were currently practicing, self-described healers who reside in Burma. These healers represented a diverse range of therapeutic modalities, including conventional psychiatry, religious healing, and traditional medicine (see Table 2.5). I had interactions with a larger number of healers from each healing sector than is indicated here, either through participant observation or informal conversation; Table 2.5 describes only those healers with whom I conducted in-depth interviews.

57 Table 2.5. Description of Healer Types (n=40)

Female Male Total (N=16) (N=24) (N=40) N % N % N % Psychiatrists 4 10.0 7 17.5 11 27.5 Psychologists 1 2.5 1 2.5 2 5.0 General Doctors 1 2.5 0 0 1 2.5 Psychiatry 2 5.0 0 0 2 5.0 Residents Nurses 3 7.5 1 2.5 4 10.0 Indigenous 0 0 2 5.0 2 5.0 Medicine Doctors Monks 0 0 2 5.0 2 5.0 Meditation 1 2.5 1 2.5 2 5.0 teachers Payoga saya 0 0 4 10.0 4 10.0 Nat gedaw 3 7.5 3 7.5 6 15.0 Ahtet lan saya 1 2.5 3 7.5 4 10.0 Total 16 40.0 24 60.0 40 100.0

Psychiatrists, including psychiatry residents and nurses, who worked at YMHH were selected from a random sample compiled of all doctors there. Other psychiatrists were recruited during visits to government outpatient clinics, private clinics, and private practices. Healers were selected using a snowball sampling technique, in which a key informant was asked to name others who were involved in treating mental illness.

Snowball sampling is an effective and useful technique for selecting small, difficult-to- reach populations such as many in the Burmese healing community (Bernard 1995). For example, I asked doctors to refer me to any other healers they knew. I also asked patients and family members for contact information of any healers they had consulted in the past.

The following event describes a typical search for and encounter with healers.

We spent the morning driving around looking for healers and family members [referred by other subjects]. We couldn’t find the payoga saya [exorcist] referred by one of the family members but heard about others while asking around. We drove to the neighborhood of one of the payoga saya we heard about. A young

58 man led the way. He knows of this healer because his wife was once possessed by something evil and they consulted him. She was cured after only one episode. It is a very poor section of Rangoon. Y (my field assistant) goes to his house alone [the appearance of a foreigner would have been too startling]. Parents point me out to their children to look at. No smiles here—people seem wary of me. The healer is afraid to meet me near his home because of the MI [military intelligence] but since I’ve come so far to do this research he agrees to meet me later at Y’s house. [fieldnote excerpt, 4/22/03]

Another time I asked my driver to stop near one of Rangoon’s general hospitals where amateur astrologers gathered to prognosticate for anxious family members and patients.

The driver told me that I would not get much information out of these “charlatans” who, in his opinion, were more opportunists than real astrologers. After a few unproductive talks with some of these fortune-tellers (they confessed that they had no experience with treating mental illness), I walked back to the car defeated. Then, the driver told me that he had studied to be an astrologer at one point but stopped after finding it too difficult to maintain the five of Buddhism30, a requirement of the trade. However, he thought that his former master could help me and he proceeded to drive me to a nearby pagoda where this astrologer practiced. I was able to interview this astrologer who, in turn, referred me to others in his field.

4. Survey respondents (n=142)

A brief survey was administered by two bilingual (Burmese and English) field assistants to 142 participants in order to learn more about general beliefs about mental illness and suffering in Burma. Field assistants were assigned different locations in

Rangoon and its surrounding suburbs. They were instructed to include participants from a

30 These (Panca sila) include: not to destroy life, not to steal, not to commit adultery, not to tell lies, and not to take intoxicating drinks (Rahula 1974).

59 diverse range of educational and occupational backgrounds, including professionals, monks and nuns, business people, dependents, laborers, students, and the unemployed.

Field assistants approached patrons and employees of a variety of stores, tea shops, monasteries, schools, as well as small farmers, taxi drivers, and pedestrians. They also interviewed people within their own social networks. All together, field assistants solicited the voluntary survey participation by oral consent of Burmese Buddhist men

(n=79) and women (n=63) who were at least 18 years of age.

D. Interpretation and Analysis

1. Data Collection

This study received IRB approval and research permits were obtained from

Burma's Ministry of Health, as well as the director of YMHH. In order to achieve the aims of this dissertation, the following qualitative data collection techniques were employed: 1) structured interviews; 2) semi-structured interviews; 3) participant observation; and 4) a brief structured survey. Interview instruments were translated from

English into Burmese and back-translated by a bilingual field assistant in Burma. Most of the standardized interviews had already been translated into Burmese and these versions were utilized. Research material obtained from subjects included tape-recorded interviews and data collected during participant observation. Most interviews were recorded using a digital recorder; however, some interviews were either not recorded due to the preference of the interviewee or lack of electricity.

While the majority of the interviews were conducted in Burmese, some respondents preferred to converse in English. Interviews in Burmese were conducted with

60 the assistance of an interpreter. (While I have studied the Burmese written and spoken language, my level of proficiency was not sufficient to pick up subtle details that were essential for providing a rich ethnographic picture of suffering and schizophrenia. During the clinical interviews, the psychiatrists helped me with any language difficulties I encountered.) The interpreter assisted me during the subsequent semi-structured interviews, as well as driving around Rangoon searching for healers. At the beginning of each interview, we invited the participant to have tea and a snack, and then chatted informally to help “break the ice.” I would then thank the participant for agreeing to participate, again describe the research, and ask her or him to sign the consent form. Once the interview began, the interpreter took over asking the questions. The advantage of working with an interpreter was that I was able to take detailed notes and observe the behavior of the interviewee; my role was rather like a very “hands-on” participant observer. As Devereux and Hoddinott (1993) point out, however, the drawback to working with an interpreter is that much of the interview information is received second hand. The fact that I was able to understand most of the interview content, had an excellent interpreter, and had good rapport with research participants helped to offset this drawback. I was also fortunate in that this same interpreter transcribed and translated all of the interviews, which provided valuable continuity.

An additional benefit to working with an interpreter in Burma was that she (or, in some cases, my supervisors) made the initial contact with potential informants. In Burma, military intelligence officers and their informers keep a close eye on foreigner’s activities. For this reason, some people were reluctant to speak with me or would not speak to me at all. As a well-respected member of the Burmese Buddhist community, the

61 presence of this interpreter (along with my permission letter from the Ministry of Health) reassured many people that their interactions with me would not bring them to harm. The interpreter also encouraged me to wear traditional Burmese dress so that “at a glance” I might pass for Burmese—a strategy to escape the scrutiny of local informers, as well as help minimize my otherness. All the same, certain people with whom I spoke qualified their words with phrases such as, “do not repeat this or I will get arrested” or “I am telling you this as my daughter, not as a researcher.”

a. Structured Interviews.

Structured interviews helped to establish patients’ clinical status, including their ability to participate in the research, their clinical diagnosis, as well as contributing to the

“natural history” of their illness (Chrisman 1977). Patients’ medical records, staff and family member reports, and a series of standardized clinical interviews provided the information necessary to determine patients’ clinical status. Psychiatrists who were familiar with American Psychiatric Association (APA) diagnostic criteria administered the standardized clinical interviews.

Once a patient had agreed to participate in the research and signed the informed consent form, the Mini Mental State Exam (MMSE) was administered to determine the patient’s ability to participate. The MMSE is the standard instrument used by psychiatrists and psychologists to assess cognitive mental status (Folstein et al. 1975).

Specifically, the MMSE assesses a patients’ orientation, attention, immediate and short- term recall, language and ability to follow simple verbal and written commands.

Furthermore, it provides a total score that places the individual on a scale of cognitive

62 function: on a scale of 0 (profound cognitive impairment) to 30 (normal cognitive function), a patient needed to have a score of 20 or higher (indicating only mild cognitive impairment) to participate in the research31.

The MMSE was followed by the administration of the Positive and Negative

Symptom Scale (PANSS)32 (Kay et al.1987) and the Structured Clinical Interview for

DSM-IV (SCID). Each of these instruments had already been translated into Burmese

(except for the Global Assessment of Functioning Scale (GAF) section of the SCID)

(Win Aung Myint 2001). The PANSS was administered to each patient in order to document the type and severity of illness symptoms. The PANSS is rated along a 7-point scale. A score between 1 and 5 was required to participate in the research, indicating an absence of severe or extreme symptoms. The SCID was administered in order to standardize the research diagnoses (establishing a principle AXIS 1 diagnosis33) of all patients in order to ensure diagnostic reliability (see Table 2.6). Only those SCID sections relevant to the research project were administered. These included:

1) Screening Module. This section briefly assesses whether or not the patient has

any specific psychiatric problems, that is, alcoholism, anxiety, psychosis, and

eating disorders.

31 The mean MMSE score was 25.95 for inpatients (SD 4.95) and 28.00 for outpatients (SD 2.25). 32 The average composite PANSS score was +1.89 for inpatients and +1.99 for outpatients, indicating that both patient groups were categorized as “positive subtype” of schizophrenia because of a low prevalence of negative symptoms. 33 Axis I diagnoses include clinical disorders, such as major mental disorders and developmental and learning disorders.

63 2) Section B: Psychotic and Associated Symptoms. This section assesses if the

following symptoms are present: delusions, auditory hallucinations, visual

hallucinations, catatonic behavior, and negative symptoms.

3) Section C: Differential Diagnosis of Psychotic Disorders. This section

determines which diagnosis, if any, is most appropriate based on duration of

symptoms, type of symptoms, and impairment of functioning. Diagnoses

include: Schizophrenia, Schizophreniform Disorder, Schizoaffective Disorder,

Delusional Disorder, Brief Psychotic Disorder, Psychotic Disorder Due to

Substance or General Medical Condition, and Psychotic Disorder Not

Otherwise Specified. Only patients with a SCID diagnosis of Schizophrenia,

Schizophreniform Disorder, Schizoaffective Disorder, or Psychotic Disorder

Not Otherwise Specified34 were included in the research project in order to

rule out organic illness, substance abuse, and illness of brief duration (see

Table 2.5).

4) Global Assessment of Functioning (GAF) Scale35. This scale of 0-100

considers psychological, social, and occupational functioning on a

hypothetical continuum from mental health to mental illness. It does not

34 Schizophreniform Disorder is identical to Schizophrenia except that the total duration of illness is at least one month but less than six months (schizophrenia symptoms must exist for at least 6 months), and impaired social or occupational functioning during the illness is not required. Schizoaffective Disorder is likewise identical to Schizophrenia except that it also includes prominent mood symptoms (depression and/or mania). Psychotic Disorder Not Otherwise Specified includes psychotic symptoms (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) about which there is inadequate information to make a specific diagnosis (APA 2000). 35 The mean GAF score was 32.25 for inpatients (SD 11.30) and 37.05 for outpatients (SD 11.10).

64 account for impaired functioning due to environmental . This scale

codes for the lowest level of functioning during the week of poorest

functioning in the past month. Patients needed to have a GAF score between

31 and 100 in order to participate in the research, which indicated that they

were not in danger of harming themselves or others and had no gross

impairment in communication.

Table 2.6. Axis 1 Diagnoses of Patient Participants

Inpatients Outpatients Total (N=20) (N=20) (N=40) N % N % N % Schizophrenia 19 95 17 85 36 90 Schizoaffective 1 5 2 10 3 7.5 Disorder Schizophreniform 0 0 1 5 1 2.5 Disorder Psychotic Disorder 0 0 0 0 0 0 Not Otherwise Specified Total 20 100 20 100 40 100

As shown in Table 2.6, 90% of patients were diagnosed with schizophrenia, 7.5% with schizoaffective disorder, 2.5% with schizophreniform disorder, and none with psychotic disorder not otherwise specified. Outpatients generally experienced fewer symptoms and less functional impairment than inpatients (as measured through MMSE and GAF scores).

65 b. Semi-Structured Interviews.

Most of the qualitative data for this dissertation were yielded from semi- structured interviews. The first semi-structured interview administered to research participants was developed for purposes of this dissertation, the Culture and Suffering

Interview (CSI). It was administered to patients, patients’ family members, and healers, and took approximately two hours to complete. Many patient CSI took place over the course of two meetings, as it was difficult for some to sit still for two hours at a time.

The CSI recorded socio-demographic information for all respondents, including age, gender, education, occupation or former occupation, marital status, household structure, religious background, and source of income. It also provided essential contextual information about Buddhism, suffering, and schizophrenia in Burma.

Respondents were asked to describe their religious beliefs and practices, and the role that religion played in the health seeking behavior and treatment of schizophrenia.

Participants were also asked open-ended questions about their general beliefs regarding the cause, distribution, and meaning of suffering. During the patient CSI the ways in which patients experienced, explained, managed, and expressed their suffering were identified. The means by which patients’ suffering affected their sense of identity, social support, and health seeking behavior were also explored. In the non-patient CSI social perceptions of suffering and mental illness were identified. The ways in which non- patients coped with and expressed their suffering were also examined. Doing so allowed patient and non-patient experiences of suffering to be compared, and also identified specific cultural norms regarding the expression and management of suffering among

Burmese Buddhists.

66 An additional in-depth, semi-structured interview (Suffering and Schizophrenia

Interview [SSI]) was administered to a sub-set of patients (n=10; 5 inpatients and 5 outpatients) 36 in order to obtain narrative data related to the following domains and elaborate upon themes that emerged in the CSI and ethnographic observations, including:

(1) life events and personhood; (2) subjective illness experience; (3) mental discipline and insight; (4) feeling and emotion; (5) suffering; (6) religious beliefs and practices; (7) health seeking behavior and treatment efficacy; (8) social and family support; and (9) quality of life and orientation toward the future. These data helped establish an understanding of the meaning and experience of schizophrenia in the context of Burmese

Buddhism and its relationship to suffering. The narrative data from the SSI were used to help construct detailed case summaries for this subset of patients.

c. Ethnographic Participant Observation.

Ethnographic participant observation was carried out at in a wide range of situations. This research method uses long-term presence and participation to build trust and familiarity in order to facilitate rapport in research relationships, as well as to establish greater understanding of the research context (Bernard 1995; Spradley 1980).

Kleinman (1988a) suggests that ethnographic research is particularly appropriate for creating knowledge about the personal world of suffering. Data gathered from participant observation served to acquire a broader understanding of local beliefs, attitudes, and

36 This subset was selected based on patients who best represented the diverse experiences and manifestations of suffering and schizophrenia, were articulate, and with whom I had established a good rapport.

67 treatments for mental illness. Extensive ethnographic fieldnotes were taken each day in order to document daily events and experiences.

At YMHH I observed inpatients during group and individual therapy sessions, meals, activities, and leisure time. I also observed outpatients during their therapy sessions and in waiting areas. During interviews with outpatients and family members in their homes, I was able to observe their living situation and family setting. As mentioned previously, I spent a great deal of time with healers in their various professional settings.

I participated in hospital activities, including conferences, social occasions, and therapy sessions. I also attended several religious events, including festivals, meditation retreats, and lectures. I observed the practices of a large number of astrologers, spirit mediums, and other traditional healers to learn more about their specific methods and clientele.

Finally, I developed firm friendships with many of the doctors, students, and others, all of whom enhanced my understanding of my research topic as well as Burmese culture in general.

d. Brief Survey.

This survey was designed to learn more about cultural beliefs and understandings of mental illness and suffering within the larger Burmese Buddhist population.

Administering the survey to a sample unassociated with the psychiatric health sector also provided an opportunity to ascertain whether or not the views of family members and healers were reflective of those held in the wider Burmese Buddhist community. Socio- demographic information was obtained from survey respondents, including age, ethnicity, religion, gender, education, and occupation. In the survey respondents identified and

68 described every kind of healer or healing technique used in Burma to treat mental illness of which they were aware. The respondent was also asked to provide any contact information for any such healer if known personally. The respondent was then asked about his or her own personal beliefs about mental illness (i.e., social attitudes, health beliefs). A series of questions related to suffering were posed to each respondent: they were asked to define suffering, identify its causes, describe their own experiences of suffering, and how they coped with their suffering. Finally, they were asked if they believed that the mentally ill suffered and to explain any answer they gave.

2. Data Analysis and Interpretation

All interviews and fieldnotes were transcribed and the data analyzed using the following qualitative and quantitative methods: a) qualitative coding; b) narrative analysis; c) case summaries of a subset of patient participants; d) quantitative analysis.

The data for qualitative analysis consisted of interview (CSI and SSI), survey and observational materials (ethnographic fieldnotes). All interviews were transcribed from the digital recordings in their entirety (the interpreter transcribed the Burmese interviews and I transcribed the English interviews). The ethnographic notes (from clinical, family, and social settings) were also recorded immediately after each interview or participant observation setting and entered into a fieldnote database. Each of these data sources was subsequently coded using the qualitative methods outlined below and used to construct a comprehensive description of suffering and schizophrenia in Burma.

All CSI and SSI interview data, as well as ethnographic fieldnotes, were entered into a qualitative computer content analysis program (ATLAS-ti) and analyzed for

69 thematic patterns. All relevant data for a particular patient were grouped together according to each thematic pattern. A coding scheme was developed and catalogued into a coding book. Examples of coding domains included, but were not limited to the following: (1) causes of suffering; (2) how suffering is expressed; (3) responses to suffering; (4) beliefs regarding the suffering of the mentally ill.

Once coded, the data were subjected to narrative analysis in order to identify salient interview themes and narrative features. Narrative analysis is commonly used in the study of illness narratives in medical anthropology (Good 1994, Kleinman 1988a).

This method is particularly appropriate for a study of suffering as illness narratives provide a means for individuals to give coherence and meaning to their suffering (Leavitt

1995; Kleinman 1988a). The following elements were coded for while conducting narrative analysis in this study: (1) intersubjectivity: fieldnotes about the nature of interview interactions among myself, the interpreter, and research participants; (2) style of narrative: affect or emotional tone of interview; (3) key metaphors or symbols used to describe or capture the experience of suffering and schizophrenia; (4) characterization: references to personal characteristics of oneself and others; and (5) stories and emplotment: elements of narrative that reveal perceptions of one’s illness, treatments utilized, religious beliefs, social support, and living situations.

Case summaries were constructed for a subset of patients (n=10; 5 inpatients, 5 outpatients) in order to identify and elaborate upon the unique worldview, life experiences, and character of each patient with schizophrenia. A profile was written for each of these patients, using all pertinent interview and ethnographic data. These case studies provided a detailed account of each person’s life and illness history, thereby

70 giving case-by-case overviews and analyses of experiences of suffering and schizophrenia in Burma.

Specific variables generated from the CSI interviews and surveys were entered into a SPSS database in order to examine correlations between particular variables.

Specific correlations were examined to help explain certain trends. The results of these analyses will be discussed further in Chapter 5.

71 CHAPTER THREE MENTAL HEALTH SECTORS IN BURMA

As Arthur Kleinman explains in “Patients and Healers in the Context of Culture”

(1980), a health care system is comprised of interrelated health care activities that are, in turn, socially organized responses to illness and disease. He emphasizes that health care systems are “social and cultural in origin, structure, function, and significance” (ibid.:27).

In keeping with this conceptualization of the health care system as a network of local cultural beliefs and practices, the local system of health care sectors and beliefs in Burma will be described, drawing on previously published literature, as well as ethnographic observations. In doing so, the history and current state of Burma’s health sectors will be broadly outlined, and the available methods of treating mental illness in Burma will be identified.

The World Health Organization (WHO) estimates that there are over 800,000 people suffering from psychotic disorders in Burma (which is in accord with international prevalence figures of 1-2%), and over 4,000,000 suffering from other mental disorders (Kent 1996). In Burma, mental illness is treated primarily within three therapeutic domains: biomedical (psychiatric), religious, and traditional (Way 2001). As in many parts of the world, pluralistic approaches to health care are the norm in Burma, rather than the exception (Aung Thaw 2002; Nash 1965). This approach is even more widespread, particularly in Burma’s urban settings. Not only do people seek a variety of treatments, either simultaneously or consecutively, but healers themselves offer complementary treatments. For example, many of the traditional healers I interviewed now blend exorcisms with prescriptions for antipsychotic drugs, and one of the psychiatrists I interviewed tells his patients to try to “let their troubles go,” applying

72 Buddhist psychology to his treatment. Yet another psychiatrist refers patients to a local exorcist when their illness appears to be caused by spirit possession rather than psychosis.

In the following sections, I describe biomedical (psychiatric), religious, and traditional healing traditions separately, but with the stated understanding that fluid boundaries exist between them.

A. Psychiatry in Burma

1. Colonialism and Western Medicine in Burma (1554-1942)

A medical system based on Western biomedical professionals and institutions developed in Southeast Asia in the beginning of the 20th century. In Burma, this development was directly linked to British colonial efforts to establish its own form of health care throughout its empire by means of a British-based medical education and hospital-based delivery system. This European presence gave rise to Western biomedicine and, eventually, psychiatry in Burma.

Prior to the British colonial period in Burma, education was exclusively monastic, and focused on Buddhist and Brahmanical texts in Pali and literary Burmese. However, with the advent of Christian mission schools and hospitals—established in the late

1500’s—some Burmese also began to receive rudimentary medical education and treatments based on a European health care system (Harvey 1967). The first Western hospital was established by French Catholic in 16891. However, they were denounced by local monks, “taken to court, stripped and exposed to mosquitos, sewn up

1 The first Christian in Burma was a French Franciscan who resided there from 1554-7, and the first European to set foot in Burma was Nicolo di Conti, a bonafide merchant of Venice, who arrived in 1435.

73 in sacks and drowned near Ava in 1693” (ibid.: 345). After this dramatic conclusion to the mission presence in Burma, missionaries stayed away until 1721 when the Barnabites

(Italian missionaries associated with the ) arrived. The Barnabite Mission remained in Burma until 1830 and was responsible for making Western medicine available to a greater number of Burmese: “They [the Burmese] have themselves no regular surgeons, and hence, in cases of fracture, dislocation, contusion, etc., they have recourse to the Barnabite missionaries, who are the only persons acquainted with the use of the lancet” (Sangermano 1995/1893). They also produced the first Burmese dictionary, as well as books on its history, , culture, and pharmacology.

Centuries later education provided the British with a powerful tool of colonization in Burma (Steinberg et al. 1987). With the advent of British colonialism, the Burmese had additional opportunities to study Western medicine and receive treatment within this health sector. At first, the majority of Burmese doctors received their medical training at

Calcutta University, which itself was modeled after the British system of higher education. Then in the 1870’s several preparatory schools—including one that focused on medicine—were established in Rangoon, followed in 1879 with the opening of

Rangoon College2. Burma still lacked its own university, however, and the idea to establish one was not expressed until sometime in the 1880’s by Sir John Jardine, who was then the Judicial Commissioner and President of the Educational Syndicate of British

Burma (Taw Sein Ko 1913). After Sir Jardine was transferred to Bombay the idea was tabled (or forgotten) until 1892 when the Director of Public Institutions in Burma suggested that the presence of a Burmese university would centralize and localize

2 Rangoon College grew out of the Government High School under Sir Charles Bernard, Chief Commissioner of British Burma, and Sir John Jardine (Taw Sein Ko 1913).

74 educational efforts that previously had been focused on education abroad. This idea was vetoed, ostensibly because of a perceived lack of students, but more probably due to imperial fears of decentralization. Despite these objections, the Decentralization

Commission visited Burma in 1907 at which time it finally recommended that Rangoon establish its own university. Rangoon University came into existence in 1920, evolving from the two Arts Colleges that had been affiliated with Calcutta University. This new university had four constituents: University College, Judson College (an American missionary college), Teacher’s Training College (which had a self-sufficient campus of high school to graduate students), and the Medical College3. The Medical College was located quite far from the main university campus and students did not attend it until in their third year of university (Mi Mi Khaing 1996/1946).

The British officials who oversaw the university’s development decided that the best curriculum would incorporate both Western and “Oriental” educational systems. It was believed that a purely Western educational model would cut university students off from “the normal life of the country” and also “inculcate independence of thought, which is liable to degenerate into impertinence and truculence,” while the Burmese system of learning “enjoins respect and submission to age, experience, and authority” (Taw Sein Ko

1913). By combining these two models, colonial administrators hoped to produce an educated class of Burmese that remained loyal to British traditions and aims.

3 Medical school courses included: , physiology and human anatomy for the B.Sc. degree. They did not include psychiatric training, except for a short lecture series delivered by the mental hospital’s medical superintendent (Berkeley-Hill 1932).

75 The medical school’s curriculum was based on a similar philosophy, borrowed from Pandit Madan Mohan Malaviya’s4 “Benares Hindu University scheme,” which he outlined in 1891. This approach was intended to address India’s shortage of “qualified medical men” in the rural areas where only Hindu and Muslim traditional healers were available; Western-trained doctors worked in urban settings providing Western medical and surgical training as well as standards of local, traditional (Ayurvedic) healing practices. Taw Sein Ko (1920:29-30) described this approach:

The result is that it is believed that vast numbers of the people have to go without any medical aid in fighting against disease, and a large number of them have in their helplessness to welcome the medical assistance of men who are often uninstructed and incompetent . . . The distinguishing feature of the proposed Medical College at Benares will be that Hindu medical will be taught here along with the European system of medicine and surgery . . . being indigenous is more congenial to the people; treatment under it is cheaper than under the European system, and it has merits of its own, which enable it to stand a favourable comparison to other systems . . . The Hindu system of medicine will be brought up to date and enriched by the incorporation of the marvellous achievements, which modern medical science has made in anatomy, physiology, surgery and all other departments of the healthing art, both on the preventive and curative side. The aim of the institution will be to provide the country with vaidyas [Ayurvedic physicians] well qualified both as physicians and surgeons. It is believed that this will be a great service to the cause of suffering humanity in India.

Although all of Burma’s medical schools were based on this educational model, the

Mandalay curriculum, in particular, would focus on indigenous medicine supplemented by training in Western medicine.

4 Pandit Madan Mohan Malaviya was an Indian politician, educator, and supporter of Hindu nationalism.

76 This adoption of the British educational system in Burma also included the decision to make English the medium of instruction5. Recommendations by the Calcutta

University Commission suggested that English be used at universities and, ideally, in secondary schools. This decision was a shift from earlier standards of using the vernacular to instruct at the university level. It was first initiated by the government of

India in 1901 because of the growing unpopularity of the vernacular and the association of English with higher social and professional status (Taw Sein Ko 1920).6 In addition to social pressures to abandon vernacular teaching in Burma, there was the practical obstacle of continuing such methods due to a paucity of textbooks in any language other than English (U Kaung 1963). Mi Mi Khaing (1996/1946) writes that up until 1935 it was still possible to enter Rangoon University with virtually no knowledge of Burmese.

Despite the establishment of medical schools in Burma, the majority of their students were from India until World War II. In addition, the majority of medical superintendents and administrators were either British or Indian. The fact that few

Burmese enrolled in medical school was often attributed to the long and rigorous training involved with medical training, as well as a Buddhist aversion to dissecting bodies in

5 This move to a Western secular style of modernization was first instituted even earlier under the initiative of King Mindon in 1870 when he established an English language school outside of the royal city of Ava (U Thant Myint 2001). 6 Prior to World War II, there were three types of instruction in Burma: the Vernacular (with over 5000 recognized vernacular schools, this form of instruction was the most common and contributed to raising the literacy level of the poorest classes), the Anglo- Vernacular (in which Burmese was used as the language of instruction but English was taught as a subject and some high level courses used English language textbooks), and the European (these so called European code schools utilized English as the , with Burmese or other European languages as an alternative second language) (Mi Mi Khaing 1996/1946).

77 anatomy7. A more likely explanation for this low matriculation rate and few positions of authority held by Burmese within the health care system may be that the British tried to prevent its colonized subjects from gaining power. For example, an infamous British professor by the name of Meggitt was in charge of teaching premedical students biology and had the reputation of preventing Burmese students from going on to a medical program (U Thet Tun 2001). Eventually, however, the number of Burmese medical students and doctors started to rise, although their practice was limited primarily to urban areas (Hirschman 1994).

Although Western hospitals and medical schools were well established in Burma by the mid 19th century, psychiatry did not exist there until 1886 when the first lunatic asylum was established on the outskirts of Rangoon, housing approximately 50 patients

(Puthu 1959)8. At this time, Western psychiatry was characterized by “custodial care,” which focused less on treatment and more on confinement in order to protect society from the “lunatics.” The primary task of doctors and nurses during this treatment era was to guard patients and keep them safe (Ohn Mar et al. 2000). When the British Colonial

Government passed the Lunacy Act of 1912, which declared that every “lunatic” was entitled to treatment and the State would cover the cost of confinement if the family was unable to pay for it (U Sein Tu 2002). In conjunction with this act and the overcrowding

7 Unclaimed bodies of unskilled laborers were used for dissection purposes in anatomy classes. 8 There is little specific mention of mental illness or its treatment in the historical record of Burma. However, there is speculation that King (who succeeded his grandfather in 1817) suffered from manic-depression, becoming unable to perform his official duties. His brother, Tharrawaddy, thus took over the throne but he also showed signs of mental illness and eventually had to be restrained (U Thant Myint 2001).

78 of the mental hospital (which was overcapacity with 750 patients by this time9), the construction of the 1200-bed Rangoon Lunatic Asylum10 was begun in 1912 and finished in 1926. These asylums were staffed by general doctors (primarily British or Indian), rather than qualified psychiatrists. This trend continued until Burma’s first psychiatrist took over the asylum in 1951 (he also happened to be one of the first Burmese persons to work there).

2. World War II and the Japanese Occupation (1942-1945)

One the eve of the evacuation of Rangoon in 1942, which heralded the arrival of the Japanese, the mental patients were released from the lunatic asylum (Allen 1984).

Due to the repatriation of many non-Burmese patients11, the residents of the mental hospital then numbered just 700. Many of the chronic patients were transferred to

(approximately 100 km north of Rangoon) where they were looked after and some returned home, but the majority escaped and were never found despite postwar efforts to locate them12. The image of several hundred mental patients wandering through the city

9 In 1918, the number of inmates was reduced to 716 because one of the patient wards had been converted into a ward for Europeans (presumably mentally ill) (Ohn Mar et al. 2000). 10 As was typical at the time, the lunatic asylum housed not only the mentally ill, but also the homeless and many criminals. A smaller hospital was eventually built in Minbu for criminal mental patients, but was destroyed by Allied air raids during World War II and was never rebuilt (Indian Medical Gazette 1910; Ohn Mar et al. 2000). 11 By 1939, the number of patients in the asylum had reached over 1,000. To reduce overcrowding problems Chinese and Indian patients were sent home to their respective countries (Ohn Mar et al. 2000). 12 The mentally ill were also left to their own devices in Burma’s rural areas. For example, Dr. Gordon Seagrave (1946:99) describes how townspeople evacuated their small village to avoid the impending arrival of the Japanese. He writes: Two women were left behind by the townspeople to watch their property, women whom they assumed the Japanese would leave alone: a crazy woman and one who

79 streets is an apt metaphor for the upheaval experienced in Burma during the Japanese occupation. Although there is little documentation of the effects this period had on

Burma’s health sectors, what is known about these consequences is reviewed below.

What is of particular interest here is the impact this occupation had on the development

(or rather lack thereof) of Western psychiatry in Burma.

At the time of evacuation, there were 315 Western hospitals in Burma. The majority of these hospitals were taken over or closed by the Japanese; only 96 remained open during their occupation. The lunatic asylum was one of the hospitals used by the

Japanese despite the fact that it had been bombed and severely damaged during Allied air raids. The Japanese reestablished a portion of the asylum to house the “mentally defective” (Intelligence Bureau, Govt. of Burma 1943); however, as with the other reopened hospitals, there was a severe shortage of medical supplies and personnel during this period (many patients escaped due to the lack of staff and the damaged walls that afforded easy access to the outside). Medical stores had been looted during the occupation so that during the process of reopening the hospitals it became necessary either to import more supplies or attempt to buy the loot back at unreasonably high prices. The Medical College, reopened by the Japanese in January 1944, lacked books and equipment, and the standards of its education were considered to be much lower than in pre-evacuation Burma. Moreover, the Japanese often refused to recognize the medical credentials of some Burmese who were qualified doctors, forcing them to perform tasks for which they were overqualified. The missionary author and surgeon, Gordon Seagrave

(1946), who operated a hospital in northern Burma during World War II, describe how

was six months pregnant. The Japanese raped them both and the pregnant woman aborted.

80 the Japanese conscripted most doctors to work in military hospitals so that civilians received little care.

Although many Burmese worked with the Japanese to pursue their medical studies in Japan or to forward their own health care agendas13, little progress was made during this period to further develop Burma’s medical infrastructure, particularly the mental health sector. Indeed, many Burmese doctors and health care workers fled into

Upper Burma to join forces with the British during the Japanese occupation. Seagrave

(1946:101) wrote, “it was amusing to see pediatricians, obstetricians, and [British or

Indian] psychiatrists learning to operate in the jungle.” When the Allied forces eventually helped oust the Japanese from Burma in 1945, Western psychiatry finally emerged from the jungle to become an important part of the country’s biomedical health sector.

3. Independence and the Birth of Burmese Psychiatry (1945-1962)

Burma’s biomedical health sector needed to be rebuilt after the Japanese occupation. In the postwar years leading up to Burma’s independence in 1948, there was a shortage of doctors, which was filled, in part, by recruiting practitioners from India.

After independence, however, matriculation of the Burmese into and graduation from medical schools increased, as did the popularity of professions based on Western medicine. This rise in popularity was due in part to the newly granted permission by the government for doctors to practice privately in addition to their government service, a privilege that had previously been restricted to teachers who conducted private tutorials

13 For example, in 1942, U , the Burmese Executive for Health, proclaimed that this period would be one of radical reform in the country’s hospital administration and also outlined a comprehensive scheme for improving the population’s health (Intelligence Bureau, Govt. of Burma 1943).

81 after school hours. Nationalism was probable motivation for many Burmese who wanted to represent more than a minority in the country’s medical professions. Yet another dominant factor that affected the precipitous rise of Western medicine in independent

Burma was the country’s new role within the international community. Out of the devastation of World War II emerged the United Nations and its 1948 Universal

Declaration of Human Rights14, which promoted the idea that everyone was entitled to receive adequate health care, a principle that was embraced throughout Southeast Asia.

Another result of Burma’s independence was the reopening of the lunatic asylum, which by 1948 had just 45 patients. At this time, the hospital’s patient population consisted of voluntary boarders, civil certified patients, criminal patients, and opium addicts (Puthu 1959). In keeping with the independence movement, the asylum’s name was changed to the Tadagalay Mental Hospital15 (Nwe Nwe Aye 2002; Ohn Mar et al.

2000). A more significant event that would forever change the state of mental health care in Burma was the induction of Burma’s first qualified psychiatrist at the mental hospital.

In 1951, this young psychiatrist, Dr. Ne Win (no relation to the country’s future dictator), returned to Burma from London where he had received his psychiatric training16. Dr. Ne

Win’s arrival marked the birth of psychiatry in Burma and sparked a series of influential

14 Article 25 of the United Declaration of Human Rights states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control” (United Nations 1948). 15 This name comes from the village of Tadagale, which was nearby the original hospital. 16 Beginning in 1957 Burmese men and women were sent abroad for training in psychiatry (to England, India, and ) and psychiatric nursing (, Canada, England, , and India) (Ohn Mar et al. 2000).

82 changes at the mental hospital and in the wider medical health sector. Today, Dr. Ne Win is affectionately referred to in Burma as the “Father of Psychiatry.”

One of the first changes that Dr. Ne Win made at the mental hospital was to put an end to the custodial care methods that had been in place since the late 1800’s. In their place, he instituted “hospital-based care,” a method that was popular at the time in most countries with established psychiatric health sectors. He discouraged the common practice of keeping mental patients isolated, eliminated the use of the straitjacket, and padded many of the hospital’s rooms. He also established a relationship with the World

Health Organization (WHO) and facilitated a visit from one of its consultants in 1955 to recommend specific measures to prevent and reduce the country’s mental health problems (Daw Saw Mya May, U Ne Win, and U Khant. n.d.). When he later became the

Medical Superintendent of the mental hospital (1960-1984), Dr. Ne Win helped to send doctors overseas to receive training in psychiatry. Another major change arrived in 1959 when the antipsychotic drug, Thorazine (Chlorpromazine), was made available in Burma and quickly became the frontline treatment for severe mental disorder at its psychiatric facilities.

Despite the growth of Burmese psychiatry during this period, it remained an unpopular specialty17. Psychiatry was considered to be a low-status career due to its lower earning potential relative to other medical specialties and its highly stigmatized and undesirable patient population18. The low status of psychiatry affected health policy in

17 Specializations of any kind were relatively rare during this time. After independence, the majority of Burma’s doctors were general practitioners; U Nu’s administration tended to value administrators over specialists. 18 One psychiatrist reported that his wife had tried to persuade him to change specialties because of the low status of the mental health field in Burma. Another psychiatrist

83 Burma, and was reflected in Burma’s outdated Mental Health . Although Dr. Ne

Win and other doctors have attempted to update these laws, they remain much the same today as they were when first established in 1912 even though Burma’s general health policies have continued to be updated and revised. Despite these lagging mental health policies, however, Burma’s post-war focus on general health care led to the establishment of Burma’s first Medical Act in 1957, which outlined the formation, duties, and rights of medical practitioners19 (Office of the Attorney General, Union of Myanmar 2000).

4. The State Mental Hospital and The Ne Win Years (1962-1988)

General Ne Win’s seizure of Burma’s government in 1962 affected the psychiatric health sector in several ways. Immediately after the coup of 1962, Ne Win’s government established the Revolutionary Council whose ideological mission statement was called the “Burmese Way to .” An excerpt from this statement reads: “only after [exploitation of ‘man by man’] has ended can an affluent state of social development be reached and all people be happy and healthy in mind and body” (Tarling

1999:118)20. The postwar years in Burma had ushered in a new generation of educated professionals, an expanding role in the international community, and ambitious health

described how people sometimes became distant when they discovered what she did; her relatives asked her “why do you want to work as a nut doctor?” 19 This act was repealed and revised in 2000 under the direction of General Than Shwe of the State Peace and Development Council (Office of the Attorney General, Union of Myanmar 2000). 20 Symbolic of this new socialist era, the mental hospital was immediately renamed the “State Mental Hospital” (although in 1967 it was renamed the Rangoon Psychiatric Hospital in order to emphasize the clinical nature of its treatment efforts) (Nwe Nwe Aye 2002).

84 care reforms. The Ne Win years and the brought many of these developments to a grinding halt.

In 1973, the Constitution of the Socialist Republic of the Union of Burma stated that “every citizen during sickness has the right to medical treatment as arranged by the state” (Daw Saw Mya May, U Ne Win, and U Khant. n.d.). The goals of the party’s health policy were:

1) To raise the health standard of the working people and to provide efficient treatment for all diseases within the country; 2) To promote the simultaneous improvement of both curative and preventive health services with high priority for the latter; 3) To narrow the gap between the urban and rural areas in availability of health services.

These goals were in keeping with objectives for mental health care outlined by the WHO

(1978) during the first inter-country group meeting on Mental Health in SE Asia in 1977.

These objectives were: to prevent and/or reduce psychiatric, neurological and psychosocial problems; to increase the effectiveness of general health services through the appropriate utilization of mental health skills and knowledge; and to develop strategies for intervention based on an increased awareness of the mental health aspects of social action and change. These guidelines were based on a new emphasis on integrating mental health with other health programs rather than on major psychiatric disease entities. Unfortunately, Ne Win’s government spent less on health care than the country’s previous administrations and did relatively little to implement the

WHO objectives (Steinberg 1998).

Despite Ne Win’s failure to develop Burma’s health sectors, many of his socialist policies made a lasting impact on the methods and quality of medical and psychiatric practice in Burma. For example, in the 1970’s Burma’s military hospitals gained general

85 psychiatry units, and the country’s urban health facilities continued to expand their mental health services.21 Under Ne Win’s administration the People’s Militia Act was passed on March 3, 1969 making military service compulsory for every doctor between the ages of 18 and 56 (Lissak 1964). This act was never successfully implemented, but it foreshadowed subsequent government policies related to medical practice in Burma22 and required all civilian medical doctors to work in state-run clinics or hospitals (Kent 1996).

He also brought all of the country’s pharmacies, drug companies, and medical schools under the control of the government (Sargent 1994).

One of the most devastating trends established under Ne Win’s leadership has been the periodic closure of Burma’s universities and medical schools (the rationale behind such closures was to punish students for holding anti-government demonstrations and to prevent future gatherings) (Fink 2001). Since 1962 Burma’s universities have been closed for approximately 20% of the time (Brandon 1998). These closures have had a drastic effect on the quality of education in general, and medical training in particular; many students have had to wait years before finishing their education or have completely abandoned their studies. To add to students’ educational difficulties, Ne Win changed the medium of instruction from English to Burmese in 1966 (an attempt to erase all remnants of British colonialism); however, the majority of textbooks were in English and censorship delays prevented them from being translated into Burmese in time to be of

21 During this period, however, Neki (1973) notes the lack of psychiatrists in Burma. 22 In the early 1990’s, Burma’s military junta began to require all civil servants (including doctors) to undergo paramilitary training and political indoctrination classes—referred to as “re-education courses”—at the Directorate of Defense Services Intelligence’s psychological warfare school (Brandon 1998; Mya Maung 1998). During these courses doctors were taught how to uphold government principles and learn how to handle a weapon.

86 much use in the classroom, which resulted in the reintroduction of English language instruction in 1980 (Brandon 1998:238)23.

At the time that Ne Win’s government was increasing its control over the general population, Burma was becoming increasingly isolated from the rest of the world.

Although the medical community was able to maintain its ties with international organizations such as the United Nations and the World Health Organization, its ability to freely exchange information with other professionals was severely curtailed. The library holdings at the Yangon Mental Health Hospital reflect the end of this freedom; few of its medical journals date past the early 60’s. These isolationist policies contributed to the failure of Ne Win’s administration to improve conditions in Burma, leading many to question the abilities of his leadership. The result of this widely held dissatisfaction culminated in the massive demonstrations launched in 1988 and the end to Ne Win’s official role in the country’s government (Tarling 1999).

5. Contemporary Psychiatry in Burma (1988-present)

In 1990, soon after General Ne Win stepped down and the SLORC became

Burma’s new ruling party, the country launched a National Health Plan that emphasized mental health for the first time. This plan aimed to integrate mental health care into existing primary health care systems, primarily through special trainings and the development of satellite clinics throughout the country. These trainings were and are given to all psychiatrists, as well as township medical officers (TMO—general

23 There is speculation that this change was actually brought about when Ne Win’s daughter was rejected from a medical school in England due to her poor English skills (Brandon 1998:238).

87 practitioners) and township health officers. At the same time, community health services were initiated in association with the WHO and the Ministry of Health 24 (U Sein Tu

2002). In 1996, Burma launched a five-year national health plan (1996-2001) with an emphasis on health development in underserved rural and border areas (Xinhua 2001). As part of these efforts to nationalize the availability of mental health care, the Ministry of

Health posted consultant psychiatrists throughout the country in all fourteen state and division hospitals (not including YMHH). The distribution of these psychiatrists is shown below, in Table 3.125.

24 In 1991, an Indian psychiatrist, Dr. S. Murthy, representing the WHO visited Burma for four weeks to deliver a series of trainings and seminars. His visit was influential in reshaping the state of Burma’s mental health care and led to the writing of a manual for mental health officers. 25 The number of psychiatrists posted in rural areas, particularly in those areas associated with drug trafficking, continues to rise. These psychiatrists primarily treat narcotic patients, but cynics believe that their growing presence is primarily due to the government’s attempts to reassure the international community that it is actively addressing the country’s growing drug problem.

88 Table 3.1. Consultant Psychiatrists Posted to Burma’s State/Division Hospitals and Clinics (N=54)

States and Divisions Hospitals and Clinics Yangon Division Thingangyun North Okkalapa Insein Yangon General (1) General (1) General (1) General (24) Thanin Thari (1) Myeik (1) Division Ayeyarwaddi Pathein (1) Hinthada (1) Division Bago Division Bago (2) (1) Pye (1) Magwe Division Magwe (1) Pakokeku (1) Division Monywa (1) Kalay (1) Mandalay Division Mandalay (3) Meikhtilar (1) Arakan State (1) Mawlamyaing (1) (1) Lashio (1) Kyaing Tong Pekon (1) (1) Kayin State Pa-an (1) Kayah State Loikaw (1) Myitchina (2) (1)

There are currently four institutes of medicine in Burma—two in Yangon, one in

Magway, and one in Mandalay26. These schools provide post-graduate programs such as the Diploma course (Dip. Med. Sc.), the Master degree course (M. Med. Sc.) and

Doctoral degree courses (Ph.D. and Dr. Med. Sc.)27. Although the department of Medical

26 Burma also has several related schools, including: the Institute of Nursing (Yangon), Institutes of Dental Medicine (Yangon and Mandalay), Institutes of Pharmacy (Yangon and Mandalay), Institutes of Paramedical Sciences (Yangon and Mandalay), and the Institute of Community Health (Magway). Mental health training is given to students of all of these schools, as well as to those in the fields of traditional medicine, law enforcement, midwifery, and social work (Ohn Mar et al. 2000). 27 In the spring of 2002, the first medical Ph.D. degrees were bestowed; and there are an additional 30 Ph.D. candidates and 140 doctoral level students in progress. As of May 2002, four people have received their Ph.D. and three have received the Dr. Med. Sc. Degrees (U Sein Tu 2002). In 2001, more than 2600 students attended Burma’s four medical schools (about 600 at each institute). However, only government staff can attend

89 Science instituted Diploma degrees in 1964 and the Master’s degree in 1967, postgraduate psychiatric courses and degrees were not offered in Burma until 197628.

Doctorate courses in the medical sciences, including psychiatry, began in 1997 (U Thuta

1999). There is currently no training for psychiatric nurses, clinical psychologists, or psychiatric social workers (Ohn Mar et al. 2000). As shown in Table 3.1 there are currently 54 working psychiatrists in Burma (about 25 or 30 have retired or are deceased), resulting in one psychiatrist per million people in Burma. These low numbers are a result of the post-1988 brain drain and the low ranking of psychiatry in the medical profession (Kent 1996)29. The medical schools have started accepting students with lower grades in the attempt to raise the ratio of doctors to population, currently about 1:3000.30

Despite the government’s stated aim to make health care a national objective,

Burma’s health care resources have greatly declined in the era of junta-controlled and managed health care (Brandon 1998). Indeed, the WHO (2000) ranked Burma’s health care system as the second worst in the world31. Moreover, access to health care services in Burma is the lowest in Southeast Asia (Carriere 1997): according to Burma’s health statistics, only 60% of the country’s population has access to public health services

Master’s and Doctorate degree courses, while doctors from the private sector are limited to the diploma courses. 28 The first part of this psychiatric training consists of lectures in General Medicine, Neurology, and the Behavioral Sciences, as well as clinical work at the psychiatric hospital. The second training phase consists of general psychiatry and related specialties (child, forensic, narcotics) at the psychiatric hospital. The total training is 1 1/2 years after which each candidate takes a final examination. 29 Educational opportunities have declined in Burma, therefore a number of students and professionals with the means to do so have left the country to pursue schooling and careers elsewhere. 30 According to Burma’s Department of Health, there are 14,800 medical doctors in the country. 31 The WHO (ibid.) ranked Sierra Leone as having the worst health care system in the world.

90 (Chandler 1998). There are also increasing shortages of medical supplies, medicines, hospital beds, and personnel, which have only contributed to Burma’s generally low health care utilization rates (Brandon 1998: Carriere 1997). Carriere (ibid.) blames

Burma’s poor health care system on its government’s low allocations for human development, curtailment of non-governmental organization (NGO) health-related activities32, refusal to allocate foreign exchange from its export revenues for social sector development, and high military spending. (Indeed, Burma has the greatest imbalance of military expenditures against health and education of any other Southeast Asia country

(Carey 1997).)

The lack of health resources in Burma is particularly evident in the mental health field. The field of psychiatry in Burma continues to grow at a much slower pace than other biomedical fields, with fewer people and funds going into mental health practice and research than into other health fields. Although there is the odd effort to develop

Burma’s mental health resources (such as the recent WHO Mental Health project established in collaboration with YMHH), such efforts tend to focus on biomedical and, to some extent, indigenous treatment methods, while traditional and religious practices are largely ignored despite their high utilization rates33 (Saing 1990; Thuta 1999).

32 The situation has worsened recently as Burma’s military junta has closed down or made difficult operations of NGO’s (Parker 2005). 33 Many psychiatrists expressed concern that the continued popularity of religious and traditional health practices in Burma would only contribute to the country’s international reputation as a pariah.

91 B. Religious Healing in Burma

Religious healing refers to a healing process that is in some way religious, with religion understood as “any cultural form that highlights the symbolic, sacred, or spiritual element of therapy” (Csordas and Lewton 1998:436; also see Csordas 1994).

Bourguignon (1976:7) defines religious healing as the “therapeutic activities of persons who are specialists in dealing with supernatural beings and/or forces (shamans, diviners, etc.) as these are conceptualized and experienced in given societies, or the healing of individuals that is experienced as, in some sense, supernatural.” Several cross-cultural examples illustrate the inseparable relationship between religion, health, illness, and healing (Appiah-Kubi 1989; Finkler 1985; Guimera 1978; Hultkrantz 1992; Katz 1982).

The Burmese context is no different where religious healing encompasses both Buddhist and supernatural forms of healing. It is appropriate to consider these healing modalities together, rather than as separate therapeutic entities for, although different in form and philosophy, they overlap to a large extent (Keyes 1977). Burmese Buddhism is not just a veneer for (see Pfanner 1966), just as textual Buddhist doctrine is not free of historical and cultural influences. For example, Burma’s spirit mediums are Buddhist and use Buddhist doctrine to inform their curative performances and treatments; and some monks often incorporate elements of the supernatural or astrological into their healing practices. Even the most devout Buddhists, when pressed, admit to having some level of belief in the supernatural world although they usually assert that it is not worth worrying about34.

34 Despite the widespread belief in the supernatural in Burma (including Ne Win’s own strong beliefs), Ne Win’s government launched a campaign against spirit beliefs and banned any films that focused on them (Tarling 1999:217).

92 In Burma, as in other parts of the world, where mental illness is highly stigmatized, religious healing is one of the few available and sanctioned mental health care alternatives to psychiatric treatment (particularly in rural areas) (Kent 1996; Way

2001). Religious healing in Burma ranges from explicitly Buddhist therapies, such as meditation, to those centered around nats, or local guardian spirits (Bekker 1994; Nash

1965, 1966b; Skidmore 1999; Spiro 1967). These approaches are motivated by etiological notions that mental illness is caused by spirit possession, offending a nat, the consequence of one’s kamma, or the failure to observe important Buddhist principles appropriately.

1. Buddhism and Healing

Burmese Buddhism, a blend of traditional Theravada Buddhism and the worship of local spirits or nats, is a very important part of daily life in Burma and plays a significant role as a health sector in its own right. As a method of healing, Buddhism is often utilized to treat mental afflictions, both mental illnesses in the psychiatric sense and more common psychological problems. In Burma, the Buddha is even referred to as a psychiatrist or physician at times: “There has never been a greater doctor than the Buddha to cure mental illness . . . ‘O , there is no medicine as effective as the medicine of

Dhamma. Please drink that.’” (U Wynn Maung 2000-2001). Buddhism is commonly perceived as an effective cure for a wide variety of ailments because it is believed that awareness of and attention to Buddhist doctrine (dhamma) enhances one’s mental health

93 (Keawkungwal 1989)35. For example, an old story tells of how monks stayed a cholera outbreak through the of their prayers and good works (Shway Yoe 1963/1882). A more recent example is illustrated in efforts to educate the Burmese public about HIV and

AIDS through monks and their teachings: “We have to use the Dhamma as a medicine for stopping human suffering by HIV-AIDS” (Nwe Nwe Aye and Sandar Lin 2003).

Many healer respondents, including psychiatrists, reported in this study that they encouraged patients to follow the five precepts, meditate, and perform good deeds in order to avoid having a mental illness in the next life. Indeed, at YMHH patients gather in front of a statue of Buddha (there is one in each unit) each evening for group worship.

Since Buddhism established a strong foothold in Burma in the 11th century,

Buddhist monks or ponggyi have played a role as religious healers and possessors of magical powers in addition to teaching and explaining Buddhist doctrine (Maung Htin

Aung 1962; Swearer 1981; Way 2001)36. As Buddhism became more widespread throughout Burma, the monastery became increasingly central to village life, and monks offered villagers education, religious guidance, and curative treatments (doctrinal cures incorporated traditional medicines, astrology, and exorcisms)37. Fifteenth century

35 According to a well-known monk in Burma, few people with mental illness can actually be cured by the dhamma. This (teacher/monk) says that the cure depends more on one’s kamma (karma) than anything else. 36 Today, there remain some monks who claim to possess mystical powers; one monk I met at a meditation retreat claimed to be able to contact people from long distances, manipulate the weather, and move objects with his mind. 37 Young novices were also instructed in these subjects (Maung 1966). For example, new novitiates into the monkhood were instructed as follows: It is incumbent upon an elect to use as medicine the urine of a cow or of a black bullock, whereon lime and juice of a lemon or other sour fruit has been poured. He may also used as medicines articles thrown out of markets, or picked up at the corners of streets. He may accept for medicinal purposes nutmegs or cloves. The

94 descriptions of monastic library collections in Burma describe several works on medicine, pharmacology, and astrology, as well as more traditional doctrinal works (Ray

2002/1946)38. One of the earliest written accounts of the healing practices of Buddhist monks comes from a description of a visit one Captain Hamilton made to a monastery in

Burma in 1709: “If any be sick or maim’d the Priests [monks], who are the Peguers’

[people from Pegu] chief physicians, keep them in their Convent, till they are cured”

(ibid.:320).

At several political junctures in Burmese history (both ancient and modern), the central role of monks and the power associated with that role became a threat to Burma’s governing bodies (Fink 2001). The scope of the Sangha’s (monastic order of monks) activities in Burma has been curtailed on several occasions in order to restrict their power and limit their influence on the greater population39. One of the most significant restrictions placed on monks in this regard has been on their role as healers. For example, in 1985 the government issued an edict that forbade monks to practice medicine, explaining this action as a means to ensure that monks spent more time on religion and less time performing “superfluous actions”40. Indeed, orthodox Buddhist monks are not

following articles also may be used medicinally—butter, cream, and honey. (Shway Yoe 1963/1882:117). 38 Monastic scholarship was central to the life of the Buddhist monk, but interest in these subjects was probably also motivated by the desire to secure a position with the king and ruling class who were impressed with ecumenical learning (Ray 2002/1946). 39 Ne Win repealed several Acts established by U Nu’s administration in order to restrict the authority of the Sangha. In 1962 the Union Buddha Sasana Council was abolished, followed in 1965 by the abolishment of the Vinasaya Act of 1949, the Dhammacariya Acta of 1950, and the Pali Education Board Act of 1952 (Tarling 1999:217). Also see Lieberman (1993) for an account of pre-colonial attempts to limit the Sangha’s power. 40 In fact, until 1985 there was a monastery in Twante (across the river from Rangoon) at which a monk specialized in the treatment of psychosis. When the government forced him to stop treating patients, he had approximately 100 patients under his care.

95 supposed to prescribe any medicinal cure except for the dhamma; the rules (rules of monastic discipline) prohibit them from practicing medicine, alchemy and astrology

(Maung Htin Aung 1966). As Obeyesekere (1989) points out, Theravada Buddhist monks are not curers per se, but rather heal “life’s ills metaphorically.” As is so often the case, however, the actual situation is very different than the ideal. In Burma, as in other

Buddhist countries, there are monks who continue to practice medicine, astrology, and exorcisms (Fink 2001). Burmese monks are particularly well known for their treatments using and yediya, a kind of promise or spell they provide to help realize supplicants’ desires. And although most Burmese claim that these are not “real monks,” they remain popular healers for much of the population41. One monk in this study reported that he circumvents the rules against practicing medicine by telling those who come to him for treatment, “Well, I can’t treat you, but when someone with a similar problem came to me in the past I did these things . . . .”

Buddhism is utilized as a religious healing method not just by the , but by individuals as well, primarily through one of two ritual routes—merit-making or meditation. Buddhists often associate poor mental health with one’s kamma, inability to control one’s mind, lack of insight, as well as the failure to observe important Buddhist principles, such as the five precepts, the Buddhist (moderation) or the

Eightfold Noble Path (right insight, right way of thinking, right speech, right action, right livelihood, right effort, right awareness, and right concentration) (Keawkungwal 1989;

Rahula 1974). Merit-making activities (such as performing good deeds, adhering to the

41 Ironically, one of Burma’s most famous historical figures, Saya San, was a monk and indigenous healer famous for his protective charms, which, unfortunately, were not powerful enough to protect him from the British bullets that killed him during the rebellion he led in 1928 (Steinberg et al. 1987).

96 five precepts, making donations, and entering the monkhood for a brief period) and meditation can help offset these risk factors and therefore are important means to achieve individual mental health.

Meditation is a powerful means of healing, because it refines the mind’s abilities to concentrate, perceive, and understand oneself, others, and the world. Meditation embodies many of the Buddhist values (such as wisdom, concentration, mental discipline, and insight) that facilitate the transcendence of suffering in this life and is the means by which Buddhists believe they can best gain control over the mind (Ames 1964; Gombrich

1983; Keawkungwal 1989; 1957) 42. The self-awareness and control that are developed through meditation not only help reduce one’s suffering, but may also be exercised to improve one’s health. For example, a monk might advise a person suffering from anxiety or depression to retreat to a meditation center in order to engage in self- contemplation and analysis (Jaspan 1969); and in Thailand a specific meditation program has been developed to treat patients with AIDS (Swearer 1995).

2. Supernatural Healing Methods

“No matter how westernized we become in Myanmar, nat worship will always help us to cope with the problems of our daily life” (quote from the documentary “Friends in High Places” by Lindsey Merrison, 2001).

42 Meditation was originally practiced almost exclusively by monks at forest retreats or monasteries. However, in recent years meditation has gained popularity among the laity, and several centers have been built to meet this growing demand (Byles 1962; Gombrich 1983; Swearer 1989; Tambiah 1985; Thera 1970). U Nu helped to establish Burma’s first Ministry of Religion in 1950, which soon sponsored Mahasi Sayadaw’s now famous meditation center in Rangoon as a paragon of Buddhist practice (Tarling 1999:216).

97 In Burma, healers use a variety of supernatural healing methods to address a diverse range of ailments; however, society generally perceives supernatural healing as being particularly effective in treating psychotic symptoms associated with cases of spirit possession. Most healers in Burma distinguish between “normal mental illness” (sei’ , such as schizophrenia) and “abnormal mental illness” (payoga, indicating spirit possession) 43; the former are generally treated by psychiatrists, the latter by supernatural healers (although most people consult a variety of healers either simultaneously or sequentially).

Spirits throughout Southeast Asia are particularly known for causing bewitchment and mental illness (Brant 1954; Jaspan 1969; Yalman 1964). In Burma, possession is most often caused by nats44, local guardian spirits that are integrated into Burmese

Buddhist beliefs and practices (Nash 1963; 1966a). Supernatural healers who treat spirit possession in Burma include nat gedaw (spirit mediums, literally “spirit wives”) payoga saya (exorcists, literally “possession experts”), and ahtet lan saya (Master of the Upper

Path, “above the road” magic or “white magic” practitioners or sorcerers) (Bekker 1989,

1994; Brac de la Perriere 1989, 1992, 1995, 1998; Nash 1965; Spiro 1967). There are several types of healing rituals designed to exorcise the offending nat from the afflicted

(Ames 1978, Spiro 1967, 1976, 1977). Although there have been some excellent descriptions of these rituals in Burma, they tend to overemphasize the role of nat gedaw as healers that, in my fieldwork, respondents claimed were rarely utilized. Therefore the

43 Healers often instruct the patient to stretch out their fingers and close their eyes. If two fingers are stuck together, then the healer knows the patient is possessed. If the fingers are spread out evenly, then it is mental illness (Spiro 1967). In my own fieldwork, this diagnostic method was the one most often used by supernatural healers. 44 For a more detailed description of nats and the cult of the 37 nats in Burma, see Maung Htin Aung (1962) and Spiro (1967).

98 rest of this section will describe the kinds of treatments each type of supernatural healer utilizes in Burma, focusing primarily on those utilized by research respondents. It is noteworthy, however, that just as there is overlap between the major health sectors in

Burma, there is overlap within the sectors as well. For example, while a payoga saya is the expert exorcist, monks and ahtet lan saya may also perform them.

The nat gedaw communicates with the nats in order to solve practical problems by seeking advice, ensuring protection, and diagnosing or curing illness (Bekker 1994).

In this research, family members and patients very rarely consulted nat gedaw in the event of illness45; in cases in which a nat gedaw was consulted, it was usually to confirm the diagnosis of spirit possession and to determine which actions the patient and family members should take to effect a cure (rather than effecting the cure herself). During the diagnostic ritual, the nat gedaw invokes her spirit husband who tells her what the patient has done to offend a particular nat. The nat gedaw is possessed by her husband during these rituals and any diagnosis or advice she gives to the patient comes from the spirit world rather than from her (Spiro 1967). Once the offense is known, the nat gedaw may negotiate with the offended spirit on behalf of the patient or may simply find out what the patient needs to do to make amends. The following is one of the earliest accounts of a nat gedaw’s attempts to cure a patient:

[Nats] are the authors of many diseases. Hence it is easy for a physician to persuade a sick man, already imbued with this notion [of supernatural causation],

45 There have been arguments that spirit beliefs are relatively confined to rural areas which, initially, could help explain this finding. However, Spiro (1967) argues that beliefs and practices surrounding nats also exist in urban domains, and this dissertation research supports his claim. Rather than indicating a lack of spirit beliefs, this finding suggests that patients believe that other kinds of supernatural healers are more effective at treating their ailments.

99 that his malady arises from the malice of Nat or witches, especially as he pretends to discover this by feeling the pulse…For this purpose a middle-aged woman, to whom they give the name of wife of the Natzo must dance, and go through a number of contortions, to the sound of a drum or some other musical instrument, in a tent erected for the occasion, in which is placed a quantity of fruits and other things as an , but which turn to the account of the dancing girl. By degrees she feigns to become infuriated and utters some incoherent words that are regarded as the answer of the Nat, who has been thus consulted with regard to the conclusion of the malady. If all these superstitious remedies are of no avail, the physicians have still another subterfuge, for they declare that the power of the Natzo is too great to be overcome (Sangermano 1995/1893:172).

People also make offerings to particular nats believed to be an agent behind an illness

(Nash 1965).

A similar type of healer who works with the spirit world to address people’s complaints in Burma is the clairvoyant or akya: amyin saya. Akya means hearing and amyin means seeing, indicating that a Burmese clairvoyant is a saya who has supernormal sight and hearing. A clairvoyant is typically a very religious person who possesses some sort of higher spiritual power that is used to help human beings. Their powers are enhanced through methods of mental concentration, such as meditation or counting beads. The clairvoyant functions in much the same way as the nat gedaw; she communicates with a particular spirit who helps her diagnose a particular problem and arrives at a means to overcome it. Except for her interaction with this spirit, the clairvoyant is also very similar to the Burmese astrologer, which will be described in the following section.

Payoga sayas46 conduct rituals involving chanting, offerings, and the invocation of spirits to help them and their patients. Some treatments include making the patient eat

46 One of the payoga saya I interviewed reported that he decided to become such a healer when his wife was diagnosed with spirit possession. Although another healer identified the spirit as that of the respondent’s father’s second wife, no treatment was effective in

100 food, drink holy water, or chew betel, which often act as a purgative or emetic; the next day, the patient vomits or defecates these things, indicating that the spirit has been cleansed from her or his body (Spiro 1967). The following excerpt describes an exorcism performed over one hundred years ago:

Thereupon he ties a rope round the patient’s neck, and after chanting a formula with occasional jerks on the line, asks the demon in the victim what he has come for. If any answer is given and an object mentioned, this is taken to be the thing required, and it is placed outside the house in the road and left there all night. It will be gone by that time if it is worth taking (by men or nats). If the evil spirit does not then go out of the man, or if the tugging at the rope brings forth no answer, stronger measures are resorted to. He is soundly beaten with a stout bamboo47, pins are stuck into him, red peppers forced into his eyes, and the louder he shrieks and groans the better pleased are his friends and relations, for it is the witch, or the natso, that is suffering, and not the sick man at all. If this treatment does not kill or cure him, a final effort is made (Shway Yoe 1963/1882:424).

Many such elements of the exorcism still exist today, although the beating of patients is going out of vogue (some patients, even in the last few years, have died as a result and the authorities have stepped in). Once the patient’s horoscope has been consulted, the patient’s body examined, and prayers offered, then a diagnosis of spirit possession can be made and “normal” mental illness ruled out. Payoga saya respondents also reported that cutting the patient’s hair and putting it in a bottle (some burned the hair) confined the spirit inflicting the symptoms.

removing the spirit. As a result of his wife’s continued problems, this respondent decided to acquire the skills to combat such “evil spirits.” 47 This stick is usually an elaborate piece of bamboo on which are carved cabalistic figures, sometimes with medicines on it. The exorcist “stands before the possessed person and threatens a blow. The witch or spirit in the victim then becomes anxious and pays reverence with clasped hands. It is then forced to relate exactly its name, place of abode, friends, and relations, and so on” (Shway Yoe 1963/1882:424).

101 Another group of healers are ahtet lan saya who are members of a gaing48, a

Buddhist led by a particularly powerful bodaw (a holy elder with magical powers gained through Buddhist practices). According to Spiro (1967), the primary goals of the ahtet lan saya are to become a weikza (wizard) and to achieve nibbana. Ahtet lan saya are observant Buddhists who keep the five precepts and regularly meditate. Through these religious activities, ahtet lan saya come under the protection of spirits who facilitate their healing abilities. Their treatments usually involve performing exorcisms as described above, prescribing the five Buddhist precepts, and the making of in (a special cabalistic charm or rune written on a piece of paper)49. Their treatments are often claimed to counteract illnesses caused by au lan saya (Master of the Lower Path, meaning “under the road” magic, sorcery, or “black magic”). Au lan saya are believed to be primarily women who cause an illness by making a medicine from dead bodies (Nash 1965)50.

They also bring evil spirits from the cemetery under their power to cause harm to others.

Although I did not meet any au lan saya and no one with whom I spoke actually knew one, they are often blamed for causing an episode of madness (Spiro 1967)51.

48 Mendelson (1960, 1961a, 1961b) describes these gaings as a means of bridging the gap between Buddhism and supernatural Burmese beliefs. 49 Burmese tattoos (a form of in) were at one time very common as a means to protect a person from au lan saya, snakebites, and other forms of harm (Nash 1965). This practice has largely died out, except for in the more remote areas in Burma. 50 Classic signs of an au lan saya’s work (candles, cabalistic markings, and upturned earth) still appear in Burma’s cemeteries (Larkin 2004). 51 Under British colonial rule in Burma, sorcery or witchcraft accusations were made illegal; however, if illnesses were difficult to cure misfortune was often attributed to sorcery and appropriate vengeance was taken (Leach 1954). Golomb (1988) questions the general absence of sorcery accusations among supernatural healers in Thailand, showing that because these healers are both feared and respected for their curative powers, local restraints protect them from sorcery accusations.

102 Buddhist monks also participate in exorcisms in cases of spirit possession and provide ritual help by way of chants and blessings, despite assertions that Buddhists are never involved with possession rites (Durrenberger 1981; Granoff 1996; Kitagawa 1989;

Way 2001; Yalman 1964). Most often monks use a curative treatment of holy water and an in: they burn the in and mix the ash with water, say a blessing over the mixture, and instruct the patient to drink it. The mixture cleanses the patient of her or his ailment

(Nash 1965). The monk also instructs the patient to observe the five precepts, meditate, and perform good deeds. (A particularly popular monk among patients I interviewed was often referred to as the “Honey Monk” because he added honey to his mixtures to make them more palatable.

C. Traditional Healing in Burma

In a discussion of the treatment of mental illness in Southeast Asia, M. Jaspan

(1969:18) writes:

In Southeast Asian folk medicine there is scarcely any such disagreement [whether mental illness is attributed to biological or psychological causes], for in all human situations, illness included, they apprehend a connection between natural environment and interpersonal relationships, whatever the external forms or symptoms. This connection is for them as unitary as our own perception of the chemico-physical oneness of ice, water, and steam.

The following traditional healing methods all emphasize this connection between the patient and the environment. The label of “traditional” is somewhat of a misnomer in the case of this dissertation because each particular health sector has acquired a certain degree of tradition within Burma. “Traditional” is used here in the sense that it represents a certain kind of healing that is neither wholly a colonial import, nor inherently linked to the religious realm.

103 1. Indigenous Medicine

Indigenous medicine is probably the most widely used treatment in Burma and it is very likely that most Burmese households contain some indigenous medicine products.

Mi Mi Khaing (1996/1946:37) describes how her parents attended her during times of sickness using only herbal remedies as no Western medicines were kept at home52.

We always had stocks of various kinds of yet-sa, a linctus power with digestive qualities containing liquorice and herbs in a salt base. . . there is a popular brand on the market called lay-myo shit-se, 80 kinds of wind, but in addition to this, each family gets a specially prepared type from their family monk.

Traditionally, the healing power of herbal remedies lay not only in their medicinal properties of the herbs themselves, but also in the special powers of the monks who prepared them. The healing powers of religion are also evident in Mi Mi Khaing’s

(1996/1946:38) description of her words of encouragement to her children: “Drink it as the medicine of the Three Gems, ‘Paya-say, taya-say, thanga-say’” (translated as “Physic of the Buddha, of the Law, of the Clergy”).

Burmese indigenous medicine corresponds to India’s Ayurvedic and Unani systems53, but also incorporates traditional elements of herbalism and magic. The basis for Burmese indigenous medicine is that the human body is composed of four elements: earth, water, fire, and air. In this system, practitioners believe illness to be caused by an imbalance of these elements, and indigenous treatments are designed to realign them.

Common reasons for such elemental imbalance include the weather, planetary positions,

52 Western medicines were particularly scarce during World War II and the use of indigenous medicine increased during this time. 53 Both of these systems are based on the theory that health is caused by the balance of elements within the body, and illness by their imbalance.

104 and certain foods or food combinations54 (Shway Yoe 1963/1882:418). According to

Burmese traditional medical beliefs there are 96 diseases, which can be treated with medicinal herbs55 and plants, animal parts (hair, fat, bones, and organs), and minerals, which are administered in a variety of forms, including pills, powders, and pastes. These treatments also include charms, spells, and amulets (Myanmar Ministry of Health 2002;

Nash 1965; Shway Yoe 1963/1882; Spiro 1967). Massage is another form of traditional healing frequently used in Burma (Nash 1965). Most commonly, however, indigenous medical doctors deal in pills and powders that they themselves have developed.

Burma’s indigenous medical doctors are commonly referred to as bama saya

(Burmese doctor), sei saya (medicine doctor), or, more officially, tai yin saya (indigenous healer)56. Indigenous medicine is considered to be a respectable profession in Burma, and some practitioners can trace their ancestry back to the royal (and titled) doctors of the king57. Until the 1900’s, however, no training was required to practice as an indigenous healer, although informal apprenticeships of five to ten years were not uncommon (Taw

54 Foods are believed to possess hot and cold properties that can also maintain a state of health or help one overcome sickness (Mi Mi Khaing 1996/1946). 55 Herbs are used to treat a variety of illness in Southeast Asia, including mental illness (Jilek 1990). Indigenous medicines include herbs such as Thway-Se (a blood tonic) and Yet-Sar (licking salt) (Hman 1990). Herbs are also used to treat the liver, as excess bile is often linked with mental illness. 56 Many people use these terms interchangeably, although there are subtle distinctions between them. A tai yin saya is someone who generally treats people only with indigenous medicines. A bama saya also treats using indigenous medicines, but can also address problems arising from au lan. In this sense, the bama saya is similar to a bodaw or ahtet lan saya but is generally considered to be less powerful. A sei saya could refer to either type of indigenous healer. 57 One such indigenous healer was Maung Hlaing, known as “the young Myoza of Yaw,” who was born in 1829. He was entrusted to King Mindon and studied at the prestigious Bagaya monastic college. He also authored a famous medical manual (U Thant Myint 2001:134).

105 Sein Ko 1913). The British civil servant, Sir J. George Scott, explains (under his penname Shway Yoe) (1963/1882:414):

It is a very simple matter starting as a doctor in Burma. All you have to do is to assert that you have acquired a special knowledge, and set to work prescribing the most villainous-tasted and drastic medicines you can concoct. As long as an undeniable result one way or the other is produced you are sure of getting a certain amount of reputation.

There was no examination at that time to become an official indigenous medical practitioner; one’s practice depended solely on one’s reputation. As Taw Sein Ko

(1913:144) describes:

No lectures are given, and the system of teaching is somewhat haphazard. The pupils follow the teachers on their rounds, and pick up odd scraps of information relating to physic, dieting, pharmacy, and massage—there being no surgery recognized in their system—which they supplement by private reading during their leisure hours. There are no separate dispensaries, and no prescriptions written, as the doctors themselves prescribe and supply their own medicine.

With the advent of Western medicine in Burma under the British colonial administration, indigenous medical doctors became concerned that their own methods would languish. Taw Sein Ko (1913:145) continues:

It may be noted that, owing to the absence of Royal patronage, and to the public patronage in large towns vacillating between the Western and Eastern systems, the study and practice of medicine and massage have suffered considerable and are in a languishing condition to the great detriment of the public health.

At the same time, however, officials noted that 80% of Burma’s population only had access to traditional healing methods due to the limited (and expensive) availability of

Western medical practitioners. As a result, the colonial administration saw fit to establish a medical school in Mandalay that would combine Western and Burmese medical systems specifically to meet the needs of rural villagers. It was recommended that, unlike

Rangoon’s universities, Mandalay’s university would operate using Burmese as the

106 medium of instruction (“a great saving of time, money, and energy”) based on the success of similar models used by Japan’s university systems and the then recent University of

Mysore in India. Taw Sein Ko (1913:147) elaborates:

Again, a Province, in its course of progressive development, has to pass through several stages, one being the adoption of its vernacular classes as the medium of instruction. As late as 1866, vernacular classes were maintained in the , Lahore, and Agra Medical Colleges, because the English languages had not spread so widely amongst the people of these localities. Without passing through that stage, in its course of evolution, Burma has now suddenly jumped to that of making English the medium of instruction in its Medical School. If the English language is the medium of instruction the cost of training becomes expensive, and the successful students, in their private practice, are obliged to charge fees, which are beyond the means of the poorer classes of people living in towns and villages.

It was also recommended that indigenous medicine be subjected to scientific standards in order to enhance its effectiveness and legitimacy. Beginning in 1916 a resolution was made by the Honorable Khan Bahadur Mir Asad Ali Khan in the Imperial

Legislature Council and approved by the Government of India to investigate the potential scientific and effectiveness of indigenous medicine. “To increase the area of usefulness of the Burmese system by modernizing it and placing it on a scientific basis would be a great humanitarian undertaking, which would bring untold blessings on the people” (Taw Sein Ko 1920:144). This undertaking has been continued under the auspices of Burma’s Traditional Medical Council, which seeks to modernize the practice of traditional medicine so that it conforms to scientific methods. According to the

Traditional Medical Council Law dictated by Burma’s State Peace and Development

Council, traditional medicine is now defined as “medicine for the well-being and longevity of people in accordance with anyone of the four nayas [methods] of traditional medicine” (Office of the Attorney General, Union of Myanmar 2000:17).

107 As a result of deeply held beliefs about the efficacy of Burmese indigenous medicine and widespread efforts to make it more available throughout the country, indigenous medicine has only grown in popularity. An institute for indigenous medical training (focusing primarily on herbal, not magical, therapies) was established in Burma to operate in tandem with Rangoon’s biomedically-based medical schools (Thamein

1994)58. This development may also have been motivated by Burma’s government’s repeated attempts to stir nationalist sentiment by legitimizing certain aspects of national culture. A similar example occurred in post-colonial India when Ayurvedic medicine became a symbol of freedom (Taylor 1976).

Today, there are ten indigenous medicine hospitals in Burma and 200 traditional medical clinics. The Department of Indigenous Medicine has also built eight herbal gardens to help supply drug manufacturing factories with ingredients for traditional medicines (Myanmar Ministry of Health 2002). It is difficult to say precisely how many indigenous medical doctors are in Burma as not all of them are licensed, but there are about 1,000 licensed practitioners (Chandler 1998).

People in Burma utilize traditional healers more frequently than other healthcare providers (Boker 1990; Jilek 1990). Although traditional healing has historically been favored primarily by the older generation, it is becoming more common among all ages to use a combination of Western and indigenous medicines (Curtis 2003; Hman 1990).

There is also evidence that indigenous medical methods are more psychologically satisfying to patients than biomedical methods (Obeyesekere 1976). Tambiah (1985:88) explains this preference by the presence of “coherence,” which “is absent in the

58 Plans are underway to upgrade the indigenous medical school to include a bachelor’s degree (Myanmar Ministry of Health 2000).

108 knowledge systems of contemporary Western societies, with their separation of

‘religious’ from ‘secular’ realms of knowledge.”

2. Divination

Divination practices in Burma include astrology, numerology, and palmistry, all of which are used to diagnose and help treat a wide range of illnesses (Shorto 1981).

Astrology is the most popular form of divination (Fink 2001; Mi Mi Khaing

1996/1946)59. Burma’s astrological tradition probably stems from India’s Brahmin tradition that came to Burma sometime in the late 1700’s60. The science of astrology and cabalistic science is set down in the volumes of the bedin called the Deitton (Mackenzie

1853; Shway Yoe 1963/1882). Bedin saya (astrologers) can help determine which treatment actions should be undertaken or avoided based on their knowledge of planetary forces (Ames 1964; Nash 1965). Robertson (1930:86) provides the following example:

The hour and minute of Maung Aye Maung’s birth were carefully noted. He was not alone in this privilege, for all over the East as well as in Burma the utmost care is taken to ascertain this fact in the case of every baby born, rich or poor. The position of the stars at the moment of parturition is considered to be of the most importance; for Astrology, with the Orientals, is neither a plaything nor a guessing game, but a study infinitely more important than Astronomy, which is accounted merely a handmaiden of the elder science. Astronomy tells only about

59 Astrology even plays a role in government policy; for example, General Ne Win made many policy decisions based on the stars. And, recently, one of Burma’s most famous astrologers was arrested after predicting the demise of the State Peace and Development Council (Democratic Voice of Burma 2006). 60 In the 1760’s, King sent to Benares (now ) for Brahmins to serve as consultants on matters of state in his court at Ava. (There is some speculation, however, that they were actually kidnapped, rather than “sent for” (Shway Yoe 1963/1882).) The nine Brahmins who arrived brought with them a collection of works known collectively as the Vyakarana on medicine, astrology, and other topics that were translated into Burmese with the help of a court sayadaw (senior monk) (Harvey 1967:249).

109 the stars: Astrology shows how they affect the fate of the individual. If either be dispensable, it is the former, not the latter.

As this passage indicates, bedin saya’s treatment usually involve addressing their client’s kamma.

Bedin saya often set up their practice outside of a pagoda and are usually consulted when a certain ailment has confounded other treatments (King 1964). Most of the bedin saya respondents said that they inherited their clients from their master. There are many methods to address a client’s kammic destiny, the most frequent of which is yediya. Yediya takes many forms, including counseling the supplicant to read the

Buddha’s teachings, making an offer of flowers (the number and kind of which are chosen by the bedin saya based on the flowers’ auspiciousness) at a pagoda, lighting a candle at a particular pagoda, avoiding or eating certain foods, or by way of an in. The astrologer often draws an in (either on paper or some sort of soft metal sheet) after meditating at an auspicious time of day. He or she places a candle in the center of the in and prays. Many bedin saya in this study reported that in cases of mental illness, the patient must place the in under his or her pillow to help cancel any previous bad deeds they may have committed. Patients might also wear the in (which is tied on a piece of knotted string around their neck or wrist) so their body is always in contact with it, thereby preventing future illness episodes (this method is frequently utilized by monks in

Burma as well).

D. Summary

By describing the historical and cultural context of Burma’s mental health care sectors, this chapter summarizes and enriches existing descriptions of how psychiatric,

110 religious, and traditional therapeutic modalities evolved and address problems associated with mental illness. The detailed descriptions of healers and the treatment forms they utilize also provide an essential framework from which to better understand the experience and treatment of schizophrenia in Burma.

111 CHAPTER FOUR EXPLANATORY MODELS OF SCHIZOPHRENIA

An explanatory model reveals how patients, their family members, and healers describe and explain the character, onset, course and outcome, and treatment choices associated with a particular illness, as well as how the persons involved give the illness experience personal and social meaning (Kleinman 1980). The first part of this chapter reviews cross-cultural studies of schizophrenia in order to illustrate how severe mental illness has been generally conceptualized in a variety of historical and cultural contexts

(also see Blue and Gaines 1992; Kleinman 1988b). The second half of this chapter focuses this discussion on the Burmese Buddhist context, presenting the explanatory models employed by patient and family member respondents.

A. General Explanatory Models of Schizophrenia

1. Illness Definition, Symptoms, and Epidemiology

Although attempts have been made to retrospectively diagnose schizophrenia in individuals such as Jesus1 and Joan of Arc, there is scant evidence to so reliably. This is not to say that certain individuals did not have schizophrenia, or another psychotic condition, but the absence of documentation and terminology make it nearly impossible to such claims2. The first clinical description consistent with schizophrenia was recorded in 1809 by John Haslam, an apothecary to Bethlehem Hospital. He described a severe form of insanity that first occurred in adolescence or early adulthood, which then

1 Dr. Albert Schweitzer’s doctoral thesis was a rebuttal to claims that had schizophrenia (Gottesman 1991). 2 The first official records of mental illness first appeared in England and Wales as a result of the Lunacy Act of 1845, and the term “psychosis” came into existence about the same time.

112 followed a course of decline: “I have painfully witnessed this hopeless and degrading change, which in a short time has transformed the most promising and vigorous intellect into a slavering and bloated idiot” (Haslam 1809 cited in Gottesman 1991:6). Subsequent psychiatric accounts of this mental illness also focused on its declining course and outcome. For example, in 1809 Phillipe Pinel described various patients suffering a form of dementia (loss of mind), and, in 1852, Benedict Morel observed patients with

“démence précoce” (early dementia). It was not until the late 19th century, however, that the various symptoms of what we now know as schizophrenia were organized into a definitive diagnostic category.

The German psychiatrist, Emil Krapelin (often referred to as the father of psychiatry, and the first to study schizophrenia cross-culturally3), was responsible for this great task. He famously described the chronic psychotic process as “dementia praecox”

(Latin for early dementia) based on its typical course of deterioration. However, in 1908, the Swiss psychiatrist, Eugen Bleuler, noted that not all cases of dementia praecox had a deteriorating course. Bleuler renamed the illness based on the observation that it was not a single disease entity, but rather a syndrome that he referred to as the “group of schizophrenias4.” He wrote: “I call dementia praecox ‘schizophrenia5’ because . . . the

‘splitting’ of the different psychic functions as one of its most important characteristics.

For the sake of convenience, I use the word in the singular although it is apparent that the

3 Kraeplin traveled to Singapore where he studied a hospital population of Malaysians, Javanese, and Chinese patients with dementia praecox, and concluded that the illness was universal (Gottesman 1991). 4 As a group of illnesses, Bleuler (1950) considered the to have different etiologies, symptoms, and courses. 5 Schizophrenia means “splitting of the mind,” referring to the splitting of various mental functions such as thought and emotion (Cornblatt et al. 1999).

113 group includes several diseases” (Bleuler 1950:8). This nomenclature change from dementia praecox to schizophrenia reflects the shift from a diagnostic emphasis on outcome to symptom patterns, which ushered in a new era of psychiatry (Andreasen and

Carpenter 1993; Cornblatt et al.1999). The German psychiatrist, Kurt Schneider, was particularly influential for identifying symptoms characteristic of schizophrenia (known as Schneiderian First-Rank Symptoms), including auditory hallucinations, thought broadcasting, delusions of control, and delusions of perception (Barrett 2004; Schneider

1959).

Today, clinicians and researchers continue to struggle with how to characterize schizophrenia. Blue and Gaines (1992) note that this lack of consistent clarity has hampered cultural research of schizophrenia6. Although there are a growing number of studies that suggest there is a biochemical basis for the illness, there does not yet exist a consistent physical measure to test for schizophrenia. In contemporary Western psychiatry, schizophrenia is most often considered to consist of two primary subtypes: positive and negative (Andreasen and Olsen 1982; Crow 1980; Jackson 1931; Strauss et al. 1974). Positive symptoms include hallucinations, delusions, thought disorder, bizarre

6 An additional difficulty in classifying illness categories, particularly cross-culturally, is how to distinguish between so-called normal and abnormal behavior. Anthropologists, , and others have tackled this problem for some time now and have shown that there is no universal definition of normality (e.g., Benedict 2001/1934; Blue and Gaines 1992; Canguilhem 1989; Devereux 1980; Edgerton 1976; Hallowell 1934). Although few would argue with the fact that culture shapes our conceptions of normality, the assumption often remains that abnormality is an acultural, universal phenomenon (Blue and Gaines 1992). However, there now exist multiple examples of how pathological conditions, and the diagnostic categories that describe them, operate within their own historical, political, and socio-economic paradigm (Barrett 1997; Good 1994; Kleinman 1988b; Lutz 1988; Obeysekere 1985). Due to the controversy over applying diagnostic categories cross-culturally, the very utility of the psychiatric diagnosis has been called into question (Bentall 1990).

114 or disorganized behavior, and catatonic behavior (Cornblatt et al.1999). Negative symptoms include blunted emotional expression, response and feeling (commonly referred to as “flat affect”), impoverished thinking and cognition (alogia), difficulties in experiencing pleasure (anhedonia), lack of energy or drive (avolition-apathy), and disturbed interpersonal relationships (social withdrawal, attentional impairment) (ibid.;

Strauss et al. 1974).

In light of the diagnostic issues described above, several cross-cultural studies have been conducted in order to ascertain if schizophrenia, and its presumed core symptoms, is a universal phenomenon. These studies have established that schizophrenia exists in nearly every social context, with an international prevalence of 1% (Cornblatt et al. 1999; Jablensky 2000; Sartorius et al. 1986; WHO 1973, 1979). Research has also found cross-cultural similarities in schizophrenia symptoms, such as “lack of insight”

(Jablensky and Sartorius 1975; Murphy 1978; Sartorius et al. 1986; WHO 1973, 1979).

However, others have argued that this research has ignored important inter- and intra- cultural differences (Gaines 1992; Hopper 1991, 2004; Kleinman 1988b). Two early transcultural studies of schizophrenia, the International Pilot Study of Schizophrenia

(IPSS) (WHO 1973, 1979) and the Determinants of Outcome Study (Sartorius et al.

1986) showed that certain subtypes of schizophrenia were more prevalent in certain cultural contexts. For example, catatonic schizophrenia, rarely found in more industrialized countries, was diagnosed in 10% of cases in less industrialized countries.

Similarly, Barrett (cited in Kleinman 1988b) reports that the sense of a split or divided self, which literally defines schizophrenia, is a feature of Western conceptions of personhood and appears less frequently in non-Western persons with schizophrenia.

115 Patient respondents in this study, for example, did not consider their illness as an alien feature of their identity; it was simply part of who they were.

2. Etiology and Onset

Despite general agreement about the prevalence of schizophrenia, there still exists much debate over its etiology. The earliest theories of schizophrenia revolved around ideas of spirit possession, and these continue to inform many indigenous notions of illness causation. Early medical theories of schizophrenia blamed its onset on family conflict (primarily enacted by the mother (Bateson 1977 /1956; Scheper-Hughes 1979) or sociological and political economic aspects of industrialized society (Devereaux 1980;

Jilek and Jilek-Aall 1970; Lin 1986; Warner 1994/1985; Wittkower and Prince 1974).

The prevailing notion today is that schizophrenia is caused by multiple factors. Although

“today’s world of claims schizophrenia as its own,” findings show that social and cultural factors also have an important role in the etiology of schizophrenia (Kleinman 2004: xv). It is most likely that schizophrenia is precipitated by a combination of environmental, biochemical, genetic, interpersonal, and intrapsychic factors. It is therefore important to examine the role that culture might play in the onset of schizophrenia and other psychotic disorders. For example, although schizophrenia occurs in every socio-economic class, lower classes tend to be more vulnerable (Cohen

1993). Schizophrenia typically occurs in late adolescence or early adulthood; however, men have a slightly earlier onset than women (Angermeyer et al. 1990; Childers and

Harding 1990; Chu et al. 1988; Goldstein 1997; Hambrecht et al. 1992; Nicole 1995;

Seeman 1997).

116 Studies have also shown that the onset of schizophrenia is characterized by a change in subjective and intersubjective functioning. In their study of subjective experiences among people with schizophrenia, Cutting and Dunne (1989:230) found that patients experienced a significant change—a “qualitative alteration” —in mental functions and experience. Chapman (1966) found that a consistent characteristic in the onset of schizophrenia was a change in the experience of self. He reported (ibid.:233) that

“changes in cognitive function are subjectively experienced by schizophrenics long before the overt appearance of signs of established disease.” These findings demonstrate the importance of attending to the phenomenology and subjective experience in studies of severe mental disorder.

3. Course and Outcome

One of the most important cross-cultural differences in the course and outcome of schizophrenia is that its prognosis appears to be better in less industrialized regions

(Edgerton 1980; Jablensky et al. 1992; Kleinman 1988a; Waxler 1979; Warner

1994/1985; WHO 1979). Several theories have been suggested to explain this trend, including social labeling, subjective experience, and familial and social support.

Religious experience may also affect the course and outcome of schizophrenia, as appears to be the case in affective disorders (Azhar and Varma 1995; Braam et al. 1997;

Griffith and Bility 1996; Koenig et al. 1998; Koenig et al. 1992; Koenig and Larson

2001; Pressman et al. 1990; Propst 1980; Propst et al. 1992; Razali et al. 1998).

The social labeling theory was developed by Waxler (1979) who found that people with schizophrenia in Sri Lanka who did not receive this stigmatizing diagnosis

117 tended to do better. Without the stigma of a psychiatric diagnosis7, it is argued that these individuals experience less social stigma and their social and occupational functioning remain more intact. This theory is supported by other anthropological research, which indicates that a clinical diagnosis not only denotes a pathological condition, but also rests on underlying (cultural) notions of self and personhood that serve to further stigmatize the person labeled. The stigma of such deviant labels and behaviors often leads to the creation of indigenous illness categories that help distance the patient or family members from more harmful associations, allowing them to maintain their hope for recovery. For example, in a study among Mexican-Americans, Jenkins (1988a) found that nervios was used as a cultural category for schizophrenia in order to reduce the stigma associated with the illness, as well as helping to narrow the gap between family members with and without schizophrenia. By employing the category of nervios (curable) in place of

“schizophrenia” (chronic) Mexican-Americans maintained an open-ended illness narrative through which hope for recovery could be recycled. Such an attitude towards

7 Kurt Schneider, another leading figure in the diagnostic history of schizophrenia, was also concerned with the potential impact of particular illness definitions. He believed that Kraeplin’s conventional psychiatric approach “saw only the illness, not the person, the patient”: Diagnostics looks at “How?” [the form of illness] not at the “What?” [the theme or content of illness]. If I find thought-withdrawal this is important to me as a certain mode of experience and as a diagnostic hint; I am not interested diagnostically whether it is the devil, the mistress or a political leader who withdraws such thoughts. Where one looks at such contents diagnostics recedes. In that case one sees only the biographical or the understandable existence (Schneider 1956 quoted in Hoenig 1983:555). In order to avoid reducing patients to a set of symptoms, isolated from their life and context, Schneider advocated employing both classic psychiatric and anthropological methods in the diagnostic process. Similarly, anthropologist Sue Estroff (1989:189) calls for a “comprehensive account of schizophrenia [that] would include the person, the subject, the self that has and is (or these) disorder(s).” She advocates that we regard patient respondents as persons with schizophrenia rather than “schizophrenic.”

118 illness reflects Good’s (1994) idea of “subjunctivizing elements in illness narratives,” which allow individuals the possibility for change.

The subjective experience of self and others also appears to play a role in the course and outcome of schizophrenia. In particular, researchers have found that feelings of alienation and exclusion may negatively affect the course schizophrenia. For example,

Corin (1990) found that patients with schizophrenia who were frequently hospitalized had little contact with family members. As a result, they perceived their position vis a vis their family as one of marginality and exclusion. Patients who were infrequently hospitalized also had little contact with family, but they did not perceive the distance as negative. These patients utilized public, anonymous space to maintain contact with the social world in a way that also allowed them to remain socially distant. Corin (ibid.:176; also see Corin and Lauzon 1992) refers to this strategy as “positive withdrawal,” which

“allow[s] them to stay simultaneously “within” and “outside” the social field, to remain

“at a distance” while staying in touch with others . . . this allows patients to manage a relationship within a social space without threatening their own boundaries.” Leferink

(1998) similarly found that the ability to maintain a secure sense of self within public space played a positive role in the course and outcome of patients’ illness.

Interpersonal dynamics also play a significant role in course and outcome

(Sullivan 1953, 1994/1927), and medical anthropologists have shown that family warmth and social support are associated with good outcome of schizophrenia (Jenkins and Karno

1992; Kleinman 1988b; Lopez et al. 2005). For example, Expressed Emotion (criticism, emotional overinvolvement, and hostility) (EE) tends to correlate with poor course and outcome in schizophrenia (Jenkins 1991, 1994a, 1994b; Karno and Jenkins 1993).

119 However, in certain cultural contexts such emotional indicators may be perceived as desirable rather than harmful. In a study of family care and schizophrenia among Indian families, Nunley (1998) found low rates of Expressed Emotion (that is, low emotional overinvolvement) despite the high level of involvement families have in Indian psychiatry. He explains (ibid.:342): “In Northern India, where a very high level of family involvement was expected, behaviors were judged to be culturally appropriate that might be taken as signs of emotional overinvolvement in Euro-American cultures.” Nunley argues that in situations in which emotional overinvolvement is culturally appropriate,

“emotional underinvolvment” should also be measured. His results emphasize the need for cultural understandings of illness in the context of family and social relationships in order to draw an accurate picture of illness dynamics.

4. Treatment

Although there is no definitive cure for schizophrenia, the methods developed to treat it, regardless of their success, reflect historical perceptions of mental illness.

Gottesman (1991:9) explains:

Whichever causal view prevailed, at different times and in different cultures, greatly influenced the treatment of the insane and whether they were permitted to remain within their social group or were isolated and abandoned, held in awe as chosen by the , or punished or killed as chosen by Satan.

Gottesman’s observations underscore the historical and cultural specificity of treatments for schizophrenia. Indeed, early accounts indicate that mental illness was treated primarily by religious healers, patients’ families, and local communities (see Ehrenwald

1956), and this continues to be the case in many parts of the world.

120 Beginning in the European Middle Ages, society began to perceive the mentally ill as a population that needed to be controlled and confined. These first sites of confinement were church-sponsored asylums, later to be replaced by state-supported hospitals (Alexander and Selesnick 1966; Kroll 1973). The history of the confinement of the mentally ill in Western Europe and the United States has been well documented

(Foucault 1965; Grob 1994). However, this “Great Confinement” did not take place in other parts of the world until the age of widespread colonial expansion when local administrators established lunatic asylums in the colonies (Sadowsky 1999). Although institutionalization became the mainstay for treating the mentally ill in many parts of the world—particularly Europe and North America—elsewhere only a minority of patients were (or are) treated in such clinical settings.

Contemporary psychiatric studies suggest that the most effective way to treat schizophrenia is through a combination of psychopharmacological and psychosocial treatments (Hogarty et al. 1995, 1997a, 1997b). Rehabilitation programs that help develop social skills and offer occupational training have also proved beneficial to people with schizophrenia (Granholm et al. 2005; Liberman et al. 1986; Roder et al. 2002). In

China, schizophrenia is also treated with acupuncture (Bloomingdale 1980) and herbal medicine (Walls et al. 1975).

The advent of drug therapy for schizophrenia occurred in the 1950’s with the introduction of a new antipsychotic medication (Kirkby 2005; Lopez-Munoz et al. 2005).

Thorazine (chlorpromazine or CPZ) became the treatment of choice for people with schizophrenia, and helped usher in a new generation of conventional antipsychotic medications, including Haldol (haloperidol), Navane (thiothixene), Stelazine

121 (trifluoperazine), Trilafon (perphenazine), and Mellaril (thioridazine). These medications suppressed psychotic symptoms while infamously inducing severe side effects, such as tardive dyskinesia (Awad 1993). In the late 1980’s, a new group of antipsychotics was introduced and again the treatment for schizophrenia was radically altered. This new group, the so-called “atypical” antipsychotics, appears to be extremely effective at reducing the positive symptoms of schizophrenia, although they—like their predecessors—have little effect on negative symptoms (Kaspar 2006; Keshavan et al.

2006). The atypicals include Clozaril (clozapine), Risperdal (risperidone), Zyprexa

(olanzapine), Seroquel (quetiapine), and Geodon (ziprasidone). While more effective than conventional neuroleptics, these sophisticated drugs remain a luxury for most of the world’s mentally ill population.

B. Explanatory Models of Schizophrenia Held by Burmese Buddhist Respondents

1. Illness Definition

The psychiatric definition of schizophrenia is based on characteristic symptoms, social and occupational dysfunction, and duration of illness. In order to ascertain

Burmese ethnopsychiatric definitions8 of schizophrenia and mental illness, patient and family member respondents were asked to explain why the patient was seeking psychiatric treatment. If respondents had alluded earlier to an illness, they were asked what kind of illness they thought it was. The majority of patients (65%) and family

8 For example, researchers found that in Laos psychosis was defined in terms of social dysfunction (particularly violence) rather than by disturbances in thought and affect (Westermeyer and Kroll 1978; Westermeyer and Wintrob 1981). Similar findings are described in Malaysia (Colson 1971) and East Africa (Edgerton 1966).

122 members (80%) described the patients’ illness as sei’ yoga, or mental illness, and nearly every respondent (87.5% of patients and 100% of family members) categorized the illness as being some sort of mental problem (see Table 4.1).

Table 4.1. Patient and Family Member Respondent’s Illness Definitions

Patients (N=40) Family Members (N=20) N % N % Mental Problems Mental Illness 26 65.0 16 80.0 Bad/Weak 4 10.0 1 5.0 Mind 0 0.0 3 15.0 Suspiciousness 3 7.5 0 0.0 Nerves/Emotion 2 5.0 0 0.0 Voices No Illness 4 10.0 0 0.0 Other Problem 1 2.5 0 0.0

The fact that all patients were receiving psychiatric treatment helps to explain the frequent definition of their illness as “mental.” (Indeed, three outpatients and two family members described the illness as schizophrenia (sei’ kazin. kalya:’ yoga in Burmese).)

One father seemed resigned to this definition of his son’s illness: “He hears voices. He’s afraid of going into crowds. All these are things that we see. I suppose it’s mental illness because these are things he sees and hears in his mind.” It is possible that a similar group of patients who were not under psychiatric care would be less likely to characterize their illness in this manner.

Some patients claimed that they did not have a mental illness, but rather characterized their experiences in terms of having a bad or weak mind9 (10%), problems

9 Indeed, Skidmore (1999) reported that none of the psychiatric patients she interviewed defined their illness as “mental,” but instead referred to their mind or brain as “not good.”

123 with one’s nerves or moods (7.5%), or particular symptoms, such as hearing voices (5%).

For example, one patient said that she did not believe that she had a mental illness, but rather had a problem controlling her temper. She explained: “I have a bad temper. I don’t know why. I can’t control myself when I’m like that. I forget everything except that I feel like hitting or killing someone. It happens even now. Not here, though [at the hospital]. It happens at home.” Similarly, some family members were reluctant to describe their relative’s condition in terms of mental illness. Fifteen percent of family members characterized their relative’s problem in terms of suspiciousness and 5% described it as having a bad or weak mind. For example, one family member described her sister’s illness as extreme suspiciousness:

Family Member (FM)10: She’s full of suspiciousness. If her friends came to pick her up, she’d hide in the house and wouldn’t see them. She has very few friends so we had to coax her into talking to her friends again. I think it’s because she has too much suspicion.

I: Would you say she has mental illness?

FM: I don’t understand it so much. Because we were recommended to see a psychiatrist, we took her there, but she’s normal most of the time. It’s just the suspicious feelings, dissatisfaction and the thought that she’s under the influence of au lan. Her mind can’t be changed.

Some patients (10%) denied that they had any illness at all (one such patient said that she was in the hospital because her parents had misinterpreted her behavior as abnormal). One inpatient explained that she was under psychiatric care and taking medicine for insomnia, not mental illness:

P: It’s a preventive medicine to make me sleep. Because here at the hospital, it’s scary if you can’t sleep after ten or eleven, because that’s when the lights go off. I’m afraid I might lie awake like in the song [cites name of song].

10 In this dissertation, the interviewer is referred to as “I” (Interviewer), and the respondent being cited as “P” (patient), “FM” (family member), or “H” (healer).

124 I: Did you used to have mental illness before?

P: No. I was happy at home, getting everything I wanted.

Another patient denied having a mental illness because “I have full consciousness.”

The data indicated that many patients described their illness in terms of its larger significance in their lives, rather than simply in terms of particular symptoms (for similar findings see Jenkins 1997). For example, when asked to elaborate when she said that she was mentally ill an inpatient explained:

I feel hot, cold. I’m deprived of food. I can’t wear nice clothes. My younger brother at home said he had to support my younger sister and that he could support only one person. He told others to just ignore me. He said don’t bother, just leave her to starve. Back at home, I didn’t have the chance to dress up. I was yelling all the time. They wouldn’t dress me up until I started doing somersaults in the toilet. They wear new clothes all the time, but just won’t let me. I really want to be pretty. I want to look dainty.

For this patient being mentally ill consisted not only of illness symptoms, but also discomfort, deprivation, and neglect.

It is noteworthy that defining one’s illness as “mental” in Burma bears a profound social stigma, providing support for Waxler’s (1979) social labeling theory described earlier. Even more stigmatizing is a psychiatric diagnosis of schizophrenia. A psychiatrist explained that as residents their professor “used to ask us to think very carefully when we diagnose a patient, because if we diagnose him as schizophrenic, people think of it as something very bad.” She further explained that in certain cases (primarily educated individuals who understood the difference between particular diagnostic categories) patients were diagnosed with a mood disorder, such as depression, even if they appeared to have schizophrenia:

Most schizophrenics go downhill. Sometimes the treatment results are not good too, so usually if a patient is termed schizophrenia chances are that the results

125 won’t be very good. Take for example, a lecturer who got here [YMHH] with a psychotic episode. If we term him as a schizophrenic, the prognosis is not good. Educated persons like him, people of high positions . . . they are termed only as [patients with] mood disorder, depression, and others don’t think of them as mental disorders anymore. Even if they do, they don’t think depression is a mental disorder. That’s why patients can bear it a lot better if we term [their illness] as depression.

2. Illness Etiology

As reported by respondents, mental illness in Burma is attributed to suffering and trauma, supernatural forces, poor physical health, kamma, genetic and biochemical agents, characteristics, elemental imbalance, and interpersonal conflict.

Earlier studies of schizophrenia in Burma showed that patients attributed their illness to spirit possession, the belief that in were buried under their houses, the attainment of special powers through meditation, and the influence of radios and hidden microphones

(believed to cause auditory hallucinations) (Kyaw Zin and Tin Nyunt Pu 1970; Tin Nyunt

Pu 1980 cited in Skidmore 1999). Respondents frequently cited more than one cause for the patient’s illness (see Table 4.2).

126 Table 4.2. Patient and Family Member Explanations for Patients’ Illness

Patients (N=40) Family Members (N=20) N % N % Suffering/Trauma Abuse/Violence 8 20.0 2 10.0 Work/school problems 3 7.5 3 15.0 Loss of parent 2 5.0 2 10.0 Unhappiness 2 5.0 1 5.0 Supernatural Sorcery 5 12.5 2 10.0 Possession 4 10.0 1 5.0 Offended a nat 2 5.0 1 5.0 Poor health Insomnia/Fatigue 3 7.5 0 0.0 Drugs/alcohol 1 2.5 1 5.0 Malnourished 2 5.0 1 5.0 2 5.0 0 0.0 Kamma/Bad deeds 12 30.0 6 30.0 Genetic/biochemical 3 7.5 2 10.0 Personality Violent/bad temper 2 5.0 2 10.0 Negative thinking 2 5.0 2 10.0 Elemental imbalance 2 5.0 0 0.0 Interpersonal conflict 2 5.0 0 0.0 Don’t know 6 15.0 1 5.0

Patients (37.5%) cited suffering and trauma as the most frequent cause of their mental illness. Specific sources of suffering and trauma that patients experienced included abuse (sexual and physical, including rape) and other acts of violence (such as witnessing public beheadings after the 1988 demonstrations) (20%), work and school problems (7.5%) (loss of job or being unable to continue one’s education), loss of a parent (5%), and general unhappiness (5%). Some family members (10%) also attributed their relative’s illness to trauma. For example, a family member said that his son’s illness occurred as a result of his experiences in the Burmese army: “He was on the hill in the

127 battlefront and he saw his senior officer shoot a Karen insurgent. That trauma must have driven him crazy.”

Thirty percent of patients and family members also cited kamma as a major cause of mental illness. Kammic explanations are often used in Buddhist explanations of illness

(Nichter 1992). For example, in a study of meditation in Thailand, Tambiah (1985) found that no matter what illness a person had it was interpreted as the consequence of past actions on their present lives. As Skidmore (1999) points out, illness is a manifestation of karmic debt, and the more serious the illness the larger the merit debt. One such patient explained: “This does not happen to others but to me because I was bad in my previous life. I have to do ECT and take medicines and injections [as a result].” Similarly, another patient stated: “I think I must have encaged little animals and birds for me to be like this now [confined in the hospital].” Fewer respondents than expected cited kamma as a cause of illness. However, when asked directly about the role kamma played in the etiology of mental illness virtually every respondent said that kamma was a major factor. It appears that it is such a fundamental health belief that many respondents thought it too obvious to mention.

Patients (17.5%) and family members (20%) also cited supernatural causes in relation to the etiology of mental illness. For example, when asked what caused her illness an outpatient explained: “Because somebody did something bad to me. In our poor neighborhood, our parents were quite wealthy, with a car, and a two-storey house. And my husband was a seaman, so people got jealous and did au lan on me, I think.” Poor health conditions were also believed to help cause mental illness. For example, 20% of patients and 10% of family members cited malaria, substance use, malnourishment, and

128 insomnia as causing the patients’ illness. It is noteworthy that many of these conditions

(particularly malaria and substance use) can cause psychotic-like symptoms; for this reason, it seems reasonable that respondents would link these factors with patients’ behavior (although these conditions were screened for in the clinical interviews conducted for this research). Doing so also helps avoid the stigma of being labeled as mentally ill. Indeed, some respondents rejected the label of mental illness in favor of less stigmatizing associations. For example, an inpatient exclaimed: “I’m not ayu [crazy]. It’s au lan.”

Respondents (7.5% of patients and 10% of family members) also believed biological and genetic factors were linked with mental illness etiology. Other respondents believed that personality problems (10% of patients and 20% of family members) or elemental imbalance (5% of patients) helped cause mental illness. Personality problems were described as the exaggeration of certain personality traits considered to be undesirable in Burmese society (e.g., aggression, conceit, negative thinking)11. Elemental imbalance was believed to manifest in physical conditions (according to Burmese indigenous medicine too much bile is linked with mental illness) or extreme weather patterns. A male inpatient explained to me:

P: It has to do with the biological set up. It happens when it gets too hot.

I: What gets too hot?

P: The earth, the stones melt down, turn into water. The world. We drink tea so we boil water in the kettle. It gets hot. It affects people. Water, earth, and fire. They’re all relatives.

11 Indeed, a frequent diagnosis given to YMHH inpatients was “acute excitement,” or mania.

129 Respondents also reported that they believed mental illness was contagious, which greatly intensified the stigma surrounding the mentally ill in Burma. Skidmore

(1999:223-224) writes that it is this belief that helps explain why families abandon their relatives at the psychiatric hospital even if the episode of madness may be of temporary duration. She explains:

Like most diseases in Myanmar (especially leprosy and AIDS), a contagious magic is thought to be at work in transmitting the condition of unreason through both blood and indirect association. By indirect association I mean that simply being in the same room as a mad person or a leper can cause the disease, yawga, to manifest in other persons present. And if the disease does not jump between people through association, it is absolutely certain that the social stigma attached to such people will also become attached to the individuals present and their relatives and friends.

3. Illness Onset

According to Western psychiatry the onset of schizophrenia is typically characterized by a change in subjective and intersubjective functioning. As described earlier, studies indicate that people with schizophrenia generally experience an alteration in their mental functioning and intrapsychic experience long before there are any exterior indications of their illness. Stories from Burmese patient respondents support these findings. For example, a male inpatient said that he heard voices and experienced an altered state of self long before his family noticed anything was wrong with him:

I heard voices and got extremely restless. I didn’t feel like working. I just wanted to wander round. I just wanted to stuff myself with food. I couldn’t even take medicines. The voices flattered me. Then I set the house on fire. I beat up people. I hit my own head with a nail [an attempt to drive the voices from his head]. I hit my nephew and my brother just before I came to the hospital. Before I got here, I left the house on a bicycle and went to the railway station. I put my bike up and slept with my body across the rails. I was getting hungry and tired, so I lay down across the tracks, not caring if I died. The train stopped and brought me here.

130 Many patients described the onset of schizophrenia in terms of the fear they experienced. For example, an inpatient said that his illness began when he started to feel afraid all of the time and worried that he would go to . A female outpatient said, “I didn’t know that I was behaving strangely. I heard voices. I got scared because my thoughts and my dreams always turned out to be true.”

Other patients characterized their experiences of self-change in terms of loss of control. An outpatient explained:

I lost control of myself when I started hearing voices. I didn’t believe much in , but after taking medicines that Dr. Ne Win gave me, I began to think I was able to connect with people who took that kind of medicine. I heard two of my school teachers telling me in that way they were arrested and the voices eventually faded away as they were taken away in a car. I didn’t hear voices until I left the monkhood. I began to get suspicious of my family. I thought they were trying to feed me with a kind of poison that would bring me slow death.

An inpatient described what happened when her illness first took hold of her:

It was at home. The voices bothered me. I had cut my head often. I hit myself on the back of the head when I heard voices. I couldn’t bear it because it was so loud and noisy. It annoyed me so much. Mother said, “Don’t you feel pity for yourself, hitting yourself like that. Control yourself,” she said. I couldn’t. Mother tried to place her hand on my head, but it was no good. I pushed away Mother’s hand and hit myself. I was annoyed. So annoyed.

Other patients associated the onset of his illness with the feeling of increasing isolation from family and society. An outpatient described this experience:

I was staying alone. I wasn’t talking and I wasn’t sleeping well, my father said. I was staring into space and I wasn’t talking. When I slept in the afternoon, I heard voices in the ear, like someone scolding me, like mother scolding me, but it wasn’t mother and I don’t know who it was.

Another male inpatient described a similar experience:

I was meditating everyday at then. I started hearing teasing voices from behind and I thought kids were doing it, so I turned round to look but there was nobody. . . I went into a daze and became completely detached from

131 everyone around me. I’d go to work but I’d find myself just sitting there. I’d pick up and do some work if I was told, but if not I’d just sit there.

Embedded in patients’ narratives of the changes they experienced with the onset of their illness is the impact these changes had on their interpersonal relationships and lifestyle. The majority of patients in Burma recalled with sadness that they had to endure not only the personal suffering associated with developing schizophrenia, but also an end to their familiar social life. For inpatients, in particular, stories of illness onset are inextricably tied to separation from family and their subsequent life in the hospital. The following is such a description offered by a female inpatient:

I became scared. My mind was going berserk. I wandered off into the streets. I walked round, watched videos [in video parlors]. So they packed me off to this hospital because I didn’t want to stay home. Because I smashed the water pots and plates.

Similarly, family member stories of the illness onset were usually linked with an event that disrupted the normal flow of family life. The sister of an inpatient said that her family first noticed the mental instability when her sister kept shouting obscenities at the neighbors. Another family member said:

She started talking strangely and repeatedly about her past and her brothers. Around that time, two of her brothers also got married and left home. Although she was living together with us, she didn’t seem to want to. When I got married to my husband, my parents asked me to look after the family of my husband, like the oldest daughter. So I raised all the younger brothers until they left home, but she didn’t want to be under my control. She seemed to want to have more freedom, and I’m quite strict with her, especially because I’m a teacher. She wanted to live on her own, have a separate business of her own. And then she began to talk about wanting to travel to where her brothers were. She didn’t want to stay home. Then she started hearing voices, like so-and-so was calling her. And that so-and-so was an imaginary person and she tried to leave the house late at night. I’d lock her in the house but she’d manage to leave around four in the morning. She’d be talking to herself and sometimes she’d say this bodaw or that bodaw was giving her instructions to do things.

Likewise, another family member described the onset of his son’s illness:

132 I noticed him imagining things. . . he refused to drink and eat home food, because he thought we were all poisoning his food. For instance, he refused to eat the apple that we gave him but would eat the discarded peeled skin. He’d go searching for water all day and drink muddy water from the stream many miles away. So he grew thinner and thinner, began losing appetite and sleep, and that’s how it started.

4. Course and Outcome

There are several predictors for the course and outcome of schizophrenia, including labeling; subjective perceptions of self, others, and the world; and interpersonal dynamics. While this research did not focus specifically on the clinical course and outcome of each patient’s illness, much of the data showed how patients and their family members perceived the illness’ progress and whether or not it could be cured.

The alteration to one’s sense of self that frequently occurs with the onset of schizophrenia seemed to affect the course of illness for many of the patients interviewed.

As anthropologist Sue Estroff (1989:189) explains schizophrenia is an illness that may overtake and redefine one’s preexisting identity, leading to questions regarding the nature and consequences of these changes:

Who and what existed before the illness, and who and what endure during and after? Some do not accept that there is an “after” with schizophrenia, only before. This question seems to be rather crucial and may be answered most accurately by one seldom asked—the individual with schizophrenia.

In Burma, individuals with schizophrenia reported that their pre-illness self was associated with happiness, self-reliance, and normality, whereas their post-illness self signified loss, suffering, dependence, and marginalization. One patient explained, “I don’t feel like a normal person. The head is not clear, the hands ache. If the head doesn’t feel good, if the body doesn’t feel good, it [the illness] gets worse.” Struggling with their new post-illness role and identity increased patients’ suffering:

133 I: When you suffer, do you feel differently about yourself?

P: I feel useless and I feel like a burden.

Similarly, Corin et al. (2004) describe how feelings of fear and terror altered the sense of self experienced by Indian patients with schizophrenia.

Many patients described not feeling like their normal selves since their illness began and associated feeling better during moments when they felt a brief return to their previous sense of self and vice versa. Several patients associated this “return to self” with having a job, hanging out with friends in the teashops, or being able to do housework. For example, when an inpatient was asked what had made her happy before she came to live at the hospital, she described being able to carry out typical household activities that she was no longer able to do at YMHH: “When I was pounding chili. I felt that way [happy] when my mother asked me to pound chili.” This desire to regain one’s former sense of self also helps explain why the majority of patients associated a return to their former identity and lifestyle with getting better.12

Many inpatients believed that this return and its association with improvement could best be achieved if they could return home or have more contact with their family.

Unfortunately, this return was impossible for many inpatients. Most of the inpatients had been hospitalized because their family could no longer manage them at home, and some patients remained at the hospital simply because they had nowhere else to go. For example, a nurse at YMHH reported that one of the inpatients was well enough to go

12 These data also indicate that notions of self among Burmese Buddhists rest upon interdependence, rather than separation, between the person and the world. Also see Corin et al. (2004), Gaines (1982a), Jenkins (1991), Kleinman (1988b), and Shweder and Bourne (1984) for similar distinctions between cultural conceptions of self and personhood.

134 home but her family did not want her back, so “she’ll probably be here at the hospital until she dies.” During a check-up with another inpatient with schizophrenia, the treating psychiatrist turned to me and said, “She is doing much better and can be discharged. The problem is if her family won’t take her. She wants to go back and that is her right but . . . .”

Patients and their family members also believed that being able to adhere to a daily routine—especially one that represented “normal” behavior or one to which they had adhered to prior to their illness—prevented their illness from getting worse. An outpatient explained, “When I was ill, I couldn’t think of anything, but now I think for my son, for the house, for the finances, like I want to help my brother.” Similarly, an inpatient explained that it was a predictable routine that made him want to stay at the hospital. He said, “I don’t take medicines regularly outside, but here we take medicines, eat at regular times, and I think that’s why I’m okay now. I’m scared I’d go nuts again if I forgot to take my medicines outside.” (The majority of patients and family members believed that the course of the illness had improved after taking medication, stating that the illness became worse if the dosage was decreased or the medication stopped.)

Many patients also claimed that their illness became worse if they suffered, that is, if they felt unhappy, alone, or were treated poorly by others. One outpatient said:

P: I think I’m getting worse sometimes.

I: Why?

P: I feel like a mad person when I’m unhappy and when I feel somebody entering my body and I feel dizzy.

I: What do you do at such at time?

135 P: I just have to put up with it. I’m scared because I don’t want to be crazy. Lately, I’ve often found myself in a daze, not being able to do anything. I can’t even do the religious routine. I feel so dull in the head and I’m in a daze. Once I felt as if I was taken out of my own body, I was so dazed.

I: What can make you feel better?

P: It gets worse when my aunts yell at me. If I take medicines, tranquilizers after talking to the doctor about it, I feel better. Sometimes, the mind calms down by itself. If I say prayers, if I take medicines, if I control myself, I feel better.

Conversely, many patients noted that their illness improved when they felt happier. For example, a patient explained the effect happiness had on his illness:

I: Who or what can make your suffering worse?

P: It gets worse when I hear voices.

I: Who or what can me you feel better?

P: I feel better if I think happy, peaceful thoughts.

Similarly, another patient said:

I: Besides the voices, are there other things that make you suffer?

P: Nothing else, besides the voices.

I: What things make you suffer less?

P: Listening to music.

I: What happens when you listen to music?

P: I feel happy.

Family members also observed that their relative’s symptoms seemed to improve during periods of happiness. These findings raise the question of whether the degree of suffering people with schizophrenia experience might be reflective of the severity of illness. For example, Ritsner et al. (2004) found that people with schizophrenia with particularly severe emotional distress had a poor subjective response to antipsychotic medication.

136 Similarly, Smith et al. (2006) found that severity of psychotic symptoms was correlated with severity of suffering, and Freeman et al. (2001) showed that emotional distress may be linked to the content of delusional beliefs.

A subset of ten patients (five inpatients and five outpatients) were interviewed and asked if they thought that their illness would get better, stay the same, or get worse in the future. All of them believed that they would get better. In contrast, the majority of family members believed that any improvement in the illness was only temporary, although most held some degree of hope that the patient would eventually recover and be able to lead a normal life. This belief seems to have been perpetuated by patient’s treating psychiatrists who warned family members that schizophrenia had no cure. An inpatient’s sister said: “I can only pray that she be well again. I feel like dying when things get so bad with her illness . . . I don’t think she’ll ever be a normal person again. The doctors say she’ll probably get worse with age, so I’m quite concerned.” Another family member said that although his son was better when he took his medication, “according to the doctors, the illness is long standing and he has not a chance of getting completely cured. I think the same too.” Some family members talked about the illness getting better, or at least its symptoms being controlled with medication, but noted that the patient had yet to return to her or his “normal” pre-illness self. The husband of an outpatient said:

FM: It’s not like the normal state before. Previously, she could wash her own clothes, do the cooking, but not anymore now. But you can say the illness itself is getting better.

I: Has she ever seemed normal since she had this illness?

FM: Only before the illness. Since the illness, it’s just controlled. No longer what she used to be when she was born.

I: Do you think she can become normal again in the future?

137 FM: No. She doesn’t even try to.

One family member, however, did believe that his son had been cured because “he has become more sociable. He stopped withdrawing from people and began to want to go out more.”

5. Treatment

Before describing the treatment actions for schizophrenia in Burma, it must be mentioned that it is not always the patients themselves who seek this treatment. Waxler

(1977:241) reports that this treatment behavior is not uncommon in “traditional societies” and that “mental illness is basically a problem of and for the family, not the sick person.”

Most often, outpatients and family members arrive at appointments together. It is quite rare to see a patient arrive alone; indeed, it is more common to see a family member arrive alone on behalf of the patient. Sometimes a family member would simply bring a photograph of the patient. This treatment by proxy reflects both the family member’s concern for patients, as well as the underlying belief that patient participation is not always necessary during the treatment encounter.

Psychiatric care and hospitalization are considered to be a “last resort” in Burma, utilized only after other treatments have been sought without success, or in cases in which no or little family or community support is available (also see Higginbotham and

Marsella 1988; Murthy 1983). Patients and family members reported that psychiatrists, with their implicit link with mental illness, made them acutely aware of the “abnormal” circumstances of their healing encounter and were therefore not always consulted first.

Indeed, a psychiatrist reported that because of the stigma involved with consulting mental

138 health care professionals, he did not necessarily advise people to consult a psychiatrist: “I don’t tell a mentally ill person to go to a psychiatrist . . . He can go to anyone as long as he is cured, or as long as he feels better or at peace. Anybody can help.”

Prior to seeking care in a hospital setting, most patients usually will have sought help from religious or traditional healers (Fraser 1934). For example, respondents frequently consulted monks, general doctors, or astrologers first, because they felt more

“normal” consulting them13. Other patients remain untreated; they are confined within the household in order to avoid the social stigma of being labeled as mentally ill14. A healer

(YMHH nurse) described how one such patient delayed seeking treatment for 40 years in order to avoid the stigma of seeking a mental health professional:

They [people with schizophrenia] don’t take treatment until they have to and when they do, they do it in a hush-hush way. One of my patients had the illness since she was 17, like talking to herself, losing interest in studies although she used to be very bright. She can’t do anything and worse, she can’t hold her bodily functions. She can’t talk coherently or sleep at night. It has been like that since 17 and it wasn’t until she was 57 that she got to this hospital.

Another healer reported that a patient’s family tells others that the patient is on a trip rather than admit their relative is a resident at YMHH.

In order to learn more about types of healers who treat mental illness in Burma, as well as about patterns of resort, a survey was administered to the general Burmese

Buddhist population of Rangoon and its vicinity (N=142). These survey respondents

13 Such patterns of resort have been observed in other Southeast Asian contexts (Brainard and Zaharlick 1989; Mollica et al. 1987; Spiro 1967). Ong (1995:1249), for example, writes that Southeast Asian refugees living in the United States seek treatment for physical, rather than mental, problems—despite any underlying psychological or psychiatric problem they might have—because mental health clinics are considered to be “synonymous with a ‘place for crazy people.’” 14 Skidmore (1999) showed similar findings in her interviews with patients residing at the Yangon Psychiatric Hospital.

139 identified every type of healer whom they believed treated mental illness (see Table 4.3).

Survey respondents identified a wide variety of healers, but the majority (63.4%) believed that psychiatrists were the most likely healers to treat mental illness in Burma.

Other types of healers commonly believed by survey respondents to treat mental illness included nat gedaw (56.3%), fortune tellers (bedin saya) (26.8%), psychologists (23.2%), indigenous medical doctors (tai yin saya and bama saya) (19.7%), monks (16.2%), payoga saya (14.8%), and meditation saya (teachers) (14.1%). Healers less commonly cited were ahtet lan saya (9.2%), au lan saya (7.0%), family and friends (4.9%), general doctors (3.5%), social workers (2.8%), and tattoo artists (0.7%).

140 Table 4.3. Healers Who Treat Mental Illness, According to Survey Respondents (N=142)

N % Psychiatrists 90 63.4 Nat gedaw 80 56.3 Bedin saya 38 26.8 Psychologists 33 23.2 Indigenous Medical Doctors 28 19.7 Monks 23 16.2 Payoga saya 21 14.8 Meditation teachers 20 14.1 Ahtet lan saya 13 9.2 Au lan saya 10 7.0 Family and Friends 7 4.9 General Doctors 5 3.5 Oneself 4 2.8 Nothing works 2 1.4 Social worker 2 1.4 Tattoo artist15 1 0.7

Patients were asked to identify each type of healer they had consulted for their mental illness (see Table 4.4). One hundred percent of patients consulted a psychiatrist.

(This finding is not surprising as psychiatric treatment was a condition of inclusion in this research). Patients also sought treatment for schizophrenia from monks (52.5%), indigenous medical doctors (45%), payoga saya (35.0%), general doctors (30%), ahtet lan saya (22.5%), and bedin saya (12.5%). Nuns (5%), clairvoyants (5%), and nat gedaw

(2.5%) were consulted less frequently by patients.

15 In Burma, many people believe that tattoos can help ward away harm. Many respondents, including patients, in this study had tattoos. When asked what purpose they served, none of the respondents said that the tattoo could help prevent or cure an illness. They claimed that the tattoos were primarily for decoration, but could also protect them from such things as snakebites, sorcery, and encounters with evil spirits. Shway Yoe (1882/1963) provides a similar, more detailed account of Burmese tattooing.

141 Table 4.4 Healers Who Patients Consulted (N=40)

N % Psychiatrists 40 100.0 Monks 21 52.5 Indigenous Medical 18 45.0 Doctors Payoga Saya 14 35.0 General Doctors 12 30.0 Ahtet lan saya 9 22.5 Bedin saya 5 12.5 Nuns 2 5.0 Clairvoyants 2 5.0 Nat gedaw 1 2.5

Most patients and their family members first consulted several religious or traditional healers; on average, they consulted four healers before resorting to a psychiatrist.

Respondents described many reasons for this pattern of resort. First, because of the stigma surrounding schizophrenia in Burma, many patients seek help from general doctors for non-specific somatic complaints or prefer to consult traditional healers who treat a wide variety of illnesses and are thus not associated with mental illness. Wealthy patients often go to one of Burma’s few private clinics where their privacy is assured.

Second, the majority of Burmese Buddhists confronted with mental illness believe that the most likely causes of schizophrenia are supernatural or kammic, both of which require religious, not psychiatric, intervention. With the onset of mental illness, the family will usually begin performing acts of merit and religious duties to help counteract any bad deeds responsible for the illness. Such activities might include making an offering of food to a monk or group of monks, making a donation to a monastery or pagoda, praying or chanting Buddhist verses, such as and suttas, or making offerings to the Buddha in one’s home or at a pagoda (also see Taw Sein Ko 1913). These

142 religious acts are carried out not only in hopes of preventing the illness in the next life, but in hopes that the Buddha (and, for some, nats) will intervene in this life and promote a quick recovery. These actions continue over time even as other treatments are sought.

This pattern of resort suggests that the prevalence of mental illness may be underestimated in Burma (U Sao Sai Lan 2002).

After religious or traditional treatments have failed to cure the patient’s illness, many family members begin to consider psychiatric treatment. Psychiatric treatment for schizophrenia in Burma today generally consists of a cocktail of psychopharmacological medications, which typically includes an antipsychotic (usually Thorazine and Haldol), an anti-anxiety drug (usually Ativan), and an anti-parkinsonian drug to help with side effects of the previous medications (usually Artane), as well as ECT (electroconvulsive shock therapy), and, infrequently, group therapy. In Burma, most of the newer medications, such as atypical antipsychotics, are not available at all or are otherwise out of reach except for very wealthy patients16. One of the psychiatrists reported that she gave most patients only half of the recommended dose of Clozaril because it was so expensive. As mentioned in the previous chapter, there are few psychiatric alternatives to medication, such as psychological or psychoanalytic treatments, available in Burma17.

Instead, patients under psychiatric care generally supplement their medication with treatments belonging to other health care sectors.

16 Skidmore (1999) notes that even CPZ is smuggled in from China and is often out of date by the time it is purchased by psychiatric patients in Burma. 17 While not an alternative per se, “self-help” books have grown in popularity in Burma, primarily because they promote individual agency and willpower as tools for self- actualization (Fink 2001). Most of these books are translations of popular American advice books that began to appear in Burma in the 1990’s.

143 In some cases, however, religious or traditional healers themselves will diagnose a patient’s condition as a “normal” mental illness and refer her or him to a psychiatrist.

Sometimes a healer’s referral to a psychiatrist is part of a symbiotic relationship the two healers share. For example, one psychiatrist referred patients to a local payoga saya if the physician’s treatment was not effective, or if he thought that the family would receive a psychological benefit from such an approach. In turn, this payoga saya referred any patient with “normal” mental illness to this psychiatrist. Healers also make use of each other’s methods. For example, a payoga saya described prescribing purgatives and holy water to patients who appeared to be possessed. In the event that such treatment failed to drive out the spirit, he prescribed modecate or CPZ, which are typically only prescribed by psychiatrists to treat psychotic disorders.

The majority of religious and traditional healers also prescribed religion to help treat the patient’s illness. Indeed, the majority of patients and family members believed that Buddhism could help treat mental illness, as well as help prevent the illness from occurring again in a future life. For this reason, many family members performed religious acts, such as praying, making donations and doing good works, on behalf of the patient. An inpatient explained, “Buddha treats the illness as soon as I pray. . . I feel relieved as soon as I start saying prayers.” Another inpatient said, “Scientifically, I’d take medicines. To have clarity of mind, I’d have to pray.” An outpatient said that he tried to keep up a routine of meditation, observing the five precepts, and gaining merit in order to help treat his illness. The wife of an outpatient said that she believed that such a routine was the only way to effectively treat her husband’s illness. She had attempted to get her

144 husband to meditate to treat his illness, particularly to put an end to the voices he heard18.

However, the wife added:

FM: But even as he meditates he says he hears voices. We’ve done all we can with medication, and this is the only option left. But if he can’t meditate, it looks like he’ll have to keep taking the medicines for the rest of his life.

I: What is it about the meditation that you think would be helpful for his illness?

FM: Buddha has shown us that even all tangible matters are impermanent, so I think meditation can help him see that the voices he hears are not real.

Some healer respondents stated that while they could not treat the illness they did their best to address the underlying cause (such as kamma) in order to prevent it from recurring in a subsequent life. For example, a monk told a patient in this study that her illness was caused by the bad deeds she had committed in a previous life. He said he could not cure her, but placed holy beads around her neck (probably an in), sprinkled her body with holy water, and advised her to avoid eating meat in the future. This monk’s actions resonated with explanations made by other respondent’s concerns with treating the underlying cause of mental illness. Consulting a psychiatrist did not necessarily indicate that the patient or family member had stopped believing that the illness was caused by kamma or payoga. For example, after a patient became unmanageable at home

(he burned down the family home and made several suicide attempts), his mother sent him to YMHH. When asked why she had sent her son to Rangoon instead of to the psychiatric hospital in Mandalay, which was much closer, she responded: “When he went to hospital, as soon as he reached the other end of the bridge he’d become normal just like that. I’ve heard people say that if some au lan did evil to someone, he could do it

18 Elsewhere, Burmese psychiatric patients have reported that meditation helps control the mind and can sometimes end auditory hallucinations (Skidmore 1999).

145 only within his own terrain.” In other words, the au lan saya whom she believed had caused her son’s illness had no power outside of central Burma. Similarly, an ahtet lan saya told me that he was unable to cure patients who were currently in YMHH because the hospital was controlled by the government, which was more powerful than his bodaw.

As a result, the ahtet lan saya would perform a curing ritual on the patient’s relatives, hoping to effect a cure from afar.

C. Summary

This chapter describes the general explanatory models of schizophrenia, as well as those specific to the Burmese Buddhist context. Doing so highlights the particular diagnostic issues associated with the cross-cultural study of schizophrenia, as well as the important role of culture in shaping how schizophrenia is conceptualized, experienced, and managed. The particular examples described by Burmese Buddhist respondents provide additional ethnographic data regarding the definition, etiology, onset, course and outcome, and treatment of schizophrenia.

146 CHAPTER FIVE THE DISCONNECT BETWEEN PATIENT RESPONDENT’S EXPERIENCES AND NON-PATIENT RESPONDENT’S PERCEPTIONS OF SUFFERING AND SCHIZOPHRENIA

In this chapter, the findings of this dissertation concerning Burmese Buddhist respondents’ experiences and perceptions of suffering and schizophrenia are discussed.

As we will see, a striking paradox emerged from these data: while all respondents voiced their belief in the Buddhist doctrine of dokkha—that is, that life is suffering and everyone suffers—non-patient respondents claimed that the mentally ill did not suffer. This claim is at odds with patient respondents who described experiencing profound suffering; indeed, they believed that they suffered more than people without mental illness. These patients also described taking similar actions as any other Burmese Buddhist to reduce and overcome their suffering. These results strongly support the idea that there is a disconnect between the subjective experience of schizophrenia and social perceptions of that experience. Additional findings suggest that sources for this disconnect may be related to Burmese Buddhist cultural conceptions of feeling and affect.

A. Burmese Buddhist Perceptions of Suffering and Schizophrenia

According to the fundamental tenets of Theravada Buddhism, as discussed in

Chapter 1, every human being experiences dokkha until achieving enlightenment. Due to the First Noble Truth, it was expected that all Burmese respondents would state that suffering was an inevitable part of life. Indeed, when respondents were asked if suffering was an inevitable feature of life that everyone could expect to experience the majority of respondents—70% percent of inpatients, 95% of outpatients, 100% of family members,

147 and 90% of healers—replied in the affirmative (see Table 5.1). Only 20% of inpatients,

5% of outpatients, and 7% of healers said that suffering was not an inevitable feature of life. Of these patient respondents, the typical response was that suffering was only inevitable if one’s basic needs were not met; some of these respondents could not explain their answer. Healer respondents typically stated that suffering was not inevitable because one might attain nibbana, which would end one’s suffering.

Table 5.1. Is suffering1 an inevitable feature of life? (N=100)

Inpatients Outpatients Family Healers (n=20) (n=20) Members (n=20) (n=40) N % N % N % N % Yes 14 70 19 95 20 100 36 90 No 4 20 1 5 0 0 3 7 Did not know 1 5 0 0 0 0 0 0 Missing 1 5 0 0 0 0 1 3

Many respondents answered this question by reiterating the Buddhist notion that life is defined by suffering. For example, when an outpatient was asked why he suffered,

1 Respondents used several terms to refer to suffering, including the Pali (dukkha) and, in relevant cases, English (suffering). Burmese terms to describe suffering included: dokkha, sei’ hsin: yè: dei (to be miserable or unhappy), dokkha khan za: dei (to experience or feel suffering), and weidana khan za: dei (to suffer, especially from an illness, usually of a physical nature). Respondent’s elaborations of suffering reflected the Buddhist notion that every aspect of life either is or becomes suffering. For example, a healer-respondent described this all-inclusive meaning of dokkha: Suffering is all that happens in the mind—feeling sad, being happy, wanting to cry, wanting to laugh, getting excited, all of it. Being hungry, being angry, feeling dokkha is used for all of it. For example, your mother dies. You feel sorrow, grief. You feel very much. You pass the exam, you’re happy. In his elaboration of dokkha, an outpatient-respondent similarly defined the of Buddhism—life is suffering: I consider whatever good or bad you experience in life as suffering, whether you’re ill or not. . . There are positive things and negative things in life, but I see life as suffering, even when good things are happening.

148 he answered “because of such a thing called life.” Likewise, a family member said,

“Until we attain nibbana, there will always be suffering. As long as there is matter−the physical being−[there will be suffering.]” Another family member summed up the situation succinctly, “As long as you’re a human, you suffer.” Similarly, a healer said that

“being conscious” meant that one would suffer. An inpatient simply explained that suffering was “democratic.” And an outpatient said that “life is all about suffering…to break away from the cycle of rebirth and death. I’d like to attain nibbana.” Another outpatient explained, slightly impatiently:

I don’t even need to say it [that suffering is inevitable]. You can find out from religious articles. Once you become a human, suffering comes together with it. If you were fortunate, and there was no suffering, you’d be born as a nat [into a higher of existence].

Given these findings, it was expected that respondents would state the belief that the mentally ill also suffered. The actual responses were surprising. All patients (100%) said that they had suffered2; however, more than half of patients’ family members (55%) and the majority of the healers (80%) reported that the mentally ill could not suffer (see

Table 5.2).

2 How representative of the general experience of schizophrenia are these patient responses? As explained in Chapter 2, out of the 44 inpatients approached to participate in this research project, 23 (53%) were oriented well enough to participate (3 were rejected for other reasons). Out of the 24 outpatients approached to participate, 23 (96%) were oriented well enough to participate. These statistics show that even after excluding several patients the majority of in- and outpatients with schizophrenia would be found competent to participate in this study and, based on the results shown in Table 5.2, would claim to suffer. It must also be reiterated that the inpatients at YMHH can generally be described as some of the most severe cases of mental illness in Burma. Recall that because of the great stigma revolving around mental illness and psychiatry, hospital- based treatment is usually a last resort undertaken by family members who can no longer manage patients on their own, or for patients who have no caretakers. Although the data presented here do not speak to the patients excluded from this research, they do show that the majority of the most severe cases of schizophrenia suffer.

149 Table 5.2. Do the mentally ill suffer? (In-depth Interview Respondents, N=100)

Inpatients Outpatients Family Members Healers (n=20) (n=20) (n=20) (n=40) N % N % N % N % Yes, the mentally ill suffer 20 100 20 100 9 45 8 20 No, the mentally ill do not 0 0 0 0 11 55 32 80 suffer

In order to determine if responses of non-patients (family members and healers who had close ties to persons with mental illness) were representative of the general population, a survey was administered to 142 Burmese Buddhists from the general

Rangoon population. The survey findings were equally surprising: 78% said that they believed that the mentally ill did not suffer (see Table 5.3).

Table 5.3. Do the mentally ill suffer? (Survey Respondents, N=142)

N % Yes, the mentally ill suffer 22 16 No, the mentally ill do not suffer 111 78 Sometimes the mentally suffer 7 5 Did not know 2 1

The overwhelming reason non-patient respondents gave for the perceived absence of suffering among people with mental illness was the inability to experience feelings; indeed, these respondents often referred to the mentally ill as insentient, senseless beings.

One psychiatrist went so far as to say that the mentally ill, specifically those with schizophrenia, could not suffer because “they are just living organisms, little more than a vegetable.” Another psychiatrist reiterated this belief, stating that people with schizophrenia did not appear to experience normal feelings:

I: Do you think people with schizophrenia suffer?

150 H: Schizophrenics do not have feelings such as happy or sad or suffering. . . For example, a schizophrenic patient would not even know sorrow when their child dies. Something like that.. . A schizophrenic cannot feel sorrow or happiness. Mood flat. Some would be giggling and laughing at their mother’s death, although they’d say they’re sad.

Another healer, who was a monk, claimed that this lack of sentience and resulting inability to suffer held consequences for the human identity of the mentally ill:

The mentally ill don’t know suffering, or any feeling for that matter. It’s almost like they are animals but they live on the human level but are in another realm within that level due to their fate. They have no suffering. They are wild, but not as much as animals. They are between animals and humans.

The association of mental illness with the inability to feel clearly affected non-patient respondents’ perceptions of the identity of the mentally ill.

Non-patient respondents also reported that the mentally ill did not suffer because they lacked awareness of not only their illness, but also reality in general. These respondents described this lack of awareness in terms of insight, or vipassana, which

Buddhists consider to be an important form of wisdom that is attained, in part, through mental discipline. Most non-patient respondents specifically stated they did not believe people with schizophrenia possessed either insight or mental discipline. A monk explained: “The mentally ill don’t know suffering, or any feeling for that matter . . . They are imbalanced in terms of earth, air, wind, and fire so they have no insight.” Some non- patient respondents claimed that the mentally ill did not suffer because they were too sick to experience suffering, and were thus unaware of any reality outside of their illness. For example, a healer respondent (an ahtet lan saya) said because the mentally ill “live in a dream world,” (i.e., experience delusions) they do not suffer. For this reason, another ahtet lan saya said that he would not mind being mentally ill, because he believed that his suffering would then come to an end because he would no longer be aware of anything

151 beyond his illness. Similarly, a family member suggested that this lack of insight was associated with a lack of worry: “As long as he has a full stomach he’s ok. . . because he has food and can do what he likes, he has no worries.” These respondents indicated that mental illness, which they perceived as a state of unawareness and lack of control, exempted patients from many adult responsibilities, particularly those concerned with religious duties and maintaining a family and livelihood in Burma.

While the majority of non-patient respondents said that the mentally ill did not suffer, 16% (n=22) of survey respondents, 45% (n=9) of family members, and 20% (n=8) of healers said that they could suffer. An additional 5% (n=12) of survey respondents said that the mentally ill could suffer in certain circumstances. There were two categories of explanation for this response3. The first category was in accord with original expectations, reflecting Buddhist ideology: no one can escape suffering. This was the most frequent explanation stated by survey respondents (n=10) and healers (n=5). Some family members (n=2) also gave this explanation. It is noteworthy, however, that many of these respondents qualified their answers, stating that while the mentally ill might be subject to existential suffering, they did not actually feel any (ordinary) suffering.

Many of these respondents further qualified their responses, explaining that the mentally ill only suffered in certain circumstances. For example, survey respondents who claimed that the mentally ill only suffered some of the time said that suffering was inversely correlated to illness severity (more severe illness symptoms was equivalent to less suffering), dependent on the cause of illness (suffering only occurred if the illness was an “abnormal” mental illness, not a “normal” mental illness, such as schizophrenia),

3 Some of the survey respondents’ explanations for why the mentally ill suffer (n=8) or sometimes suffer (n=1) were missing.

152 and required the presence of insight and feeling. Some family members, healers, and survey respondents also stated that the mentally ill only suffered during times of lucidity, insight, and apparent normality. An outpatient’s sister explained:

She only suffers when she is in a normal frame of mind. When she’s abnormal, she doesn’t know suffering. She’d use nasty words, get contentious, and quarrelsome. I don’t think she suffers at those times.

A bedin saya stated: “The mentally ill only suffer when they are lucid. Then they suffer in their subconscious mind, whereas normal people suffer in their conscious mind.” A meditation teacher similarly stated that the mentally ill suffered, but remained unaware of their suffering. An ahtet lan saya said that the mentally ill suffered less than others because they were out of touch with reality. Many respondents who said that the mentally ill did not suffer also stated that they had the potential to do so during periods of insight.

For example, a psychiatrist said that people with schizophrenia could only suffer during lucid moments when they had insight into reality and could acknowledge that they were ill. Indeed, many non-patient respondents said that if the mentally ill could gain insight they would not only gain the ability to suffer, but also the potential to be cured of their illness.

The second category of family members (n=7), healers (n=3), and survey respondents (n=4) asserted that the mentally ill did experience ordinary suffering, particularly related either to their illness (illness symptoms, lost opportunities, social stigma, or, in the case of inpatients, being separated from family) or socio-economic hardship. Respondents (family members and two healers) who had a relative with a mental illness were particularly likely to give this explanation. For example, an outpatient’s father said:

153 I: You said your son suffers because of his illness.

FM: I think he does, although he doesn’t say so.

I: Why do you think he suffers?

FM: I can see he feels lost and lonely in the way he moves about.

Another family member described how her sister (an outpatient) suffered:

I: Do you think your daughter suffers because of her illness?

FM: Of course.

I: In what way?

FM: She often talks about the things she misses out on, like education.

Neither patient category (see Table 5.4), healer type (see Table 5.5), gender, age, marital status, nor socio-economic status (see Table 5.6) was a significant factor in non- patients’ perceptions of suffering and mental illness. However, non-patient respondents with a mentally ill relative were more likely to say that the mentally ill suffered. It appears that personal or familial connection to a person with mental illness increases the likelihood that a non-patient will perceive the mentally ill as suffering.

Table 5.4. Family member responses by patient category (N=20)

Yes, the mentally ill No, the mentally ill do not suffer suffer N % N % Family Members4 with inpatient relative (n=7) 4 57 3 43 with outpatient relative (n=13) 5 39 8 61 X2 = .64, p >.05

4 The family members who answered “yes” included: three parents, three siblings, one sister-in-law, one spouse, and one cousin. Those who replied “no” were: six parents, one sibling, one uncle, and three spouses.

154 Table 5.5. Healer responses by healer type (N=40)

Yes, the mentally ill No, the mentally ill do not suffer suffer N % N % Healers5 Biomedical (n=19) 4 21 15 79 Religious (n=15) 3 20 12 80 Traditional (n=6) 1 17 5 83 X2= .06, p >.05

5 The healers who answered “yes” included: one psychiatrist, one psychiatry resident, one nurse, one psychologist, two meditation teachers, one fortune teller, and one spirit medium. Those who replied “no” were: nine psychiatrists, one psychiatry resident, one general doctor, three nurses, one psychologist, two monks, one meditation teacher, five fortune tellers, two indigenous doctors, four exorcists, and three spirit mediums.

155 Table 5.6. Non-patient responses by socio-demographic characteristics (Family member, healer, and survey respondents, N=202)

Yes, the No, the Sometimes the Do not mentally ill mentally ill do mentally ill know suffer not suffer suffer N % N % N % N % Gendera -Female (n=93) 20 22 68 73 3 3 2 2 -Male (n=109) 19 17 86 79 4 4 0 0 Age b -18 to 20 (n=21) 2 9 17 81 1 5 1 5 - 21 to 30 (n=44) 9 20 32 73 2 5 1 2 - 31 to 40 (n=41) 8 20 32 78 1 2 0 0 - 41 to 50 (n=33) 3 9 28 85 2 6 0 0 - 51 to 60 (n=36) 7 19 29 81 0 0 0 0 - 61 to 70 (n=15) 6 40 9 60 0 0 0 0 - 71 to 80 (n=8) 1 12 7 88 0 0 0 0 - 81 to 90 (n=4) 3 75 0 0 1 25 0 0 Marital Status c (n=60)6 -Married (n=44) 12 28 32 72 0 0 0 0 -Single (n=10) 2 20 8 80 0 0 0 0 -Separated/Divorced 2 67 1 33 0 0 0 0 (n=3) -Widowed (n=3) 1 33 2 67 0 0 0 0 Education d - >10th (n=44) 6 13 36 82 2 5 0 0 - 10th graduate (n=41) 6 14 33 81 2 5 0 0 - Some college (n=29) 6 21 20 69 2 7 1 3 - College grad (n=47) 8 17 38 81 0 0 1 2 - Post-graduate (n=28) 10 36 18 64 0 0 0 0 - Monastic (n=10) 3 30 6 60 1 10 0 0 - None (n=2) 0 0 2 100 0 0 0 0 -Missing (n=1) 0 0 1 100 0 0 0 0 Occupation e - Professional (n=35) 9 26 25 71 0 0 1 3 - Managerial/Admin. 9 20 36 78 1 2 0 0 (n=46) -Service/Manual (n=51) 8 16 39 76 4 8 0 0 -Unskilled/None (n=40) 8 20 29 72 2 5 1 3 - Missing (n=30) 5 17 25 83 0 0 0 0 aX2= 3.02, p >.05; bX2= 30.58, p >.05; cX2= 3.39, p >.05; dX2= 17.066, p >.05; eX2= 14.88 p >.05.

6 Data on marital status was not collected for survey respondents.

156 B. Experiences of Suffering among Burmese Buddhists with Schizophrenia

The findings presented earlier in Tables 5.2 and 5.3 show that the majority of non- patient respondents believe that the mentally ill are incapable of experiencing suffering.

However, Table 5.3 also shows that virtually every patient respondent said that he or she did experience suffering. Moreover, 60% of inpatients and 80% of outpatients stated that they suffered more intensely than people without any mental illness (see Table 5.7).

Table 5.7. Do you suffer more than, less than, or the same as people with no mental illness? (N=40)

Inpatients Outpatients (n=20) (n=20) N % N % More 12 60 16 80 Less 2 10 1 5 Same 3 15 2 10 Did not 3 15 1 5 know X2= 2.10, p >.05

These patients attributed the majority of their suffering to schizophrenia; other sources of suffering included loneliness and isolation, disruptions to their sense of identity, dreams, responsibilities, as well as poor living conditions. Patient respondents also explained that they suffered more than people with no mental illness because their suffering was exacerbated by the triple burden of illness symptoms, social stigma, and lost opportunities. The few who said they suffered less than or the same as others indicated that they were trying to minimize the stigmatizing differences between them and non-mentally ill persons; indeed, some denied having an illness at all.

The following interview excerpts highlight the particular ways in which people with schizophrenia experience a degree of suffering unimaginable to people without

157 mental illness. First, and perhaps most obvious, is the experience of psychotic symptoms, which, as described in Chapter 1, can be so severe as to be traumatic. For example, when a patient was asked to describe how the suffering associated with his mental illness had affected him, he gave the following response: “I’m not much alive anymore.” Another patient said that auditory hallucinations connote greater suffering for the mentally ill:

I: Who do you think suffers more, you or someone without this illness?

P: People who hear voices will suffer more.

One outpatient described this correlation between hearing voices and suffering: “The times that cause me the most mental suffering is when I heard voices, and I’m happiest when I don’t hear them.” In the following interview excerpt another patient described the suffering caused by feelings of paranoia and suspicion:

I: Last time we talked, you said you suffered because of your brother’s death. You also suffer because you have to stay at the hospital and also when you can’t smoke. Which of these caused you the most suffering?

P: The fear that people might harm me and that I might harm myself.

The intensity of such illness-related suffering is exacerbated by both its pervasiveness and its persistence. For example, one patient said that his suffering overwhelmed virtually every aspect of his daily life:

I: Why do you think you had to suffer?

P: Because things didn’t go well, like in eating, wearing, going, coming.

Another patient described the persistence of his suffering and expressed frustration that his auditory hallucinations and suffering seemed beyond his control:

I: Have you suffered?

P: I have been ill. My head feels thick.

158 I: Do you suffer when you hear voices?

P: I don’t want to, but I can’t get rid of them. It upsets me. It’s noisy.

Another patient similarly described the overwhelming nature of not only her illness- related suffering, but also that of her medical treatment:

When the nurse gave me Artane7 my eyelids would shrink up and I don’t feel good in the chest. I can’t eat or sleep, I feel restless, and my head starts shaking. I suffer a lot. I told her to reduce the amount of medicine, to reduce CPZ to just two tabs because the medicines are so strong that I suffer from nerve disorders. Ma __ [another patient] has the same problem. We help each other so we can save our lives. I help her mostly. As for the sleep problem, I’ve got used to it already. I have had to take medicines for 15 years, 4 months, and 19 days [the length of time she has been an inpatient].

These excerpts provide compelling support for patients’ claims that they experience acute and chronic suffering. They also demonstrate the primacy of illness-related suffering over other sources of suffering; recall the patient whose suffering from symptoms of schizophrenia was worse than his own brother’s death.

For many patients suffering was synonymous with mental illness, which became evident in the terms patients used to describe both suffering and mental illness. For example, many patient respondents referred to their mental illness using both explicit and idiomatic terms of suffering, such as dokkha, sei’ hsin: yè: dei, weidana khan za: dei, or sei’ ma kaun bu (this literally means that one’s head is not good, but can also mean unhappiness). The association between suffering and mental illness became particularly evident in the additional, in-depth interviews that were conducted with a subset (n=10) of inpatient and outpatient respondents. For example, a patient alluded to this association when he compared suffering with a metaphor for mental illness: “suffering is like not

7 Artane is an antiparkinsonian agent used to control the side effects of antipsychotic medications.

159 being full in the head, like a pot without water.” Another patient even defined his illness in terms of suffering: “I’d say it’s [the illness] a lot of suffering.” This subset of patients so closely linked the experience of suffering with that of their illness that seven out of ten patient respondents believed that their suffering would end if their mental illness was cured and they would be able to resume a normal life. As one patient explained:

I: If your illness was cured, would you expect your suffering to also end?

P: To a large percentage, yes. Then I’ll be able to do things.

I: What things?

P: Like I can do whatever I want without any health problems and I’d be more sociable.

This response, echoed by other patients, speaks to the impact suffering and schizophrenia has on patients’ general functioning and quality of life.

Isolation and loneliness were other sources of suffering for patients. Inpatients, in particular, described how they suffered because living at YMHH forced them to be isolated from their family and home environment. Patients stated that this separation exacerbated their illness symptoms and degree to which they suffered. An inpatient explained: “If my sister can’t take care of me, I have to live like a crazy person, but if she can take care of me, I can live like a normal person. Here in the hospital . . . I feel scared.

The mind inside gets scared.” Reiterating this desire to be with family, another inpatient said: “Those in my room also suffer like me. They want to go home.” Many patients reported that their illness would improve if they could only return home. An inpatient said that she felt better when she was home with her family: “There’s nothing wrong with me if I can stay at home.” Another inpatient reiterated this belief: “I get well when I get to go home. I suffer more if I’m locked up.” Another inpatient stated simply, “I suffer

160 because I want to go home.8” The longing to go home was especially acute for long-term inpatients. Having witnessed the intake and release of numerous other patients, these inpatients knew that they would most likely never leave the hospital. Indeed, an inpatient said: “My parents said I’ll be left alone here when they die.” One of the inpatients described how this knowledge made her suffer:

It [suffering] doesn’t happen to others. I think it’s because only I’ve been here long term in a malaria-ridden place. Some went home after one week at the most. They can be with their family in a nice place. I suffer more because I’m separated from my parents and relatives and don’t have anyone to look after me.

Although the hospital is, in fact, malaria-free, this patient’s choice of words illustrates her general attitude about the consequences of her confinement. Indeed, it was not uncommon for patients to refer to the hospital as a jail. For example, a patient said,

“Being here at this hospital jail. I can’t see my parents and my siblings.”

Referring to the hospital as a jail reveals that, for some patients, residence there was involuntary. For example, some patients were brought to the hospital without their knowledge: they were told that they were going to the pagoda or to visit a friend and, instead, were admitted to YMHH. An inpatient described such an experience: “About four, five months after my mother’s death, my sister became mean with me and brought me here without telling me where they were taking me.” Many patients reported that such involuntary separations only increased their sense of loneliness. Other patients lost contact with their families once they took up residence at YMHH. For example, after an inpatient had recovered sufficiently to be released from the hospital, he returned home

8 This phrase, “I want to go home,” was repeated so often by inpatients that the interpreter commented it should be the title for this dissertation.

161 where he found that his family had moved without telling him, and had not left a forwarding address.

Patients also described their suffering in terms of the general disruption the illness had had on their lives. This disruption was manifested in a diminished sense of self, an inability to live the kind of life they wanted, as well as frustrated expectations for the future. For example, patient respondents also reported experiencing heightened feelings of inferiority and social marginalization after the onset of their illness. Many patients said that suffering (in the context of their illness) made them feel “small” or “worthless as a person.” One patient said that suffering had turned her into a “rough person” and that she had “become a lowly person.” Similarly, an inpatient said: “I’d like to be a different person . . . I feel inferior.” Likewise, other patients said, “[When I suffer] I begin to take on the bad guy form” and “I feel like dying.” One outpatient described feeling like she had lost out in life. Another patient elaborated on this feeling of loss: “You become a lowlife. You become a person without money or a job.”

Patients also reported that beliefs regarding their suffering and kammic destiny had negatively affected their sense of identity. The presence of their mental illness indicated that they had committed bad deeds in a previous life, thereby suggesting that their character was morally deficient. (Indeed, as Skidmore points out (1999), the more severe the illness the greater the karmic debt is believed to be.) An outpatient explained:

“I feel as if I’m unlucky, and I think I suffer more than others. I try to come to terms with the past deeds as my sayas said.”

In particular, patients reported experiencing lost occupational opportunities. One outpatient described the impact of his illness as being “the end of the world.” For this

162 outpatient, his illness heralded not only the end of his career, but also the end of his success, both of which were important parts of his identity:

I: What would you say caused the most suffering in your life?

P: It was the time I realized I had this illness and that it was the end of the world.

I: So you really thought your life had come to an end when you had this illness?

P: Yes, I can no longer work and there’ll be no success.

Another patient stated that with the advent of his illness he had lost his ability to “get things done,” thereby losing some degree of control over the circumstances of his life:

I: Who do you think suffers more, you or someone without this illness?

P: Me, of course.

I: Can you give me an example?

P: I suffer of course when a normal person has a normal frame of mind and I am ill. A normal person can make things happen, but mentally ill people like us can’t do things at our will, can’t get things done. That’s suffering.

One inpatient explained how his illness had disrupted his ability to hold a job, which, in turn, affected his family’s ability to care for him: “I think people with mental illness suffer more. They have financial difficulties. There are people who their family can’t cope with and so dump them here [YMHH].” Another patient poignantly described how his illness had disrupted his chance at happiness: “All my life, I’ve never had any happiness. Something is missing.” These narrative excerpts further underscore the presence of and intense impact that suffering has for people with schizophrenia in Burma.

Related to the disruption in patients’ occupational lives was another significant source of suffering: disruption in their ability to make financial contributions to their family, as well as general socio-economic hardship. The majority of patients were from

163 lower-income backgrounds and meeting their basic needs had always been a general concern. For some patients, the suffering incurred because of their poverty overshadowed all other sources of suffering. For example, an outpatient said that his poverty-induced suffering was even worse than the suffering caused by his illness: “It’s [poverty] worse than the illness because it’s not easy to borrow money from others.” Other patients simply stated that suffering meant “not having money” or “being poor,” and one inpatient stated that suffering was caused primarily by “being poor, not having enough, not being satisfied. Conscious thoughts like that.” Conversely, these patients equated happiness with having these needs met. An inpatient reiterated this claim when she said, “If I get to eat what I want, have enough money to spend, be with Ko ___ [her lover], then I’m happy.” Patients reported that such disruptions to their pre-illness role as financial provider were sources of suffering and anxiety. An inpatient explained:

P: It’s [suffering] bad because of my mental illness.

I: So do you suffer because you have mental illness?

P: Yes. I’ve become crazy because of [her uncle]. They all bullied me, relatives from both my parents’ side. I’ve had to take it with my head down . . . They all knew I could earn a lot. But not anymore now that I’ve gone crazy. They had a hard time earning money. They kept citing prayers to ward off danger. They said they cited the prayer to make my illness get better, to make the financial situation better.

This particular manifestation of suffering was especially acute for those outpatients with families to support. For such outpatients, their suffering was compounded by the responsibility they had to care for their families9. An outpatient explained: “I’m suffering

9 Outpatient respondents (25%) were more likely to be married and have a family than inpatient respondents (10%) (See Table 2.2, Chapter 2).

164 from ill health, so I can’t work and support my kids in education and get them where I want them to be, so it hurts a lot, for myself as well as for my children.”

For other patients the illness had disrupted their education and future opportunities. One outpatient described how she suffered because she could no longer continue her education:

I: Have you yourself suffered?

P: Yes, in education and the financial difficulties of my parents.

I: What caused you the most suffering in life?

P: When I have to do something against my will, like having to take the road I don’t want to…because of my health. It’s a hindrance to my studies.

Another outpatient described a similar experience:

I: What would you say has caused you the most suffering?

P: When I failed the exam in 2002, when I couldn’t study. And when I had to see the payoga saya…I was scared and having to take their medicines when there was nothing wrong with me made me suffer…The main thing is father. If he had allowed me to attend classes, I’d be fine in my studies and I wouldn’t suffer.

Patients indicated that such disruptions signified much more than an end to their education or ability to provide for their families. It also signaled an end to having a normal life and a sad relinquishing of their previous hopes for the future. It was, in the words of the outpatient quoted earlier, “the end of the world.”

Inpatients also consistently described the physical conditions at YMHH as a source of suffering, particularly for those living in the free rooms. These patients cited the crowded and hectic wards and shortages of food, water, and electricity as increasing not only the degree to which they suffered, but also their sense of loneliness and worthlessness. One patient’s words captured these shortages: “Here we suffer from a

165 food shortage problem. Even water is scarce, if there’s no running water. Sometimes we have to buy bottled water at 100 kyat each. It’s threatening our existence here.” One inpatient explained that because his family rarely visited and gave him money to buy food, he often went hungry: “I don’t have any money because my family won’t come here [to the hospital]. I’m always hungry because I don’t have the money. I drink water but it doesn’t fill the stomach.” Another inpatient elaborated: “Here you suffer. They feed us with food that dogs won’t even eat.10” Another inpatient described the general misery associated with living at YMHH:

The people in the room are so restless I feel like killing myself out of misery sometimes. I begin to feel down and out. I have never been in trouble before. Having lived in confinement for 15 years, I don’t want to be in this world anymore if the nurses won’t take me home.

When asked how she suffered, another inpatient similarly responded by describing the crowded conditions of the free room in which she lived, as well as her general lack of freedom:

I was allowed to walk outside only this morning [for this interview]. After being in a room a long time, we collide against each other and I have no space of my own, so I suffer. I wish I could look after and live forever with a doctor as soon as possible. I don’t want to live here.

The preceding narrative findings describe the many ways in which people with schizophrenia in Burma suffer. As Buddhists, it is, of course, expected that patients will state that suffering is a matter of course in their daily life. However, as a result of the unique suffering associated with schizophrenia, these findings appear to support patients’

10 YMMH psychiatrists admitted that many patients were suffering from malnutrition, skin infections, and vitamin deficiencies due to inadequate diet.

166 claims that their suffering is manifested more broadly and intensely than it is for non- patients.

C. Burmese Buddhist Means of Managing Suffering

The ways in which Burmese Buddhists manage their suffering were identified in order to ascertain if there were important differences between patients’ and non-patients’ coping strategies that might help explain the disconnect. Failure, on the part of patients, to participate in the struggle to end their suffering might suggest to other Burmese

Buddhists that they do not suffer at all.

In order to ascertain how Burmese Buddhists generally manage their suffering, and whether or not patient respondents attempt to overcome their suffering, the general coping strategies respondents utilized were identified (see Table 5.8); that is, it was reported whether respondents actively attempted to reduce or transcend their suffering, or simply tried to bear it. Specific methods respondents employed to manage their suffering, with particular attention to strategies utilized for illness-related suffering, were then examined. The majority of respondents (95% of inpatients, 80% of outpatients, 75% of family members, and 80% of healers) reported that they actively tried to reduce their suffering.

167 Table 5.8. How do you cope with your suffering? (N=100)

Inpatients Outpatients Family Members Healers (n=20) (n=20) (n=20) (n=40) N % N % N % N % Acts to reduce 19 95 16 80 15 75 32 80 suffering Bears suffering 1 5 4 20 5 25 3 8 Missing 0 0 0 0 0 0 5 12

It is noteworthy that patient, family member, and healer respondents took similar actions to cope with their suffering. The most common means of doing so was by carrying out a variety of Buddhist activities; these included upholding the precepts, counting beads, meditating, performing good deeds, and going to the pagoda.

Respondents said that they also turned to supernatural venues to help alleviate their suffering, including consulting astrologers, ahtet lan saya, or giving offerings to the nats.

Other coping strategies utilized by each respondent group included: acceptance and resignation that suffering was an inevitable part of life and a result of kamma; rationalization, that is, “others suffer more”; social withdrawal or distraction; and seeking counsel and support from family, friends, and healers. Patients also described how medical treatment was often an effective means of coping with their suffering. The few respondents who chose to bear with their suffering did so out of resignation—they figured that there was no escaping suffering despite their attempts to overcome it—and to avoid drawing attention to their distress. Many respondents used several coping strategies simultaneously or sequentially.

The fact that most respondents turned to Buddhism to reduce their suffering highlights and underscores the importance of religion for Burmese Buddhists within each respondent subgroup. Respondents explained that Buddhism helped alleviate the distress

168 they experienced in this life, as well as helped avoid or minimize potential suffering associated with their future lives11. For example, most patients, family members, and healers believed that doing good deeds in this life could help prevent more suffering in the next life. As one family member explained, “Some cope with music, entertainment, with family or religion. Suffering can be relieved in this life, but to be relieved of suffering in the next lives, we have to do religion.” Likewise, a patient explained that

Buddhism provided the only way to reduce suffering: “There’s no other person who can control or reduce suffering. There’s only Buddha.” Many patients said that actively pursuing Buddhist aims, such as those described earlier, gave them peace of mind and heightened their sense of well being; indeed, some patients found religion so helpful that they wanted to join the Buddhist clergy. For example, an inpatient explained why he wanted to be a monk: “To be rid of such sufferings. Because I’ve learnt from meditation that religion is one of the ways to reduce sufferings.” In contrast to non-patient respondents’ claims that the mentally ill lack insight into the nature of Buddhist reality, these findings illustrate that patients exhibit awareness of Buddhist doctrine and the importance of Buddhism in the context of suffering.

Respondents said that the practice of Buddhism was especially helpful when dealing with illness-related suffering. Indeed, patients and family members reported that their religious activities had increased with the onset of mental illness. For example, a patient explained: “It [the illness] won’t happen if I meditate, count beads, say prayers.

That’s also why I want to become a . I probably did something bad in my previous

11 Indeed, a psychiatrist reported that people who followed religious traditions other than Buddhism suffered more because they did not recognize the effects of their own actions on their suffering.

169 life for me to suffer in this life, so I have to do good in this life.” Another patient’s auditory hallucinations were manifested in the voices of monks and the Buddha urging her to do good deeds. These voices inspired this patient to practice Buddhism more regularly in hopes that it would help her overcome her illness and suffering12. Another patient described how reciting Buddhist reduced her illness symptoms: “Saying mantras prevents me from hearing voices. It also had to do with whether I’m happy or not. If I’m happy, I hear voices less.” Likewise, an inpatient explained how the practice of Buddhism made her feel better:

P: I never stop praying. I used to pray always at home.

I: Did it make you feel better when you prayed at home?

P: Yes. I felt better.

I: How?

P: At first I felt anger and ignorance. But when I prayed, I felt at peace as if I’d gone to neiban [nibbana]. When I felt that way, I didn’t want to come back to this life.

A family member explained how Buddhism helped her to cope with the burden of her son’s mental illness:

P: I say prayers in the morning, count beads, and I try to mediate when the surrounding is peaceful.

I: Why do you do these things?

P: For many reasons. For the things I suffered. Because of my son’s health condition . . . I suffered. And religion is the only way to cope with suffering. The only way to find peace of mind is by doing religion.

12 Skidmore (1999) also reports that Burmese psychiatric patients incorporated culturally familiar (Buddhist) images into their “delusions.” She notes that in the event that patients were unable to visit pagodas in person, they visited them in their dreams.

170 Practicing Buddhism also gave patients and their families hope that they might prevent the onset of mental illness in their future lives. For example, one patient said, “I meditate and pray that I will not be crazy in my next life.” These narrative excerpts particularly underscore the relationship between schizophrenia and suffering. For all patient respondents in this study, schizophrenia—like life for a Buddhist—was suffering.

Conversely, being free of illness symptoms allowed patients to experience happiness.

Patient respondents also reported that insight and mental discipline were essential for managing their suffering; they described how Buddhism (e.g., meditation, reciting mantras, practicing dhamma) helped them gain mental discipline, allowing them to better manage their illness and suffering. For example, an outpatient, who was also a practicing monk, described how Buddhism and mental discipline affected the course and outcome of his illness:

When the illness happens, you cannot control it if you haven’t prepared yourself well with religion . . . I accept the fact that meditation and practicing dhamma can control the illness. . . Religion says that you have to be ever conscious of everything. When you have the illness, you lose control. But if you can get complete control, the illness will go away. Mind is the most important thing. [Mental discipline] has a good effect. By having mental discipline, you avoid making mistakes, just like a normal person.

Another patient respondent explained how his illness improved or worsened depending on how much mental discipline he had achieved: “I try to have it, but I can’t really say I have full control of the mind . . . The more you practice to have concentration of the mind through meditation, the better it is. If there is less mental discipline, the illness gets worse and the suffering gets worse.”

Likewise, an outpatient said, “I feel better when I meditate and count beads . . . [mental discipline] helps control both [illness and suffering]. Because the thoughts are under

171 control, I don’t suffer too much and I don’t do bad things.” Another patient described suffering as losing control of his mind. Contrary to non-patient respondents’ claims that patients suffer because of a lack of insight and mental discipline, these examples indicate that patients suffer more when they lack awareness and control. Indeed, patients described how insight and mental discipline were important aspects of managing their suffering and illness.

Many respondents also described managing their suffering by resigning themselves to its inevitability. They felt that their suffering was a result of their fate. An outpatient explained, “I take comfort in the fact that my kamma is bad, and that the reaction of my past deeds is not over yet.” As a psychiatrist said, “By accepting suffering as a fact of life, we can cope with it, stop it.” “It’s written that I’d be like this,” said a patient about his mental illness. “I take solace in that.” Another patient said, “Suffering is caused by bad deeds and the only way to reduce suffering is to accept that.” Likewise, a patient said, “I feel better when I manage to come to terms with the fact that I’m having a bad life now because of the bad deeds in the previous life.” A healer explained the virtues of resignation when he described how it helped him accept his mother’s death:

I: How do you cope [with suffering]?

H: My mother died in ’78. I loved my mother very much, but I felt better if I think that it’s not just my mother who died. Her fate was already written to have a short life. Even Buddha could not avoid death, that it’s fate. Fate decides what happens in life. You feel better when you think of it from a positive point of view. I always have this in me to make the best of the situation I’m in.

Respondents reported that kamma was a means of rationalizing their suffering and took comfort in the belief that their present suffering was somewhat beyond their control. For example, this woman described taking comfort from a fellow inpatient:

172 I: Who do you spend the most time with in the daytime?

P: With Ma ___. Some say we are like husband and wife, but I tell them we are more like mother and daughter. I spend all the time with her. When I say I want to watch TV, she comforts me by saying I will get to go home one day, and we are here for a long time only because of our past bad deeds.

However, respondents also described taking comfort in the fact that they had some control over their future suffering by doing good deeds and accumulating merit. This sense of responsibility was illustrated in the words of a healer:

I: What should you do to reduce the suffering in this life?

H: Like the saying “Look no further than within yourself if you wish to seek the truth.”

In their understanding of suffering and means of coping with it, patients, like other respondents, demonstrate consciousness of their own kammic responsibility for their illness and suffering.

Respondents also took comfort in their observations that other people suffered too. A family member respondent explained: “Find solace in the mind [by saying] ‘I suffer just like they do,’ and take solace in the fact.” Respondents described how the knowledge that suffering touches the lives of everyone reassured them that they were not alone in the experience. A patient explained this perspective on suffering: “I comfort myself in the fact I’m not alone in suffering, and that I shouldn’t wallow in misery. The illness was something that was beyond my control anyway.”

Other respondents tried to cope with their suffering by withdrawing from its source, either through social withdrawal or distraction. For example, family members described taking breaks from their caregiver roles. One family member explained that getting away from her sister for a brief time alleviated her suffering:

173 I: Besides praying to Buddha what kinds of things do you do to make your suffering go away?

FM: Mostly I pray to Buddha but at other times when it’s still light I go off to the other end of the area and buy food, go on an eating spree.

I: Do those things work for you?

FM: Yes. Just to get away from her [her sister, an outpatient], it’s a relief from suffering.

Another family member described taking similar actions:

I: When you suffer, do you usually bear it or try to cope with it?

FM: I don’t do anything if her illness doesn’t get worse, but when it does I get away from the house. Lucky I’m in the family business because it wouldn’t do if I were working for someone else.

Other respondents distracted themselves through work, entertainment, or substance use

(usually alcohol). A patient explained how she distracted herself from her suffering:

I: What do people do to cope with their suffering?

P: They turn to something to take their mind off it. For me, I pray, read a book, or do some crochet.

Likewise, a family member described immersing himself in his work:

I: When you suffer, do you just bear it or do you try to do something about it?

FM: I try to find ways like losing myself in work, so it’ll take my mind off everything else. When the work is done, and I manage to stop thinking about it I feel better.

An inpatient also described the healing power of work:

I: How can regular work prevent suffering?

P: Working can calm the mind and make things happen, like vegetable patches.

I: Does watching your creations give you happiness?

P: Yes.

174 As many of these respondents indicate, multiple coping strategies were carried out simultaneously; that is, in addition to distracting themselves, many respondents also carried out religious activities. These findings also show how patients, like other respondents, made conscious choices about how best to cope with their suffering.

Patients also described their medical treatment as an effective means of coping with their suffering. Patients explained how medication and ECT helped alleviate their illness symptoms, which, in turn, reduced their suffering. A patient explained:

I: Do you cope in the same way for all kinds of suffering?

P: I cope with it in the same way. I take a bath, and take medicines.

Likewise, an inpatient responded:

I: What do you do to relieve your suffering?

P: I just take medicines. I take shots.

As described earlier, many patients described the combination of religious healing and medication as the most effective means of managing their suffering13. A patient explained: “In my case, I keep faith in Buddha. If it’s the bad deeds catching up with me,

I have to rough it out or do yediya or take medical treatment after finding out the one who has done black magic on you.” As illustrated in the following excerpt, patients’ reliance on medication to relieve their suffering took on the tone of religious fervor: “People rely on Buddha and on dhamma teachings . . . I have to rely on Buddha and Artane. I have to pray so a kind nurse will give me Artane.”

13 Skidmore (1999) also reported that psychiatric patients associated the combination of Buddhism and Chlorpromazine with good health. She argued that it was the sedative properties of psychiatric drugs that the patients most appreciate.

175 Patients also reported that certain elements of their treatment were critical for overcoming their illness-related suffering, because these aspects of their life helped facilitate self-control, discipline, and awareness. For many patients, this was one of the most important results of taking medication—medication helped to clear their minds, enhancing their awareness and allowing them to concentrate and control themselves “like a normal person.” A patient explained:

I don’t have control over my illness. Only the medication can control that. The medication helps me say prayers and without it I can’t sleep and I go crazy. Prayers and medicine make me feel better. I pray to Buddha and make wishes, then I feel lighter and suffer less.

Similarly, another inpatient stated:

P: The treatments like ECT help me cure the illness.

I: How do they help you with the mind?

P: I have less suffering. I have more tranquility and clarity of the mind.

Patients reported that having mental clarity or peace of mind helped alleviate both their suffering and illness symptoms. For example, an outpatient respondent said, “The illness would not have happened if I had peace of mind.” These states of mind represented the presence of mental discipline, a feature that many patients associated with improved illness course and the reduction of suffering.

For some patients, the most helpful element of their medical treatment was that it allowed them to maintain a predictable routine, which enhanced their sense of control and mental discipline. An inpatient explained:

I: Do you think you have mental discipline?

P: Yes, here [at YMHH], but not at home.

I: Why here and not at home?

176 P: Here, everything is done by the clock. At home there’s no one to command me to do things like take medicines or eat regularly.

I: Besides that, what else helps you to have mental discipline?

P: Reading magazines and watching TV help.

I: How does that help you have mental discipline?

P: It’s better to have self-control than having someone controlling me . . . Mental discipline helps me to do things as a routine.

Because they feared the loss of routine associated with life outside of YMHH, some inpatients were loath to leave the hospital even after they had recovered sufficiently to be discharged.

In contrast to most respondents who actively attempted to overcome their suffering, some claimed that they did nothing to reduce their suffering. Outpatients (20%) and family members (25%) were more likely than the other subgroups (healers 8% and inpatients 5%) to simply put up with their suffering. This finding can perhaps be explained in terms of the responsibility these subgroups felt for their dependents. A family member explained:

I: When you do suffer, how does that feel?

FM: I feel as if there’s a lump in the throat. I have to bear it because I don’t want to share my sorrow with another.

As will be described later in this chapter, many patient respondents deliberately hid their suffering to spare the feelings of others.

The means by which respondents chose to cope with or ignore their suffering illustrate how Burmese Buddhists gave meaning to their suffering. Members of each respondent group—patients, family members, and healers—took deliberate action to transform their suffering into something sufferable, no matter if their suffering stemmed

177 from hallucinations, poverty, or their continued place within the cycle of rebirth. What is significant here is that patients were just as likely as family members and healers to make attempts to transform their suffering into a more manageable and meaningful experience.

In doing so, they further demonstrated a marked presence of insight, mental discipline, and sense of responsibility that non-patients deny they possess.

D. Suffering, Feeling, and Affect Among Burmese Buddhist Respondents

It appears that differences in the experience and management of suffering cannot explain the disconnect. The possible roles that feeling and affect might play in explaining this finding were therefore considered, and the data examined with respect to two possible explanations: if people with schizophrenia suffer, as they say they do, then it appears there is either (1) a failure on the part of patient respondents to effectively communicate their suffering with others, or (2) a failure on the part of non-patient respondents to perceive patients’ suffering. The first explanation involved identifying cultural norms surrounding emotional expression among Burmese Buddhists and addressing a series of related questions: did people with schizophrenia express their suffering differently than others or in ways that were unrecognizable to other Burmese

Buddhists? If so, did the mentally ill believe that they expressed their suffering in recognizable ways, yet actually did not do so? Or, did they purposely and effectively hide their suffering so that it was truly not apparent to other people? The second explanation involved exploring the role that social stigma might play in influencing perceptions of suffering and schizophrenia. For example, did people have preconceived notions that caused a lack of communication with the mentally ill? Or did people have difficulty

178 empathizing with the mentally ill because they did not see them as sentient beings—in other words, as human—in the first place?

1. Burmese Buddhist Cultural Norms for Expressing Suffering

To answer these questions all respondents were asked if it was generally possible to tell whether or not a person was suffering (see Table 5.9) and, if so, how that suffering was expressed. In doing so, particular cultural norms for expressing suffering among

Burmese Buddhists were identified.

Table 5.9. Can you tell if someone else is suffering? (N=100)

Inpatients Outpatients Family Members Healers (n=20) (n=20) (n=20) (n=40) N % N % N % N % Yes 15 75 11 55 18 90 33 83 No 1 5 5 25 0 0 2 5 Did not 2 10 4 20 0 0 0 0 know Missing 2 10 0 0 2 10 5 12

The majority of respondents (75% of inpatients, 55% of outpatients, 90% of family members, and 83% of healers), regardless of respondent group, claimed that they could tell if someone else was suffering. Respondents reported that suffering was usually apparent through a person’s exterior presentation, namely facial expression and bodily comportment (unhappy facial expressions, poor hygiene, infrequent eye contact, and lethargic behavior). For example, a family member said that abnormal expressions and behavior were indications of suffering:

I: Can you tell if a person is suffering?

179 FM: Yes. His or her facial expression or his behavior is no longer normal. It may be erratic, or he may have a gloomy face, so you know something’s wrong.

I: What do you mean by “no longer normal?”

FM: When you are in the right frame of mind, you’re normal, but when something’s bothering you, you’re short-tempered and curt. It’s obvious.

A patient said that suffering became apparent when a person exhibited emotional distress, such as crying:

I: How do you know if a person is suffering?

P: It’s happening to someone near me [the patient in the next bed]. She’s crying all the time because her mother has not come. She says she’s brought here because her mother thinks she’s bad. It’s so upsetting.

Most respondents who said they could not tell if another person was suffering explained that people frequently hid their suffering so it was difficult to discern.

No qualitative differences existed in how patients, family members, or healers described expressions of suffering (although outpatients were more likely than respondents in the other subgroups to say that they were unable to tell if others were suffering). These results suggest that not only are there shared perceptions of how suffering is communicated in Burma, but also that people with schizophrenia are as capable as anyone at recognizing the cultural cues underlying these emotional experiences. If the mentally ill truly did not suffer, one would expect them to lack expertise in identifying visible modes of suffering.

2. Respondents’ Expressions of Suffering

Respondents were also asked if their own suffering was discernible to others (see

Table 5.10) in order to ascertain whether or not certain respondents were more likely to

180 express or hide their suffering than others. How patient respondents presented, or believed they conveyed, their suffering to the world was also explored.

Table 5.10. Can others tell if you are suffering? (N=100)

Inpatients Outpatients Family Members Healers (n=20) (n=20) (n=20) (n=40) N % N % N % N % Yes 10 50 11 55 12 60 8 20 No 8 40 7 35 6 30 10 25 Sometimes 0 0 1 5 0 0 2 5 Did not know 0 0 1 5 0 0 0 0 Missing 2 10 0 0 2 10 20 50

Fifty percent of inpatients, 55% of outpatients, 60% of family members, and 20% of healers believed that their own suffering was visible to others. These data are in contrast to the earlier reports (see Table 5.6) by 75% of inpatients, 55% of outpatients, 90% of family members, and 83% healers that they could discern whether or not someone else was suffering. However, respondents’ descriptions of how they expressed their own suffering differed little from their general responses described earlier: most people said that they expressed their suffering through unhappy facial expressions and withdrawn behavior. For example, consider the following family member interview excerpt:

I: Can people tell if you’re suffering?

FM: I don’t know about others, but I observe others and if they’re suffering then I try to comfort myself that there are people who suffer more than I do.

I: Does it show on your face? FM: Yes, the mind and the body don’t connect, like sometimes I’d be miles away and would not even notice that the bus has gone past the stop I’m supposed to get off at.

A patient explained that his suffering was visible through his anger and tears:

181 I: Can people tell if you’re suffering?

P: Not everyone, just my friends. They know I’ve been to the hospital more than 30 times. They can tell by my appearance.

I: How can they tell?

P: When I get angry, they know…When I suffer, I tend to cry.

Other respondents said that they neglected their work and withdrew from friends and family. For example:

I: Can people tell if you’re suffering?

P: Yes. I don’t look the same. I have a fallen face. I stop caring about people round me. I don’t feel like talking. I want to be alone.

Some respondents said that their suffering became apparent through unusual behaviors, such as mood change or self-neglect. For example, a family member respondent described how her behavior changed when she suffered: “The tone of my voice may even change when I suffer and I may not be quite civil.” A patient explained: “When I’m suffering, I won’t have a bath or clean myself.” Likewise, another patient said:

I: Do people know if you’re suffering?

P: Yes. I wouldn’t have the facial expression of a normal person. I’d look scared.

What is especially noteworthy about the data presented in Table 5.7 and the preceding excerpts is that patients, both in- and outpatients, were more likely than healers and almost as likely as family members to believe that others could tell if they suffered; that is, they believed that they were expressing their suffering in ways that were comprehensible and communicable to the general Burmese Buddhist community.

Patients also reported that they deliberately did not express their suffering: 40% of inpatients and 35% of outpatients reported that others could not tell if they were

182 suffering. As will be discussed in greater detail in the following chapter, it is culturally desirable in Burma to keep control over one’s emotions; excessive expression of emotion can be associated with immaturity, madness, and abnormality. Indeed, many of these patients said that they had deliberately hid their suffering to avoid these stigmatizing associations. For example, an inpatient described how suffering was generally expressed and why it was sometimes important to hide it: “The face is sad and it cries loudly and tells people he’s suffering. Kids do that. But I’m an adult.” Another inpatient described a similar distinction between immature and mature ways of expressing (or not expressing) suffering:

Before my friend died when we were young, she liked to wrestle, so I often cried because it hurt and caused suffering…it also hurt when she pinched me too. She also spit at my face and into the food and because I was only just growing up, so I cried like a child. I couldn’t suffer like a grown up [i.e., repress her tears].

Yet another inpatient said that she also hid her suffering, “because I feel ashamed … I don’t want to tell others about myself.” These interview excerpts illustrate the ways in which the mentally ill try to hide their suffering from others, as well as reveal some of the motivation behind these actions. Patients with schizophrenia in Burma are often acutely aware of the social implications behind expressing or hiding certain emotions, and therefore purposefully hide their suffering in an attempt to minimize their abnormal status, and thereby present a relatively normal face to society.

These data indicate that the mentally ill had more reason to hide their suffering from others, but the means by which they did so did not differ remarkably from other respondents. Patients were strikingly similar to non-mentally ill respondents in how they expressed their suffering: they cried, acted strangely, and withdrew. Even those respondents who tried to hide their suffering from others had similar reasons for doing so.

183 Many respondents, both patients and family members alike, stated that one reason for keeping one’s emotions, particularly distressing ones such as suffering, in check was to avoid causing additional worry. For example, one family member described how he kept himself from weeping after the deaths of his wife and sister in order to appear strong to his extended family. Likewise, an outpatient explained that he kept his suffering from his family because “I’m worried that they might suffer too.” Similarly, another outpatient said that he tried to keep his suffering from his family:

P: I feel a lot when my parents are suffering financially, but I don’t tell them how I feel. I just put up with it.

I: Why not?

P: They’re suffering too, so I’m worried that it might make it worse if I tell them I suffer.

Yet another inpatient said: “My parents don’t know I’m in pain, that I’m suffering.” In particular, patients reported the need to shield their families from their suffering because they felt that they had already caused enough distress as a result of their illness. Hiding their suffering was one of the few means at their disposal for helping ease the family burden of mental illness.

Patients also explained that they hid their suffering from others because they thought others would not understand or take them seriously. For example, an inpatient said that she carried on like a “normal person” when she suffered because she did not think other people would understand what she was going through. She said, “Everyone has happy or sad feelings, but I won’t say anything. I stay quiet.” Patients reported feeling this way because they believed their illness experiences were difficult for other

184 people to understand. Another patient explained that it was this feeling of difference that prevented him from sharing his suffering:

I: What happens when you do experience a lot of suffering? How do you feel?

P: I feel upset, depressed. My mind is unclear.

I: When you feel like that, can other people tell if you’re suffering? P: They’d only know when I tell them I’m hearing voices and that they upset me.

These excerpts show that even when their emotions are not visibly apparent, people with schizophrenia do experience feelings, such as suffering. Because of cultural norms regarding emotional expression (particularly in regard to their relationship to social stigma), family obligation, and illness symptoms many patients made very sophisticated choices about how and when to express their emotions.

Interestingly, many of these choices reflected great empathy—in addition to experiencing their own suffering, the mentally ill also indicated (as did other non-patient respondents) that they were capable of feeling, or imagining, the suffering of others.

Indeed, the reasons respondents gave for hiding their suffering often reflected this ability.

When patients were asked how they felt when they saw other people suffering, many explicitly said that they were empathetic. For example, with regard to the suffering of others a patient said: “I feel sorry. It hurts.” Other patients tried to make the sufferer feel better. Consider the following excerpt:

I: How do you feel when you see others suffering?

P: I feel sorry for them when I know why they are suffering and I try to comfort them as much as I can.

These narrative examples illustrate yet again that the mentally ill do suffer, not just from their own subjective experiences, but also because of their ability to relate to the distress

185 of others. This presence of empathy is especially ironic given previously discussed assumptions on the part of clinicians that people with schizophrenia lack the ability to establish an empathic bond with other people.

3. The Problems of Expressing Suffering for People with Schizophrenia

In order to capture more detail about the emotional life of people with schizophrenia in Burma, a subset (n=10) of patients were interviewed about their feelings and affect. The subset findings further attested to the deliberate choices patients made in regard to their emotions and their consciousness of being able to suffer. Patients in this subset said that they never had difficulties experiencing emotion, but they did say that their decisions to express their feelings were contingent upon certain circumstances. For example, the presence of a sympathetic listener, as well as manageable degrees of suffering and illness symptoms, facilitated patients’ desire and ability to express and share their feelings. As an inpatient indicated, patients were often accustomed to a lack of empathy in their social interactions. He explained: “I can express myself, like I’m expressing myself to you now. I want to talk to people who like me, not to those who don’t like me.” Most patients also believed that they had fewer venues to express their suffering. A patient elaborated, describing first someone without a mental illness, then someone with a mental illness: “There are two kinds of people: a person who others can console, who understand the reason for the suffering, who can share it; and a person who suffers on her own and can’t share it. They suffer more.” Other patients reported a similar perception that they could not share the burden of suffering with others.

186 Patients also explained that overwhelming suffering and illness symptoms made expressing their feelings difficult. These patients indicated it was easier for them to express their emotions when they were not also overwhelmed with feelings of distress. A patient explained: “I can’t express myself well when I suffer.” Another patient explained:

“[When I suffer] I don’t feel like getting along with them [friends and family].” Likewise, an outpatient said:

I: Does your attitude toward others change when you suffer?

P: I don’t like it when they’re around. I feel like I want to be alone.

Patients also said that other people’s dismissal of their suffering made them want to withdraw even more. An inpatient explained: “I don’t feel like talking to anyone when

I’m unhappy. I respond a little if they make positive talk, but I just wave my hand [in dismissal] when they make negative talk.” Likewise, troubling illness symptoms made patients fearful of sharing their personal experiences with others. They feared being misunderstood, harmed, or further marginalized. For example, a patient explained: “I can

[express my feelings] most of the time, but sometimes my thoughts are so strange that I cannot make myself understood.” Another patient reiterated this challenge when he explained that he sometimes hid his feelings from others because “some thoughts are so bad I can’t tell people.” An outpatient explained that his suspicion toward other people prevented him from sharing his feelings with others. He chose to keep his feelings to himself out of fear that others would use them to cause him harm:

I: Do you feel you can express your feelings, or are you a person who has trouble with expressing your feelings?

P: Yes, when I’m all right, but not when I’m ill.

I: Why was it hard for you to express your feelings when you were ill?

187 P: Because I was suspicious of people.

I: But when you’re ill, you still have feelings, but you were not able to express your feelings?

P: Yes.

These data serve as a powerful counterpoint to the idea that the mentally ill do not suffer; they also suggest that because of patients’ fears concerning sharing their feelings they may not receive help in times of acute need.

The following example further illustrates how preconceived notions about mental illness and emotion, as well as a general lack of communication with people with schizophrenia reinforce the disconnect between patients’ experiences and social perceptions of suffering. At the YMHH, during a weekly meeting, one of the psychiatry residents presented the case of a 33 year- Buddhist male who had been arrested for stealing a car. The police had brought him to the hospital for evaluation after he exhibited signs of mental illness—visual hallucinations, and delusions of grandeur— while in jail. The resident gave the particulars of the patient’s personal and medical history, after which the patient himself entered the room. The patient stood in front of the seated psychiatrists. He seemed eager to please, as well as anxious and agitated. When the psychiatrists began to question him, the patient started to cry, complaining that ghosts with long hair had followed him into the room. As the psychiatrists debated the patient’s diagnosis, it became clear that many of them believed the man was lying about his symptoms in order to avoid returning to jail (a psychiatric diagnosis would gain him entry into YMHH rather than jail). To help determine the veracity of the man’s claims, one of the doctors presented the patient with the following scenario: he told the patient that if he was truly mentally ill he would have to stay at the hospital for six years and undergo

188 various treatments, including ECT, whereas if the patient would admit that he was not mentally ill he would go to jail, but only for one year. The patient continued to cry and said that the most important thing was that he receive help and medical treatment. This response caused the doctors to laugh and reinforced their opinion that the man was lying: they explained that the ability to express such deep emotions, particularly with acute insight into the nature of his situation, indicated that the patient was just faking the whole thing.

The point of this story is not whether the man was mentally ill or not. Instead, this story illustrates how prejudicial notions about mental illness and emotional expression could interfere with a patient’s ability to effectively communicate her or his suffering. An outpatient explained that it was this communication gap that prevented him from sharing his suffering with others: “They don’t believe me, they just say I’m saying all this because I’m crazy.” This disregard was echoed in the words of another patient as he described feeling marginalized by his friends and family: “They regard me as a crazy person. They have marginalized me . . . my family never accepts whatever I say.” A statement made by a healer, cited earlier in this chapter, provides further basis for this patient’s complaint: “A schizophrenic cannot feel sorrow or happiness. Mood flat. Some would be giggling and laughing at their mother’s death, although they’d say they’re sad”

[emphasis added]. Byron Good (1994:9) has written that without an empirical referent— in this case being a culturally acknowledged means of feeling and affect—“the very meaningfulness of the complaint is called into question.” Here, it is the very presence of suffering that is called into question.

189 As indicated throughout this chapter, the data did not support the belief held by non-patient respondents that the mentally ill do not suffer. Neither did the data support the idea that cultural norms regarding emotional expression were responsible for this belief. Instead, the data show that the mentally ill express their suffering in the same way as members of the non-mentally ill population. Likewise, they hide their suffering with similar frequency and for similar reasons as other people. These results do indicate, however, that social stigma plays a role in how the mentally ill expressed their suffering and how others perceived their suffering. Patients described how healers and family members consistently ignored or disregarded their suffering, which impacted their desire and ability to share and seek help for their suffering. Healers and family members interpreted patients’ reticence to express their feelings as further evidence that they did not experience a normal range of emotion. These findings suggest that this interpretation, along with the preexisting belief that people with schizophrenia do not suffer in the first place, may compromise non-patient respondent’s capacity to empathize with the mentally ill and perceive them as fully human.

E. Summary

The fact that patients in this study say that they are able to feel and express suffering, and, indeed, claim to experience it more intensely and more expressively than others indicates that there is a major disconnect between the experience of mental illness and how others perceive the mentally ill. This disconnect cannot be explained by differences in how the mentally ill and others cope with suffering, nor in how they express their feelings or perceive the affective displays of others. The data does suggest,

190 however, that this disconnect can be partially explained by both preconceived notions of the mentally ill (i.e., that they lack an emotional life and the ability to express emotion) and a general disregard for their distress. In the following chapter, further explanations and implications this disconnect has for people with schizophrenia in Burma will be examined, particularly in terms of their status and identity as human beings.

191 CHAPTER SIX THE ROLE OF SUFFERING IN BURMESE BUDDHIST IDENTITY AND ITS IMPACT ON THE EXPERIENCE AND PERCEPTIONS OF SCHIZOPHRENIA

Among Burmese Buddhists, suffering and the struggle to overcome that suffering are essential features of humanity; only when one has escaped the cycle of rebirth and achieved enlightenment−that is, is no longer human−does suffering, and the struggle to transcend it, cease to exist. Recall the family member quoted in Chapter 5 who said, “As long as you’re human you suffer.” Although these words were intended to speak to the inevitability of suffering, they also underscore the intrinsic link between suffering and humanity. Thus one possible resolution to the paradox described in Chapter 5 is that

Burmese Buddhists do not believe people with schizophrenia suffer because they do not fully accept them as human beings. This perception is reflected in the Abhidhamma

Pitaka,1 which states that if an individual is disabled then “people are not apt to accept you as a full human being” (Min 1987:9)2.

By definition, mental illness is an impairment of the mind. For Burmese

Buddhists, the mind (sei’), which is considered to be an integrated space of feeling, thought, and consciousness, plays an important role in constituting human identity. As

1 The Pali canon is the earliest collection of Buddhist canonical literature and was first set down in writing in approximately 25 B.C.E. in Sri Lanka. This canon, known as Tipitaka or The Three Baskets, consists of the , the , and the Abhidhamma Pitaka. The latter is known as the Basket of Ultimate Things or Truths and consists of seven volumes, which are generally credited as being the direct teachings of the Buddha. The Abhidhamma Pitaka is a scholastic elaboration of the Buddha’s teachings related to psychological aspects of life and the possibilities of the human mind, primarily through an analysis of the entire realm of consciousness (Guenther 1973; U Kyaw Min 1987; Sircar 1999; Thera 1998/1949). 2 Indeed, to be ordained as a Buddhist monk one must be free from any physical or mental disability (Gombrich 1988).

192 stated in the Dhammapada3 (cited in Way 2001:2), the mind is the basis for existence and enlightenment: “Mind is the forerunner of all mental states and the four aggregates of existence. Mind is their principal component. It is only through the mind that fulfillment can be realized.” The significance of the mind is further illustrated in a saying included in a Myanmar Ministry of Health (2003) pamphlet about mental illness: “When you lose your property, you have lost something. When you lose a part of your body, you have lost a great deal. When you lose your mind, you have lost everything.” Given the primacy of the mind in Burmese Buddhist ideology, it is possible that people with schizophrenia in

Burma are considered to be much more than mentally impaired—their completeness as human beings may be in question.

A healthy and able mind is a vital component of Buddhist existence, and might also be considered a building block on the path to enlightenment. Indeed, Rahula

(1974:42-43) defines enlightenment in terms of perfect mental health and the absence of mental illness:

When the secret is discovered, when the Truth is seen, all the forces which feverishly produce the continuity of samsara in illusion become calm and incapable of producing any more karma-formations, because there is no more illusion, no more ‘thirst’ for continuity. It is like a mental disease which is cured when the cause or the secret of the malady is discovered and seen by the patient . . . He who has realized the Truth, , is the happiest being in the world. He is free from all “complexes” and obsessions, the worries and troubles that torment others. His mental health is perfect.

From this Buddhist perspective, mental health is based upon the presence of a balanced, detached, and disciplined mind that is free from any mental impurities4 (Johnson 1993), a

3 The dates to the 5th century and is one of the volumes included in the Sutta Pitaka. 4 Mental impurities or defilements include greed, hate, delusion, conceit, speculative views, skeptical doubt, mental torpor, haughtiness, shamelessness, and lack of moral

193 state that facilitates successful adherence to important Buddhist principles, such as the five precepts and the Middle Path, and activities that can improve one’s kammic destiny

(Keawkungwal 1989; Rahula 1974). Mental illness embodies the opposite of those

Buddhist characteristics valued in terms of current and future existence.

Non-patient respondents’ observations that patients lack feeling, insight, and mental discipline suggest that these elements are essential features of Burmese Buddhist identity and therefore are prerequisites to suffering. Below the cultural significance of these features will be examined more closely to better understand why Burmese Buddhist respondents associate them with human identity, as well as the role they play in how

Burmese Buddhists perceive and interact with the mentally ill.

A. Features of Human Identity among Burmese Buddhists

Throughout the world, emotion is mediated by cultural norms (Jenkins and Karno

1992; Lutz 1988; Shweder and LeVine 1984), therefore deviation from cultural mores of feeling and affect is considered to be, at the very least, inappropriate and often a reflection of a more serious disturbance, such as mental illness (Jenkins 1996; Kleinman

1988b; Kleinman and Good 1985; Leff 1977; Nussbaum 1995). In such cases, Jenkins

(1996:79) explains:

Emotions are unusual or abnormal not because they are unrecognizable features of human experience but because they appear more severe or prolonged, and they often cooccur with an array of other behavioral or cognitive disturbances that (as a syndrome) are outside the range of culturally prescribed orientations in the world.

dread (Ames 1964). Indeed, insanity is one of the eight calamities listed in the Burmese wheel of life, a devotional prayer called The Awgatha. The other calamities are being mute, deaf, stammering, blind, crippled, lacking concentration, and feeble-minded (Nash 1965:114).

194

As appears to be the case among Burmese Buddhists, the identity of individuals whose affective displays fail to reflect cultural norms of emotion—because they are severe, prolonged, or apparently absent—is profoundly affected.

Ethnographic studies show in many parts of Asia cultural norms regarding feeling and affect are based in part upon the ability to control one’s emotions, particularly by minimizing displays of intense feelings (Caudill 1976; Kleinman 1980, 1982; Laderman

1991; Schwarcz 1997). In particular, these studies show how identity is shaped by how well individuals manage their emotions according to these cultural prescriptions. For example, Hildred Geertz (1959) showed that in Javanese culture a smoothed-out, external demeanor represented an understanding of and socialization into an idealized version of cultural identity. Similar results were found among the Balinese for whom identity was based upon how well a “person managed to hide traces of turmoil, distress, disgust, disappointment, shame, sadness, anger, offense, jealousy or envy” and “everyone is best served if all would ‘not care,’ ‘forget,’ the bygones and engage in a cheerful countenance” (Wikan 1989:302, 304).

Burmese Buddhist respondents also indicated the importance of emotional control and detachment when they defined the parameters of emotional cultural norms as consisting of neither too much or too little expression. For example, a healer respondent described the consequences of feeling too much: “There is a Burmese saying: ‘You do everything in moderation.’ If you feel too much about anything, you’ll have a breakdown.

You have to be careful.” A family member attributed her suffering to a similar failure to experience emotions in moderation: “[I suffered] probably because I had intense feelings.” Similar findings have been reported elsewhere in Burma (Bekker 1994;

195 Skidmore 1999, 2003). For example, Skidmore (1999:222) described observing a woman shouting obscenities in Burma, causing a friend to whisper that the woman could be mentally ill because “when she is angry, it shows on her face.”

The emphasis placed upon affective control in Burma reflects the importance of balance and detachment in Buddhist ideology. For Buddhists, balance is illustrative of the

Middle Path, which dictates moderation in all things, including emotion and its expression. The ability to maintain emotional control also reflects awareness of the central features of existence, namely dokkha, annica, and anatta (de Silva 1991; Thera

1970). For example, in strong emotions are considered to be just one symbolic aspect of life’s impermanence and therefore not worth holding onto. This perspective is summed up in the words of a Nepali song: “Even if you feel sorrow now, once you may be happy” (Desjarlais 1992:130). Similarly, in Goldstein and Tsarong (1985:28) describe how monks’ “detached affect” reflected “the dominant Buddhist value of non- attachment and non-dependence.” Lopez (2001:218-19) further illustrates the importance of emotional detachment in a Buddhist tale “of a dispassion that challenges the credulity even of the gods.” In a former life, the Buddha was a farmer whose son died from a snakebite:

[After the death] the family stood around the flaming [funeral] pyre, without any of emotion, causing , the chief of the gods, who happened to be passing by, to ask whether they were roasting an animal. When he was told that it was a human body in the fire, Indra asked if he had been an enemy. Told that it was not an enemy but the farmer’s son, Indra commented that the boy must not have been loved by his father. The farmer assured him that the boy had been very dear to him. When Indra asked why, then, he did not weep, the farmer replied that the boy had suffered his fate and that lamenting could not restore him. When asked why she did not weep, the mother said, “As children cry in vain to grasp the moon above, so mortals idly mourn the loss of those they love. No friends’ lament can touch the ashes of the dead. Why should I grieve. He fares the way he had to tread.”

196 A family member respondent described a similar response to suffering: “My sister died.

My wife died. I didn’t weep. I did what I had to do . . . because I know the law of impermanence.” These examples illustrate the consistent importance of emotional detachment among Buddhists from a wide range of cultural backgrounds.

The findings of this dissertation, in conjunction with these ethnographic examples, indicate that Buddhist notions of personhood and identity are to a large degree based upon the ability to successfully manage one’s emotions according to these culturally prescribed ideals of control and detachment from feelings, experiences, and ideas of self. These ideals have deep implications not only for one’s human identity, but also for one’s spiritual status: the maintenance of control and detachment affects one’s place within samsara (Min 1987). As (1982:48) explains: “Only through the destruction of all emotion, that is, by the attainment of detachment, can the cessation of rebirth and thus the end of suffering be attained.” The Dhammapada (cited in Plamintr

1991:103) similarly states: “Good is restraint in action, speech and mind. One should be restrained everywhere. He who is restrained in every way is freed from all suffering.”

If a smoothed out external demeanor is considered to be the basis for the ideal, normal Burmese Buddhist identity, then abnormality is defined in terms of extreme affective displays. For example, severe mental illness is frequently associated with irrationality and uncontrolled “savage” or violent emotion ( Laderman 1991; Lucas and

Barrett1995; Skidmore 2003). The absence of emotional expression is another indicator of abnormality throughout the world. For example, schizophrenia is commonly associated with flat affect, or blunted emotional expression (one of the negative symptoms), and this feature has been linked historically with diminished emotional capacity (Andreasen 1984;

197 Andreasen and Carpenter 1993; Andreasen and Olsen 1982; APA 2000). These associations are prevalent in Burma among healers familiar with the symptoms of schizophrenia, as well as the general population; neither that the mentally ill can express suffering in a culturally normative way. For example, a healer reported that people with schizophrenia do not suffer, because they show no outward expression of it:

“Normal people express suffering because they have emotions. For example, a normal person cries if her mother dies; people with schizophrenia wouldn’t cry so one can see that one clearly suffers while the other doesn’t.” Likewise, a Burmese psychiatry fellow,

Aung Thaw (2002: 84), described the lack of emotional expression he observed in

YMHH forensic patients with schizophrenia as evidence that they were incapable of experiencing strong feelings, such as remorse, about their criminal actions: “Most of the schizophrenic patients showed no emotional response to their behavior, thus many of them showed no regret.” (Interestingly, the sole forensic inpatient I interviewed told me that he believed he suffered more than other people because of the remorse he felt for murdering his father.)

Despite the cultural ideal of suppressing strong emotions among Burmese

Buddhists, people with schizophrenia who appear to lack a rich emotional life are not perceived as masters of affective control, as a monk who exhibits detached affect might be, but rather as devoid of any feeling at all—there is a difference between having emotions and consciously controlling them, and not having any feeling at all. Lutz

(1988:57) captures the importance of this distinction: “It is better, most would agree, to be emotional than to be dead or alienated.” Perceived as emotionally dead, people with schizophrenia are further alienated and dehumanized in Burmese .

198 Examples in the psychiatric literature also speak to the association of feeling (and suffering) with external indicators of emotion. Consider the following excerpts, the first from a prominent researcher (a clinical psychologist) of schizophrenia in the United

States, and the second from a well-known German psychiatrist:

Looking at things superficially, one might think that a person is better off no longer hearing voices or feeling persecuted. Indeed, one might think the patient is better off once he has lost his capacity to feel intensely. But the “burned-out” schizophrenic is an empty shell—he cannot think, feel, or act. The schizophrenic who hears voices can hope that medication will drive away the voices and that he can return to a relatively normal life. The schizophrenic with defect symptoms [negative symptoms] has lost the capacity both to suffer and to hope—and at present, medicine has no good remedy to offer for this loss (Andreasen 1984:62- 63).

If this absence [of feeling] is complete, as can happen in acute psychosis, the patient is fully conscious and orientated, sees, hears, observes and remembers, but he lets everything pass him by with the same total indifference; happiness, pleasure, something positive in which he is involved, danger, sorrow, and annihilation are all the same. He remains “dead with wakeful eyes”. . . This absence of feeling shows itself objectively in the patient not taking food, in a passive indifference to being hurt, burnt, etc. (Jaspers 1997/1963:111).

Jenkins (2004:44) speculates that the perspectives reflected in the excerpts above can be explained in terms of two analytic errors: “conflation of experience with expression of emotion” and “clash of perspectives between observer and subject—this is in fact a failure of intersubjectivity.” She also writes (ibid.:42) that “the perception that such persons [those with schizophrenia] do not have emotions may compromise their claim to human status.”

The findings presented in this dissertation illustrate that the capacity to feel is an integral part of being human among Burmese Buddhists, and that the ability to express one’s feelings in ways that reflect the Buddhist values of control and detachment is particularly indicative of an individual’s status as a socialized human being. Individuals

199 whose affect fails to reflect these cultural norms and values are therefore associated with inhuman characteristics. The following words from a healer respondent, which appeared in Chapter 5, clearly show how the mentally ill are associated with inhuman qualities— wild, bestial, lower on the kammic hierarchy than humans—because of the perception that they cannot feel:

The mentally ill don’t know suffering, or any feeling for that matter. It’s almost like they are animals but they live on the human level but are in another realm within that level due to their fate. They have no suffering. They are wild, but not as much as animals. They are between animals and humans.

This example further illustrates how the mentally ill are associated with reduced human identity among Burmese Buddhists and how this association shapes local perceptions of their ability to suffer.

Respondents also indicated that awareness of reality, as dictated by the presence of insight, was another important determinant of Burmese Buddhist identity. In Buddhist ideology this awareness is best known as insight (vipassana), which is a key to understanding and overcoming suffering. As stated in the , one cannot overcome suffering until one has insight into the nature of suffering and its cause. True insight for a Buddhist involves a state of deep awareness and understanding of the world’s . The Buddhist scholar, Lopez (2001:53-54), explains: “It is impossible to destroy the seeds for future suffering and rebirth until one understands the lack of self at a deep level of concentration . . . Using this concentrated mind to understand the absence of self produces a state called insight.” Insight is achieved through practiced mental concentration and discipline. This process allows one to gain control of the mind, to purge the mind of its impurities, and to prepare it for a heightened state of awareness. Spiro (1982:48) describes this process as “a state of calmness and

200 tranquility of mind such that all stimuli, both internal and external, are extruded from consciousness.” As essential features of Buddhist doctrine and practice, insight and mental discipline are important components of religious identity among Burmese

Buddhists.

From a psychiatric perspective—in Burma and other parts of the world—insight refers to a person’s awareness of her or his illness. For example, if a person with schizophrenia denies having an illness or does not recognize psychotic symptoms as abnormal, he or she is described as lacking insight (Amador et al. 1993; WHO 1973). The psychiatrist Karl Jaspers (1997/1963:419) provides further explanation:

The term “awareness of illness” is applied to the patient’s attitude when he expresses a feeling of being ill and changed, but there is no extension of this awareness to all his symptoms nor to the illness as a whole. It does not involve any objectively correct estimate of the severity of the illness or any objectively correct judgment of its particular type. Only when all this is present and there has been a correct judgment of all the symptoms and the illness as a whole according to type and severity, can we speak of insight, with the reservation that judgment can only be expected to reach that degree of accuracy attainable by the average, normal individual who comes from the same cultural background as the patient.

This “lack of insight” is a hallmark of schizophrenia, because it implies a disconnection with reality. However, in the Burmese Buddhist belief system, lack of insight also indicates a chronic inability to grasp or appreciate the fundamental features of one’s spiritual existence. A passage from a Burmese guide to insight meditation further illustrates this link among mental discipline, insight, and mental health (Ven. Sayadaw U

Janakabhivamsa 1985:77):

So long as the mind is defiled, a meditator cannot realize any mental process or physical process. Only when the mind is well concentrated on the object of meditation (either mental or physical processes), is it free from all kinds of defilements or hindrances. Thus the mind becomes clear and penetrative; so penetrative that it realizes the true nature of mental and physical process as they really are.

201 Non-patient respondents reported patients’ failure to understand the world around them, and lack of the mechanisms to do so, compromised their ability to suffer. They based their claims on the perception that patients’ illness symptoms overwhelmed their ability to attend to anything beyond their own subjective experience of hallucinations and delusions. Non-patient respondents described these symptoms as pathological impairments that prevented patients from attaining mental discipline and, consequently, insight. Patients were therefore perceived as incapable of realizing the true nature of reality, as well as their own inner experience. For this reason, some non-patient respondents described patients as being unaware of their own feelings, drives (including hunger), and attachments. Indeed, many non-patient respondents associated the perceived absence of these features among the mentally ill with the loss of a “normal self” and “true consciousness.” For example, a healer (a payoga saya) said that it was this lack of a normal self that explained why the mentally ill did not suffer. “Their normal self is gone so they don’t even feel cold or hunger.” Because of its essential role not only in apprehending reality, but also in experiencing fundamental emotions it appears that for

Burmese Buddhists insight is a precursor to consciously experiencing many features of normal human existence and identity.

Burmese Buddhist ideas regarding feeling and insight appear to play a role not only in shaping a person’s current identity, but also their kammic destiny. Respondents reported that awareness of reality, as well as the ability to maintain emotional and mental control, were essential for carrying out Buddhist activities associated with increasing one’s merit and prospects of rebirth. They also reported that the mentally ill were unable to attain the state of mind or conduct activities important for one’s kammic future

202 because of their lack of feeling, insight, and mental discipline. As a psychiatry resident explained, “patients [with schizophrenia] do not have concentration so they can’t practice religion.” And an ahtet lan saya said that the mentally ill were unable to uphold the five precepts because of their lack of mental discipline. Indeed, each initiate into the monkhood must state “he is free from all defects, corporeal infirmities, and mental incapacities that would otherwise debar him from entering our holy state” (Shway Yoe

1963/1882:116). This perception of the mentally ill further damages their social and spiritual status. Consider the following description of among Shan

Buddhists:

The worst humans are those who do not practice religion and do not recognize their obligations. These are people in name only, tailless animals or people with the ears of animals. It is practicing the religion and recognizing obligations that makes people human (Tannenbaum and Durrenberger 1988:126).

One could argue that many Burmese Buddhists also fail to recognize their religious obligations, but their identity as human beings is not affected as severely as persons with mental illness. As Shway Yoe (1963/1882:434) writes: “[The outcast] is the connecting link with the state of animals, the highest state of punishment. He is considered no better than an animal in thought; he meets with less tolerance in actual life.” It appears that there is a difference between choosing not to carry out certain religious duties and being unable to do so because of fundamental emotional and mental flaws. The ability to feel, think, and act according to ideal Buddhist values allows individuals to participate in the very human act of transcending suffering. In doing so, Burmese Buddhists affirm their traditional values and transform their own kammic identity, thus reflecting and preserving the Buddhist worldview.

203 B. The Impact of Dehumanization on the Experience of Schizophrenia

The previous section delineated how human identity is constructed among

Burmese Buddhists, particularly showing how social norms regarding emotional expression and mental ability play an important role in constituting that identity. We learned that these norms are important for determining whether or not a person is perceived as capable of suffering, and, in turn, their humanity. This section describes the practical implications of dehumanization in terms of how it impacts patients’ social interactions, as well as various elements of their health seeking actions and treatment experiences.

1. Buddhism, Stigma, and Social Interactions with the Mentally Ill

The following scene I observed during my fieldwork in Burma indicates how

Burmese Buddhists often behave toward the mentally ill. At a neighborhood teashop I observed a trio of young men who were smoking and drinking tea at a nearby table. A local man appeared, who had a reputation of being crazy (based on his disorganized appearance, eccentric behavior, and homelessness), and approached them. Although the young men had been laughing at the older man from a distance, they offered him food and tea from their table. He refused, only accepting a cigarette. Watching this scene unfold, I was struck by the dichotomy of the men’s mockery with their gesture of material generosity toward an elder; if the elder man had not appeared to be mentally ill, this lack of respect would have been especially remarkable in the eyes of other Burmese

Buddhists. In this case, however, because of his crazy-like demeanor, it appeared that no rules of social etiquette had been breached.

204 This element of mockery in Burmese interactions with the mentally ill has been reported elsewhere. For example, in the previous chapter it was described how psychiatrists laughed in response to a patient’s complaints. Skidmore (1999) similarly observed that mockery was a primary form of communication between Burmese psychiatric inpatients and hospital staff. On a tour of the psychiatric hospital she observed that the “superintendent leered at the patients, called out to them, and laughed loudly at them before turning back to the main building” (ibid.:229). She also reported that a visiting American psychiatrist was “surprised by the lack of compassion that appears to be shown to the patients by the staff,” and was, himself, ridiculed for “recommending the advantages of getting to know patients as ‘human beings,’ ‘individuals,’ and not necessarily medicating but talking” (ibid.). Puthu (1959:201) similarly observed that the majority of attendants at the Rangoon psychiatric hospital lacked “the attitude of kindliness and sympathy.” Mockery and apparent lack of compassion are also evident in an oft-cited Buddhist story in which a madwoman is publicly ridiculed and despised

(Plamintr 1991:60):

Demented Patachara, once beautiful and desired by many wealthy youths, roamed the city streets, naked and emaciated. People made fun of her and the street urchins threw stones and dirt at her. She suffered a great deal. No one could help her. No one ever wanted to.

Drawing on reports of child rearing in Burma that showed similar attitudes in parents towards their children (e.g., Hitson and Funkenstein 1959; Hitson 1969; Mi Mi

Khaing 1996/1946; Nash 1965; Spiro 1969), Skidmore interprets mockery in the context of Burmese psychiatry as a means of teaching patients correct social behavior by teaching them to hide any signs of deviance. While mockery may indeed function as a way of socializing psychiatric patients, it seems probable that stigma also plays a role here in a

205 way that it does not in parent’s interactions with their children. Erving Goffman (1963:5) explains that such stigmatizing attitudes result in the dehumanization and discrimination of particular individuals and groups:

By definition, of course, we believe the person with a stigma is not quite human. On this assumption we exercise varieties of discrimination, through which we effectively, if often unthinkingly, reduce his life chances. We construct a stigma- theory, an ideology to explain his inferiority and account for the danger he represents, sometimes rationalizing an animosity based on other differences . . . .

Such stigmatizing ideologies are reflected in a study of attitudes towards the mentally ill among Burmese basic health workers and schoolteachers in which the majority of respondents expressed the belief that the mentally ill should be isolated from the rest of the population (Nwe Nwe Aye 2002). Respondents explained their attitudes as resulting from a general fear of mentally ill persons, as well as fear that mental illness was contagious (also see Skidmore 1999). An earlier study showed that 92% of health assistants and nurses also believed that the mentally ill should be avoided and isolated for similar reasons (Swe Swe Win and Thu Ta 1990). These findings are especially notable as the majority of these respondents worked closely with the mentally ill. Some scholars have suggested that Burmese children are particularly taught to distrust anyone outside of their family (Hitson and Funkenstein 1959; Pye 1962), which might only exacerbate a general fear of those individuals who seem especially strange, frightening, and Other. For example, Pye (ibid.: 205) writes:

The child learns to look upward toward a social hierarchy in which all above are to be treated with complete deference; and he also learns to look outward from his immediate family to his relatives, his neighborhood, his village, on to distant strangers, and to feel that each cocentric circle is increasingly an area of danger.

It appears that the dehumanizing attitudes regarding patients’ status and identity compromise non-patient respondents’ capacity to empathize with the mentally ill and

206 regard them with true compassion. Instead, the mentally ill are regarded as objects of sympathy and pity, rather than as subjects of empathy and identification.

Such apparent lack of compassion in the context of Buddhism is described elsewhere by anthropologist Lindsay French (1994). In her study of Cambodian amputees, French expected that, in accord with the values of Theravada Buddhism, people in Cambodian society would treat the amputees with compassion. Instead, she found that amputees were viewed with fear and anxiety (ibid.:74):

Amputees in Site II elicited not a generalized anxiety about war but quite specific anxiety about personal safety: people were afraid of them. Amputees, in particular young male amputees, had acquired a reputation for violence, extortion, and theft, and tended to be given a wide berth. Amputees were almost universally looked down upon, but rarely regarded with compassion; their central experience was one of degradation and abandonment, by their leaders, their families, and the society as a whole.

French explains this paradox in terms of karmic theory, which dictates difference depending on where a being falls on the karmic hierarchy (also see Hanks 1976). As

Keyes (1983:204) explains: “Kammic theory not only explains those physical and social differences among humans that are apparent at birth (or that can be deduced to have existed at birth), but it also is used to explain conditions which emerge during the course of a lifetime.” As disabled individuals, amputees were perceived as existing lower on the karmic hierarchy than non-amputees, and were thus considered less capable of experiencing and expressing complex emotions and behaviors. The result of their degraded social and spiritual identity was that amputees were not treated in accord with

Buddhist values of compassion. The mentally ill in Burma are perceived by other

Burmese Buddhists in much the same light as amputees in Cambodia, that is, with fear, anxiety, disrespect, and as not fully human.

207 Despite such attitudes in Burma, however, I observed that the mentally ill were often treated well, not only within their care-giving environments, but also society at large (as in the tea shop example). On the one hand, Buddhist conceptions of human identity generate prejudicial notions concerning the mentally ill; on the other hand,

Buddhist ethics somewhat positively inform the social interactions between patients and non-patients. The findings of this dissertation also suggest that the kindness non-patients did show to people with schizophrenia was sometimes motivated not just by pity, but also by their own kammic concerns. Shway Yoe (1963/1882:433-34) argued:

[T]he “doctrine of kan (kamma) also accounts for the equanimity and callousness with which Buddhists view human misery and the taking of human life, notwithstanding the law which forbids the killing of even the smallest insect. They recognise apathetically the working out of inexorable destiny, and watch a man drowning in the river with undisturbed tranquility, for they are not called upon or even justified in stirring a hand to prevent it. You cannot combat manifest fate.

This ethical ambiguity among Buddhists has been described elsewhere. For example,

Kitagawa (1989) describes how Buddhist’s own spiritual strivings can interfere with ethical considerations. To illustrate this point, he describes a story in which members of a monastic community ignore a sick monk so they could focus on their own religious tasks.

He writes (ibid.:17) “monks were inclined either to strive for their spiritual growth at the expense of compassion (caring for others) or to give themselves to the work of caring for others at the expense of their own spiritual vocation.”

It is difficult to make sense of these apparently paradoxical attitudes toward the mentally ill. Do Burmese Buddhist’s attitudes of mockery and fear indicate a general lack of compassion toward the mentally ill, as French argued was the case regarding amputees in Cambodia? Skidmore remained undecided about whether or not the mockery she

208 observed was truly “callous and counterproductive,” but suggested that it served to silence patients’ actual illness experiences5. Patients themselves reported that they found such disregard for their experiences frustrating, hurtful, and isolating. From patients’ point of view, the failure to legitimize their suffering and human identity was a source of additional distress, which often accompanied a relapse in illness symptoms. Recall that in previous chapters patients described how suffering made their illness worse. As the psychotherapist Searles (1988/1961:108) writes, dehumanization is a source of great anxiety for people with schizophrenia:

If there is any single most basic threat to the paranoid schizophrenic person, it is, I believe that his identity will be reduced to that of only part of a person . . . rather than his being a whole person. There is the danger that his individuality may be submerged in symbiotic relatedness with the other person. There is the danger that his status in the world of fellow human beings will be reduced to that of an animal, a dead person, or an inanimate object. And there is, finally, the danger that, in the eyes of human beings, he may cease totally to exist.

A more general question one might ask is if it is even possible to feel compassion or empathy for a person who is perceived as a lower being, incapable of basic human functions, such as suffering. As Paul Farmer writes (1997:272): “The suffering of individuals whose lives and struggles recall our own tend to move us; the suffering of those who are distanced, whether by geography, gender, “race,” or culture, is sometimes less affecting.” For example, one recent study found that American college students were less likely to feel empathy for people whose distress was expressed most inconsistently with the cultural norms to which they were accustomed (Nelson and Baumgarte 2004).

The stigma surrounding mental illness only intensifies this distance. This distance is illustrated in a study of attitudes toward the mentally ill in Nigeria in which16% of

5 For example, Skidmore argues that patients learn to invalidate and ridicule their own experiences in order to appear cured and thus be allowed to leave the hospital.

209 respondents believed that the mentally ill should be shot and 31% believed that they should be forced to leave the country (Bintie 1970). A prominent example of the realization of this view occurred between 1940 and 1945 when over 200,000 psychiatric patients (approximately 70% of whom had schizophrenia6) were killed in Germany as part of Operation T-4—the precursor to the selective murder campaigns of Jews, homosexuals, and Gypsies during World War II—after doctors drafted The Law on

Euthanasia for the Incurably Ill (Aly 1994). These examples show how the process of dehumanization and the denial of suffering can jeopardize people’s well being and social status, as well as their lives7.

2. Dehumanization and the Ambivalent Role of Buddhism in the Treatment of Schizophrenia

The previous section revealed a thread of ambivalence running through Burmese

Buddhists’ social interactions with the mentally ill. Despite Buddhism’s emphasis on compassion, the mentally ill are instead frequently subjected to public mockery and disregard, as well as occasional kindness. How do these conflicting elements within

Buddhism—compassion vs. a dehumanization of the mentally ill—affect health-seeking actions for schizophrenia? In light of the consistent presence of mockery, apparent lack of

6 A more precise count of patients with schizophrenia is confounded because many were given less severe diagnoses by beneficent asylum directors who realized that these patients were the first to be killed (Aly 1994). 7 The same processes of dehumanization that underlie the perceptions described above have justified historical and contemporary attitudes regarding the ability of the mentally ill to suffer. For example, Warner (1994/1985) describes early European approaches to mental illness, when “the management techniques were those of animal trainers because the insane were regarded as bestial . . . the insane were left naked in the cold and damp because they were believed to possess inhuman resistance to the effects of the elements.” Warner claims such methods reflected not the moral degeneracy of the doctors, but rather the contemporary view that the mentally ill were morally impaired and, thus, inhuman.

210 compassion, and dehumanization in both social and therapeutic contexts, how likely is it that the holistic concerns of Burmese Buddhists with schizophrenia will be addressed?

Going back to the story described in the previous section, we find an analogy in the manner in which the homeless man was treated by the boys in the teashop and how patients are treated by their family members and healers. In each example, there is an element of ambivalence exhibited toward the mentally ill, illustrated in their simultaneously kind and cruel treatment. In terms of the treatment of schizophrenia, this ambivalence also appears in several ways.

We have learned throughout this dissertation that suffering plays a pervasive role in the lives of Burmese Buddhists with schizophrenia. Patients experience profound suffering as a result of their illness symptoms, existential concerns (both present and future), social stigma, erosion of social support, socio-economic hardship, lost opportunities, as well as concern about the impact their illness has on their families and communities. Patients therefore perceived treatments for their illness as most efficacious when they addressed their suffering and validated them as human beings. Patients stated that their illness and suffering were linked so closely that the eradication of one would help cure the other. A patient explained: “Only when my mental illness is cured will my suffering end.” Similarly, an inpatient stated: “I mean to say suffering will be reduced only when the illness is cured.” Another inpatient explained:

I: If your illness is cured, do you expect your suffering will end?

P: Yes.

I: Why do you think that?

P: After I’m cured, there will be changes in surroundings and situations, and that will end the suffering.

211 Likewise, an outpatient said: “I think that the less I suffer, the more I’m likely to be cured.” This link between illness and suffering led patients to interpret the treatment of their illness as a simultaneous, if indirect, means of addressing suffering.

Patient respondents consistently reported that Buddhism, often in combination with medication, was the most effective means of addressing both their illness and suffering. For this reason, patients claimed that their Buddhist activities had increased after the onset of their illness, and that the first healers they contacted for treatment were those who utilized religious therapies. (Indeed, monks were the most frequently consulted healers, after psychiatrists.) Patients gave several explanations for their belief in the therapeutic efficacy of Buddhism and religious healers. As described in greater detail previously in this dissertation, Buddhism addressed patients’ present and future concerns regarding their illness and suffering by enabling them to gain merit and counteract their kammic destiny. Patients therefore perceived Buddhist practices as a means of personal and spiritual transformation, which appeared to be largely absent in purely pharmacologically based treatments8. The transformative effects of Buddhism in the context of mental illness are also illustrated in the story of Patachara, the madwoman who was cured by the Buddha. While Patachara listened to the Buddha address the crowds, he said to her (Ven. Sayadaw U Janakabhivamsa 1985:56-58):

“Dear sister, be mindful.” Because of the soothing voice of the Buddha, the madwoman came to her senses. She then sat at the edge of the audience and listened to the discourse. The Buddha, knowing that she had come to her senses, aimed his discourse at her. Listening to the discourse given by the Buddha, the woman’s mind gradually absorbed the essence of the doctrine . . . thus she

8 Western medicine and psychiatry are generally considered to be empty of religious elements. However, Good (1994) claims that all forms of medicine incorporate elements of the soteriological and, in this regard, border the realm of the sacred. Also see Gaines (1982b) for the role of in the practice of Western psychiatrists.

212 progressively experienced all the stages of insight knowledge while listening to the discourse . . .Through her own personal experience of the Dhamma by means of mindfulness and meditation, the sorrow, worries, and lamentation she had totally disappeared from her mind and she became a “new woman.”

In this way, the context of Buddhism “provides a system of meaning for . . . Buddhists, for locating and understanding and even modifying their existential problems” (Tambiah

1985:103). Skidmore (1999) similarly showed that Burmese psychiatric patients gave their lives a sense of meaning by placing their illness narratives in the context of

Buddhist epics.

Patients also believed that it was necessary for treatments to address and alleviate their current illness, but also prevent the incidence of schizophrenia in a future life. As reported in Chapter 4 a subset of ten patients believed they would recover from schizophrenia, if not in this lifetime then the next. Despite this hope for recovery, many patients were anxious that they might be reborn with schizophrenia, and this apprehension figured strongly in their perceptions of the efficacy of their treatment. For example, one inpatient believed so strongly in the power of his treatment at YMHH, he said “I’ll come to the hospital if it [schizophrenia] happens in the next life.” Another inpatient reported that Buddhism, in conjunction with his medical treatment, would help prevent the future onset of suffering and illness:

I: Do you think you can prevent suffering in your next life?

P: If the nurses help me, yes. As for my next life, I already know. The monk who often comes to this hospital, and General Khin Nyunt [Burma’s former prime minister] told me that they’d make me a powerful figure so I won’t be inflicted with the disease, that I’d be a celestial being . . . .

These examples illustrate how Buddhist beliefs operate in tandem with patients’ hopes for recovery.

213 The preceding paragraphs reflect patients’ perspective that recovery involves much more than a cure from schizophrenia; patients explicitly evaluated the efficacy of their treatment in terms of how well it addressed their holistic concerns, which encompassed not only their illness, but also their suffering, minimized their feelings of isolation, and validated their personhood. As very few healers believed that their patients with schizophrenia could suffer, however, there was a failure within each health sector to attend explicitly to patients’ suffering and thus address their complaints holistically.

Despite this therapeutic failure, patient respondents reported that many healers indirectly addressed their suffering by expressing concern for patients’ general well being, such as providing food, clothing, and attention. In these situations, patients experienced the treatment of their illness as more efficacious than those they received from healers who were more dismissive and less compassionate. For example, when I asked a patient which healer had provided her with the best treatment, she told me it had been her psychiatrist.

She elaborated, stating, “He fed me, clothed me.” Despite complaints about the conditions at YMHH, many patients said that the staff showed them kindness, which helped alleviate their suffering. For example, a patient said: “The nurses keep me happy.

They offer me snacks, make sure there’s nothing lacking. They also comfort me.”

Similarly, another patient said: “Kind-hearted staff and friends can make me feel better if they talk to me.” As a patient stated, “It makes me happy when someone talks to me nicely.” For this reason, a patient said that his psychiatrist’s treatment was effective because he, unlike the patient’s family, listened to his complaints:

I: Does your family understand or help you?

P: Only some of what I say. They don’t believe me, they just say I’m saying all this because I’m crazy. I can only tell Sayagyi [her treating psychiatrist].

214 Just as disregard for their humanity negatively impacted their illness and sense of self, patients reported that social interactions that validated their existence had several positive consequences. For example, although patients reported that they withdrew from others during times of intense suffering, they also said that positive social interactions helped alleviate illness symptoms and overcome the suffering they associated with loneliness and social exclusion. Patients said that they felt better when others listened to them and took their suffering seriously. For this reason, a male inpatient commented that his participation in this dissertation research had been the most significant event of his life. When asked to elaborate, he said:

P: I’m proud of the fact that I’ve been interviewed by you. I’m glad. That’s all.

I: What about the interview has made it memorable for you?

P: Nobody has bothered to ask for an interview except you.

In a statement that evoked the desire for social interaction, as well as affirmation of his status as a full human being, another inpatient said: “I don’t like staying alone. Humans like to have company.” However, many patients, particularly inpatients, felt that they did not have enough contact with their friends and family, nor had a social network that gave them adequate emotional (or financial) support. This desire is notable given that each patient was rarely alone, whether living at home or at the hospital. (The only outpatient respondent who lived alone also worked every day in a busy office.) These findings indicate that there may be a correlation between severity of illness symptoms and social support. Other studies similarly show that social support for people with schizophrenia diminishes with impaired social and occupational functioning (Fenton & McGlashan,

1991; Ponizovsky et al. 2004; Semple et al. 1999), as well as severity of negative

215 symptoms (Mueser et al. 1990; Patterson et al. 1997). These data suggest that being attuned to patients’ suffering and providing consistent social support may be an important component of treatment for schizophrenia.

Patients described compassionate healers from each health sector; however, patients reported that religious healers, primarily monks, were most likely to conduct their therapeutic actions in accord with their expectations of efficacy. They described monks’ treatments as particularly beneficial because they were compassionate, minimized patients’ feelings of loneliness, otherness, and exclusion, and gave them an explicit means to address and overcome their suffering through the practice of Buddhism.

Patients reported that monks’ emphasis on dhamma as a form of treatment gave them both a sense of greater purpose (gaining merit, improving their kamma) and a heightened sense of their own agency in overcoming their illness and suffering. For example, a patient described how a monk encouraged him to do good deeds. In particular, patients reported experiencing a renewed sense of identity9 and hope for recovery10 during their encounters with religious healers. Another patient described her interactions with the monks who had treated her mental illness: “They made me feel better. ‘[They said] Don’t think about these things anymore [delusions]. Your sufferings are over. Now you’re a new person.’”

9 Others have shown that religion plays a central role in how persons with schizophrenia reconstruct their sense of self and recovery (Adler and Jenkins 2001; Mohr and Huguelet 2004). 10 The ability to instill hope may enhance patients’ sense of treatment efficacy; for example, in a study of hopelessness and psychosis, investigators suggested that feelings of hopelessness were associated with poor illness outcome (Aguilar et al. 1997; also see Good 1994).

216 Despite the importance of Buddhism for patients’ sense of their recovery, its role was less clear in the health seeking efforts of their family members. Family members believed, on the one hand, that Buddhism could help alleviate patients’ illness symptoms

(through the development of insight and mental discipline), and prevent the incidence of schizophrenia in a future life by means of merit accumulation; on the other hand, family members also reported that the majority of patients were unable to understand or practice

Buddhism in a way that made it an effective feature of their recovery. For this reason, family members carried out religious activities on behalf of patients, gaining merit that they could then transfer to the patient and improve their kamma (decreasing the likelihood of future illness), since they believed that patients were unable to accumulate their own merit. In doing so, family members said they were not addressing patients’ suffering, but rather their own suffering because their health seeking actions also helped accumulate merit for themselves11. A family member respondent explained: “According to the Dhamma teachings, I think [my] suffering can be prevented by helping other people who are suffering or helping mental patients.”

Like family members, many healers also believed that developing patients’ understanding and practice of Buddhism could help improve the course and outcome of schizophrenia. Two other studies of mental illness in Burma showed similar results.

These studies found that 88% of basic health staff (Nwe Nwe Aye 2002), 97% of health assistants, and 76% of nurses (Swe Swe Win and Thu Ta 1990) believed that Buddhism

11 Family members also reported that by performing acts of merit on patients’ behalf their merit might be transferred to the patients, thus helping ensure that they would be reborn without a mental illness. Collins (1982) and Obeysekere (1968) describe a similar of merit to help the karmic progress of deceased relatives.

217 was a helpful aspect of treatment for mental illness. Respondents explained more specifically that the development of insight, mental discipline, and a general understanding of the fundamental principles of Buddhism could help cure a patients’ illness and, in turn, help them develop their own means for overcoming their existential suffering (e.g., avoiding mental illness in a future life, being reborn into a better life). A family member explained:

I: Do you think practicing religion can help his [the patient’s] illness or your suffering?

FM: Yes. If you really understand the concept of impermanence, I think his illness will be cured.

Many healers (these were primarily religious and traditional healers, but did include some psychiatrists) reported that they prescribed Buddhism as a remedy for patients’ illness. A bedin saya said that she first treats mental illness using religious methods; only when those methods fail, does she suggest patients see a doctor and receive medication (that is, if the illness is a “normal” mental illness). Another family member, first cited in Chapter

4, described her belief that her husband might recover from schizophrenia if he could learn to meditate, thus gaining insight and mental discipline:

FM: But even as he meditates he says he hears voices. We’ve done all we can with medication, and this is the only option left. But if he can’t meditate, it looks like he’ll have to keep taking the medicines for the rest of his life.

I: What is it about the meditation that you think would be helpful for his illness?

FM: Buddha has shown us that even all tangible matters are impermanent, so I think meditation can help him see that the voices he hears are not real.

Her words speak to her faith in the curative nature of Buddhism, as well as her doubts regarding her husbands’ ability to truly make use of Buddhism to recover from schizophrenia. Other family members and healers frequently echoed these doubts.

218 Despite their stated belief in the curative effects of these features of Buddhism, most non- patient respondents made only halfhearted attempts to help patients develop them. In explanation, respondents said that few patients were actually capable of implementing

Buddhism in a practical way that would benefit the course and outcome of their illness or future lives. Recall the psychiatrist cited in Chapter 4 who said that people with schizophrenia could not practice religion because they could not concentrate.

Many family members and healers did not believe that patients could be permanently cured of schizophrenia and it is possible that this belief enhanced their ambivalence about cultivating patients’ Buddhist practices. (Other studies of beliefs regarding mental illness in Burma similarly show that few health workers believe that mental illness has a good outcome (Nwe Nwe Aye 2002; Swe Swe Win and Thu Ta

1990).) Some healers also stated that they lacked the time and resources to devote to this aspect of patients’ treatment12. However, respondents also indicated (and I observed) that some of these healers devoted more of their attention to those patients who could fully benefit from religion—those who they believed could suffer, such as patients with depression. For example, monks came to YMHH to perform the Kathina13 ceremony, after which there a procession of staff and patients to a nearby monastery. However, only

“settled” (i.e., not psychotic), male patients were allowed to join in the procession.

Indeed, when I first arrived at YMHH psychiatrists told me that I should study depression instead of schizophrenia because only the former could suffer.

12 A study of attitudes towards mental health care among Tibetan refugees showed that providers similarly perceived other (non-mental) health issues as more important (Mercer et al. 2005). 13 The or Robe-Offering ceremony is performed at the end of the rainy season for the benefit of local monks.

219 Given the central importance of Buddhism in recovery from illness and suffering, it is especially ironic that in the specific case of mental illness, these same Buddhist ideological understandings serve to undermine treatment by further marginalizing patients and their suffering. These explanations further reflect the ambivalent role of

Buddhism in the treatment of schizophrenia: as opposed to other illnesses and diseases, where these same family members and healers might prescribe Buddhism as an important and attainable treatment goal, it appears that in the case of schizophrenia religion is considered to be an important, but unrealistic aspect of recovery.

D. Summary

This chapter examined the apparent paradoxical failure on the part of Buddhists to acknowledge and legitimize the suffering of people with schizophrenia. It is argued that

Buddhist conceptions of human identity have a negative role in creating social prejudice regarding the mentally ill. Although Burmese Buddhists consider suffering to be an essential feature of human identity, they do not consider people with schizophrenia to be completely human, and thus not fully capable of suffering.

Feeling, insight, and mental discipline play a key role in constituting human identity among Burmese Buddhists. Respondents indicated that one’s humanity rests not only on the presence of these features, but also on how well one is able to utilize them to reflect the cultural norms and ideals of control and awareness. Non-patient respondents’ denial that people with schizophrenia possess these qualities attests to the dehumanization of the mentally ill among Burmese Buddhists. The fact that patient respondents actually are capable of feeling, awareness, and control, and attempted to

220 communicate those capabilities with others suggests that their status as non-humans interferes with others’ ability to recognize their true humanity.

This “failure of intersubjectivity” also reflects the influence social stigma and dehumanization have on the nature and meaning of social interactions between Burmese

Buddhist patients and non-patients, particularly with regard to the treatment of schizophrenia. It was expected that because so much of Buddhist doctrine and practice focus on transcending sufferingboth ordinary and existentialthat people with schizophrenia would be uniquely positioned and supported to address their illness-related suffering. It was therefore surprising to find that although patients described the importance of Buddhism for coping with their illness and suffering, Buddhism actually played an ambivalent role in the ways in which family members sought help for patients, as well as healers’ treatment methods. It appears that the unique ways in which Buddhism generally addresses suffering fail to be implemented in cases of schizophrenia, primarily because of the role it plays in generating stigmatizing views of patients’ identity.

221 CHAPTER SEVEN CONCLUSION

A. Summary of the Dissertation

The focus of this dissertation has been to explore the influence of Buddhist understandings of suffering on the experiences and perceptions of schizophrenia among

Burmese Buddhists. Through this exploration we learned that Buddhist doctrine and practice play an important role in how patients experience, interpret, and cope with their illness and suffering. As we learned in Chapter 4, patients and their family members usually first consulted religious or traditional healers because of these healer’s less explicit (and less stigmatizing) association with mental illness, and because of notions linking the etiology of schizophrenia with supernatural or kammic forces. Patients and family members therefore carried out religious acts of merit and obeisance, such as going to the pagoda, making offerings to Buddha and the nats, and praying or chanting, in hope that these actions would promote recovery from schizophrenia in the current life, as well as preventing its onset in a subsequent one. (Indeed, patients and family members reported an increase in their religious activities after the onset of the illness, which supports similar findings among other patients with psychotic illness (Kirov et al. 1998;

Kroll and Sheehan 1989; Neeleman and Lewis 1994).) These religious actions were continued even after other forms of treatments were sought. We also learned that many healers, particularly religious and traditional healers, prescribed religious duties

(following Buddhist precepts, meditation, performing acts of merit, etc.) as a means of treating patients’ illness.

In Chapter 5 the importance of Buddhism was further illustrated as a meaningful way of interpreting and managing suffering for Burmese Buddhists. Patients, family

222 members, and healers all described the ways in which they utilized Buddhism to address their suffering, particularly by carrying out a variety of religious activities similar to those described above. As in the case of illness, respondents also reported turning to supernatural venues to help alleviate their suffering, including consulting astrologers, ahtet lan saya, or giving offerings to the nats. Respondents also drew on the Buddhist notion of cause and effect (kamma) to explain and rationalize their suffering, and it was from this perspective that Buddhism helped address their future suffering. As a family member explained, “Suffering can be relieved in this life, but to be relieved of suffering in the next lives we have to do religion.”

Patients reported that Buddhism was particularly helpful for addressing their illness-related suffering. Pursuing explicitly Buddhist aims gave many patients peace and clarity of mind, helped reconstruct their identity, enhanced their sense of well-being, as well as their feelings of purpose and control regarding the current and future outcome of their illness. Because Buddhism promotes individual responsibility for one’s kammic destiny, patients experienced their participation in religious activities as a means of spiritual progression. However, many patients also explained that employing a combination of religious and pharmacological therapies was the best way to alleviate their illness-related suffering. For example, a patient stated: “People rely on Buddha and on dhamma teachings . . . I have to rely on Buddha and Artane.” Patients explained that medication helped facilitate mental clarity, concentration, discipline, and awareness, which enabled them to pursue their religious practices more effectively and thereby better address their illness and suffering. A patient explained:

I don’t have control over my illness. Only the medication can control that. The medication helps me say prayers and without it I can’t sleep and I go crazy.

223 Prayers and medication make me feel better. I pray to Buddha and make wishes, then I feel lighter and suffer less.

Other research has reported similar findings among Christians with severe mental illness, whose religious understandings of suffering helped them interpret and cope with their illness (Adler and Jenkins 2001; Bergstresser 2001; Favazza 1982; Gaines and Farmer

1986).

In Chapter 6 we learned of the role that Buddhist understandings of suffering played in perceptions of treatment efficacy. Patients reported that their health seeking behavior for schizophrenia was also motivated by the desire to eliminate their suffering.

Indeed, they believed that their illness and suffering were so integrally linked that the eradication of one would help cure the other. As a patient explained: “Only when my mental illness is cured will my suffering end.” Another patient similarly stated: “I think that the less I suffer, the more I’m likely to be cured.” This link between suffering and illness led patients to interpret the treatment of their illness as a simultaneous means of addressing their suffering. For this reason, patients perceived treatments for their illness as most efficacious when their aims were holistic. Patients also reported that religious healers, primarily monks, were most likely to conduct their therapeutic actions in accord with these expectations of efficacy. They described monks’ treatments as particularly beneficial because they not only addressed their illness symptoms, but were also compassionate, minimized their feelings of loneliness and exclusion, and gave them an explicit means to address and overcome their suffering through Buddhist practices.

Despite the importance of Buddhism in patients’ efforts to address their illness and suffering, we learned that it played a relatively ambivalent role in the ways family members and healers addressed patients’ health concerns. This ambivalence appears to be

224 largely related to a paradox that emerged, indicating that Buddhist understandings of suffering also influence social perceptions of schizophrenia. Although Burmese

Buddhists believe that suffering is a central feature of human existence and that every human being suffers, non-patient respondents perceived persons with schizophrenia as incapable of suffering, primarily because of a putative absence of feeling, insight, and mental discipline among patients. This paradoxical finding suggests the presence of a disconnect between the social perceptions of schizophrenia and patients’ actual experiences, particularly in light of patient respondents’ convincing and compelling narrative evidence to support their claims that suffering was a central feature of their lives.

In order to understand the existence of this paradox, the ways in which Burmese

Buddhists with schizophrenia suffer were described, and patients’ and non-patients’ methods and motivations for managing and expressing their suffering were compared.

Patients reported that suffering was a pervasive and persistent feature of their daily lives, and was primarily associated with their illness. They claimed that they not only suffered, but that they also suffered more than people without a mental illness. As described above, most respondents utilized Buddhism as a means of managing their suffering, and there were no remarkable differences in how patients and non-patients employed these religious strategies. Patients were just as likely as family members and healers to make attempts to transform their suffering into a more manageable and meaningful experience.

In doing so, they further demonstrated a marked presence of the very features that non- patients deny they possess. As Clifford Geertz (1973:104) explains: “The problem of suffering is, paradoxically, not how to avoid suffering, but how to suffer . . . how to make

225 something sufferable.” It appears that people with schizophrenia not only suffer like other people (perhaps more so), but they also participate in the struggle to make their life

“sufferable,” to transcend their suffering by infusing it with meaning, and attempt to overcome it by breaking free from samsara.

These findings also showed that people with schizophrenia express their suffering in culturally normative ways. Patients not only expressed their suffering in much the same way as non-patients, but also hid their suffering with similar frequency and for similar reasons as non-patients, primarily to protect overburdening themselves or others.

However, these findings did indicate that social prejudice played a role in how patients expressed their suffering and how others perceived their suffering. Despite patients’ efforts to convey their suffering to other Burmese Buddhists, these attempts were generally discounted or disregarded, which impacted patients’ desire and ability to share and seek help for their suffering. A patient elaborated: “They don’t believe me, they just say I’m saying all this [that he suffers] because I’m crazy.” Non-patients interpreted patients’ reticence to express their feelings as further evidence that they did not experience a normal range of emotion. In Jenkins’ (2004:44) words, there was a “failure of intersubjectivity” at work here.

In Chapter 6 the apparently paradoxical failure on the part of non-patients to acknowledge and legitimize the authenticity of patients’ suffering was further examined.

Here we learned that Buddhist conceptions of human identity appear to play a negative role in fostering prejudicial attitudes toward the mentally ill. Respondents indicated that humanity rests on the presence of feeling, insight, and mental discipline, as well as how able one is to utilize these features to reflect the Buddhist values of control and

226 awareness. Non-patient respondents’ denial that people with schizophrenia possess these qualities indicates that they do not consider them to be fully human. The fact that patient respondents actually are capable of feeling, awareness, and control, and attempted to communicate those capabilities with others suggests that their status as non-humans interferes with others’ ability to recognize their true humanity. These findings help resolve the paradox of suffering and schizophrenia: if the mentally ill are not fully human, then their assumed lack of suffering by non-patient respondents is not a violation of Buddhist tenets that human beings suffer. There remain very real consequences of this paradox, and the cultural prejudice it generates, for persons with schizophrenia in Burma.

For example, the dehumanizing attitudes regarding patients’ status and identity appeared to compromise non-patient respondents’ capacity to empathize with the mentally ill and regard them with true compassion.

In Chapter 6 additional consequences that these prejudicial attitudes had for patients were discussed, particularly in the context of their health seeking attempts. Like patients, family members and healers also expressed faith in the curative power of

Buddhism for illness, including mental illness. They reported that certain Buddhist practices, such as meditation, might alleviate certain symptoms of schizophrenia, as well as counteract patients’ kammic destiny. However, family members and healers disregarded and discounted patients’ complaints regarding their suffering, thus patients’ suffering often went unheeded during therapeutic transactions. Moreover, it appears that, in the case of schizophrenia, non-patient respondents’ actual attempts to develop patients’ understanding of and participation in Buddhist practices were halfhearted. Many of these family members and healers believed patients lacked feeling, insight, and mental

227 discipline and were thus incapable of conducting themselves as a normal Burmese

Buddhist might. Consequently, family members carried out Buddhist practices on behalf of patients; and healers devoted more attention to those patients they believed truly suffered. In light of patients’ reports that suffering pervades virtually every aspect of their lives—their subjective well-being, identity, social interactions and support, illness course, outcome, and treatment—the failure to address their suffering appears to be a consequential omission. Given the central importance of Buddhism in the recovery from illness and suffering, it is especially ironic that in the specific case of mental illness, these same Buddhist ideological understandings serve to undermine treatment by further marginalizing patients and their suffering.

The results of this dissertation indicate that Buddhist understandings of suffering have a large influence on the subjective experience and social perceptions of schizophrenia among Burmese Buddhists. It appears that these understandings both help and hinder patients’ attempts to make their life and illness experiences more sufferable.

These findings address a gap in current understandings of the relationship between religion and psychotic illness experience. In particular, this dissertation described how

Buddhist understandings of suffering influenced the subjective experience of severe mental illness, the construction of identity and personhood, the expression and meaning of emotion, the nature and meaning of social and clinical interactions, health beliefs, as well as patterns of health seeking behavior. This dissertation also serves as an ethnographic study of Burma’s mental health care sectors and explanatory models of severe mental illness. Given that suffering is a common and pervasive feature of a wide range of human experiences, the issues raised in this dissertation may also serve as a

228 paradigm for understanding the construction of human identity in other cultural contexts.

As a whole, this dissertation provides links among various subjects germane to anthropology, psychiatry, and psychology, including religious healing, ethnopsychiatry,

Southeast Asian studies, and health care utilization.

However, the results presented in this dissertation raise several questions. First, although this study examined patient claims regarding the role of suffering in the course and outcome of their illness, it is not equivalent to clinical evidence for this relationship.

Second, patients reported that intense suffering and social disregard for their suffering affected their outward displays of emotion. This finding raises questions regarding the meaning and function of the “flat affect” that is commonly associated with schizophrenia.

Third, it is unclear how specific the findings regarding the relationship between the construction of human identity and the marginalization of the mentally ill are to the context of Burmese Buddhism. Although further clinical and ethnographic research would be needed to fully address these questions, they are explored in a general way below.

B. The Role of Subjective Experience

A key to understanding the influence of Buddhist understandings of suffering was to delve into the subjective experience of schizophrenia and to present the narrative of patients themselves. Doing so not only allowed a group of people that is commonly marginalized throughout the world to have a voice, but also provided evidence for how important suffering is in the context of health, illness, and the construction of personhood. In particular, patients indicated that the subjective experience of suffering

229 played an important role in the course, outcome, and treatment of their illness. Based on these findings, and the work of other scholars (e.g., Awad and Hogan 1994; Jenkins and

Barrett 2004), it appears that the importance of subjective experience in shaping the experience of mental illness has been underestimated in the biomedical literature.

In anthropology, the interest in the subjective experience of illness is part of the call for “an anthropology of experience” (Gaines 1992; Kleinman 1992; Turner and

Bruner 1986) and “experience near” research (Wikan 1991). As a result of this experience-centered research, suffering has emerged as a focal point for study centered on illness and disease (Bakan 1968; Cassell 1991; Kleinman 1986, 1988a, 1995b;

Kleinman and Kleinman 1995, 1997a; Wikan 1989). Indeed, Kleinman and Kleinman

(1997b) refer to suffering as a "master subject." The emergent “anthropology of suffering”, in which this dissertation is situated, has become an important area of inquiry, resulting in several important and pioneering works that explore the personal, social, and political dimensions of suffering (e.g., Das, et al. 2001; Good et al. 1992; Kleinman, Das, and Locke 1997; Kleinman 1988a; Kleinman and Kleinman 1995).

This literature picks up a previous thread of scholarship that first began early in the 20th century. It was during this period in which phenomenological and psychoanalytic approaches to psychiatric disorders prevailed, and the inner life of persons with mental illness was perceived as an important factor in illness onset, course and outcome, and treatment (e.g., Kaplan 1964). With the advent of biochemical theories of mental illness, starting with the development of psychotropic medication in the 1950’s, pharmacological treatment became a more common treatment for schizophrenia, frequently replacing more time-intensive psychodynamic approaches to treating severe mental illness. With this

230 trend, the inner experiences of persons with schizophrenia became less important as an object of inquiry (Strauss 1994a, 1994b).

Although medication has transformed the lives of many people with schizophrenia, it has so far failed to be a magic bullet treatment. This failure has helped renew interest in the role subjective experience plays in a wide range of illness-related factors. In particular, there is growing evidence that subjective experience shapes several important clinical aspects of mental illness (Chapman 1966; Corin 1990; Cutting and

Dunne 1989; Hogarty et al. 1995; Jenkins and Karno 1992; Jenkins and Barrett 2004;

Leff and Vaughn 1985; Strauss 1994a, 1994b; Strauss and Carpenter 1981). The results of this dissertation support this link between subjective experience and the clinical findings of schizophrenia: patients described how suffering affected the onset, course and outcome, and perceptions of treatment efficacy. Although these data do not speak to the correlation between patients’ subjective reports and the clinical course and outcome of their illness, the fact that patients reported a correlation indicates that this area deserves further study. Given the ways in which schizophrenia can affect patients’ sense of self and identity (Corin et al. 2004; Estroff 1989; Searles 1988/1961), studies that further investigate the role suffering plays in the construction of personhood might be especially fruitful. As Fabrega (1989:286) writes:

[Understanding the self and schizophrenia] informs about culture because schizophrenia affects in a central way the integrated functioning of personal self- structures responsible for the production, regulation, and interpretation of cultural behavior. The study of persons with schizophrenic illnesses is thus a window through which one can look into and clarify basic properties of self-functioning.

In light of the importance of subjective experience in shaping illness experience, understanding the contextual meaning and impact of suffering—itself an important

231 feature of subjective experience—in the context of health and illness has the potential of benefiting clinical features of schizophrenia.

C. The Meaning and Function of Feeling and Affect

The findings presented in this dissertation show that patients with schizophrenia experience intense emotions in the form of persistent and pervasive suffering. This finding, in conjunction with several recent studies, contradicts earlier research that correlated lack of emotional expression with absence of feeling (Andreasen 1984; Jaspers

1997/1963). For example, Western psychologists and psychiatrists recently found that the flat affect associated with severe mental illness is misleading and that people with schizophrenia experience much greater emotion than others perceive (Earnst and Kring

1997; Kring and Germans 2004; Kring and Neale 1996; Silver and Shlomo 2002).

Indeed, there is some indication that people with schizophrenia actually experience more intense emotions than others do, particularly negative emotions (Myin-Germeys et al.

2000). What these previous studies leave unclear, however, is how people with schizophrenia believe they convey their emotional experiences1. The data presented in this dissertation help address this gap by describing how patient respondents believe they appear to the rest of the world—as intensely feeling human beings.

The ways in which Burmese Buddhist patients described how suffering affected their emotional and social experiences suggests that elements of the negative symptoms of schizophrenia may possibly be a self-protective strategy to minimize events that either cause distress, exacerbate other illness symptoms, or both (Barnett et al. 1996; Stampfer

1 One study, however, Kring (1991, cited in Kring and Germans 2004) suggests that people with schizophrenia are unaware of how unexpressive they appear.

232 1990). For example, Flack et al. (1999:3) suggest that “schizophrenia patients may dampen their own emotional expressions in an effort to control emotional feelings they have difficulty tolerating.” The following excerpt from a first person account of schizophrenia (Anonymous 1981:196) similarly indicates how social withdrawal may help reduce the distress associated with psychotic symptoms:

The largest problem I face—I think the basic one—is the intensity and variety of my feelings, and my low threshold for handling other people’s feelings, especially negative ones . . . I cannot share negative feelings other people have, because I am too sensitive to them; yet I can give a great deal of love and concern when I am protected against feelings like anger and cynicism.

Dr. Robert van den Bosch (1995:338) describes such strategies as a means of adapting to the outer world by protecting the inner world. He explains:

Schizophrenia occurs in the inner world and most people in the outer world fail to understand the inner necessity for reframing and neutralizing the incomprehensible and frightening experiences of this disorder. But the basic drive is a simple rule: self-protection comes first.

The Burmese Buddhist patients who participated in this dissertation research reported that they similarly chose to dampen the outward expression of intense feelings, such as suffering, in order to protect themselves and those around them. Of course, as described in Chapter 6, the particular norms and values surrounding feeling and affect among Burmese Buddhists surely play a role in patients’ decisions to express or withhold their feelings from others. Given the apparent role that suffering and social interactions play in patients’ experiences and expressions of emotion, further research into the subjective meaning and function of certain clinical features of schizophrenia appear warranted.

233 D. Human Identity and the Authenticity of Suffering

As patient respondents described throughout this dissertation, schizophrenia is commonly associated with feelings of fear, helplessness, anxiety, loneliness, and misery.

The suffering caused by schizophrenia can be so severe that the illness itself may be traumatizing, causing many individuals with schizophrenia to develop Posttraumatic

Stress Disorder (Hough et al. 1996; McGorry 1991a; Mueser and Rosenberg 2003; Shaw et al. 1997; Stampfer 1990; Williams-Keeler et al. 1994; Wilson 1988). Studies also show that schizophrenia intensifies other forms of suffering (Browne 1996; Cohen 1993; Heila et al.1999; Katschnig 2000; Kleinman and Kleinman 1997a; McFarlane 1995; Penn and

Martin 1998; Warner 1994/1985). Patient respondents provided numerous examples to support these findings. For example, patients reported experiencing intense suffering as a result of loss of identity, poverty, social stigma, separation from family, and frustrated dreams. This combination of suffering, both directly and indirectly related to schizophrenia, adds weight to patients’ claims that they suffer more than people without mental illness. In Burma, patients with schizophrenia experience an additional layer of hardship because their suffering is ignored, their status as human beings questioned, and their existential fate at risk of not only being subject to perpetual samsara, but also of being reborn with a severe mental illness.

The social perceptions that fail to recognize the authenticity of the suffering associated with schizophrenia are analogous to some clinical views of chronic pain. For example, Kleinman (1988a:57) describes how many clinicians doubt the reality of patients’ chronic pain:

If there is a single experience shared by virtually all chronic pain patients it is that at some point those around them—chiefly practitioners, but also at times family

234 members—come to question the authenticity of the patient’s experience of pain. This response contributes powerfully to patients’ dissatisfaction with the professional treatment system and to their search for alternatives.

Kleinman also writes (1992:170) that these patients’ reports of distress are frequently

“challenged and disconfirmed.” Jean Jackson (1992:143) elaborates on the ways in which the reality of pain is often challenged by showing how it is categorized according to notions of authenticity: “real pain,” “unreal pain” (somatized pain), “imaginary pain,” and “no pain” (malingering). She writes (1992:139-140):

Pain is invisible. We infer the presence of pain in someone else indirectly, from observation (e.g., a broken leg) or through communication from the sufferer— pain behavior. Pain behavior can be an attempt to communicate the experience of pain or the expression of affects—of suffering, of demoralization, of other feelings and ideas associated with the pain experience.

Kleinman argues that it is this intersubjective invisibility that makes chronic pain difficult for others to appreciate, understand, believe, and treat. For this reason, he describes how many clinicians deny the reality of patients’ chronic pain because they perceive it as “too extreme, too troubling, too difficult to control” (1992:180). We have seen how the suffering of Burmese Buddhists with schizophrenia is considered to be equally invisible.

However, in the case of schizophrenia, suffering is not considered problematic in the same way that chronic pain often is; the suffering of patients with schizophrenia is even more easily dismissed because it is less overtly apparent as a result of pre-conceived notions regarding their ability to feel in the first place. This perception may further obscure and impede patients’ ability and desire to communicate their suffering with others. As this dissertation illustrates, even when patients used the plainest language or

“pain behavior,” their suffering remained disbelieved by others.

235 As the Stanley Cavell (1997:95) asserts, any study of suffering must also include “a study of society’s silence toward it.” And Kleinman, Das, and Locke

(1997:xiii) argue that one of the most important questions regarding pain and suffering is

“how such suffering is produced in societies and how acknowledgement of pain, as a cultural process, is given or withheld2.” David Morris (1997) suggests that such an

“ideological blindness to suffering,” such as that described among Burmese Buddhists, operates on the principle of “moral communities.” Moral communities, a concept developed by philosopher Tom Regan (1991), describe a situation in which two groups exist in relation to each other, one with membership in the moral community, the other without. In Burma, persons with schizophrenia are denied membership into the moral community of Burmese Buddhist society, as well as into the global community of human beings. Kleinman (1992:170-171) refers to these communities as “local moral worlds” that construct “different intersubjective experiences of suffering [and] that construction turns on experiences of delegitimation and relegitimation.” Loewy (1991) similarly argues that the capacity to suffer is an underpinning condition of community. Patient respondents appear to have limited access to the local moral worlds in which their suffering is legitimized, and are therefore denied the opportunity to experience social transcendence from delegitimate to legitimate suffering.

Addressing these issues in the context of Burmese Buddhism is not only important for understanding local cultural processes, but also because it can help explain how individuals and societies confront the moral question of human identity. From this perspective, the issues raised in this dissertation may serve as a paradigm for

2 Spellman (1997) refers to the ways in which attention is brought to some people’s suffering but not others as the “economy of attention.”

236 understanding the construction and moral transactions of human identity in other cultural contexts. The suffering of the mentally ill has been discounted and disregarded as a result of their marginalization and dehumanization in a variety of historical and cultural contexts. Given this precedent, it remains unclear how specific the findings presented in this dissertation are to the context of Burmese Buddhism. For example, other studies also illustrate how religion has both negative and positive associations with mental health

(Koenig and Larson 2001), and, in particular, can generate and rationalize hatred and prejudice (Pruyser 1977). Further research, particularly ethnographic research among non-Buddhists, into the nature of such cultural and historical beliefs about suffering and schizophrenia would be needed to fully address this question. On the other hand, it is possible that the processes by which people define human identity have certain invariant features (such as the association among the expression of emotion, suffering, and humanity) that transcend specific cultural manifestations or descriptions. In this case, such future work might be valuable in identifying broader patterns by which social prejudice operates to marginalize individuals on the basis of their association (or lack thereof) with human identity.

E. Concluding Reflections

Understanding that the problem(s) of suffering cannot be approached from a universal perspective, but must be examined in its particular cultural context helps reveal an important subtext of suffering: in a given historical, religious, and cultural context it is believed that only certain kinds of people will suffer (sinners, committers of bad deeds, etc.). Understanding how individuals and ideologies justify or explain why certain people

237 suffer or do not suffer helps us better understand how these elements help define human identity. As Spellman (1997) argues, those whose suffering we take seriously are those whose humanity we take seriously.

The philosopher, Louis Lavelle (1940/1963), described suffering as an experience that pervades every aspect of life, as well as one of the most intense and acute states of being to which humans are subject. The centrality of suffering to the human condition indicates that further ethnographic research in this area, particularly in the context of religion, has the potential to illuminate the existential grounds of human identity and experience (Bowker 1970; Kleinman and Kleinman 1997a). Indeed, the sociologist, Max

Weber regarded the whole character and style of different societies as being determined by their (religious) understandings of suffering (Bowker 1970). As Komatra

Chuengsatiansup (2001:31-32) argues, the role of anthropology in investigating suffering is to unveil the social origins and structural sources of human misery. Because suffering profoundly impacts such a wide range of human experiences—whether due to poverty, violence, or illness—its study stands to shed important insight into anthropological studies of personhood, health and illness, and socio-political issues. In a world in which international aid organizations rank countries according to an "International Human

Suffering Index" (Kelley 1989), judges place definable limits on suffering damage awards in civil cases (Gilpin 1997), and lawyers calculate the degree of suffering for wrongful death claims (Glaberson 2001), the benefits of understanding and appreciating the cultural underpinnings of suffering would appear to extend well beyond the field of anthropology.

238 When the ability of a person to feel pain and suffering is questioned, what is really at stake is that person’s integrity and identity as a human being. In this dissertation research not only did the majority of non-patient respondents deny the ability of people with schizophrenia to suffer, but they also referred to them, directly and indirectly, as less than human: the mentally ill were often referred to as vegetables and lacking consciousness. Sadly, this perception further reinforces the stigma of mental illness in

Burma and negatively affects cultural conceptions of personhood among the mentally ill.

For example, I recall my first visit to YMHH. As I waited to speak with my supervisor, a man approached me and asked, “Miss, do you hate me?” Startled, I quickly replied, “No, of course not. Why would I hate you?” He responded, “Because I have a mental disease.”

This encounter reminded me of an interaction I had with an outpatient with schizophrenia during fieldwork I conducted in Cleveland, Ohio. During a conversation, he asked me:

“Do you think of me and care about me as a human being? I am a human, you know.”

These statements illustrate how the experience and perception of schizophrenia can produce anxiety about one’s status as a worthwhile human being. In turn, this dilemma leads to a quest for affirmation of one’s identity. As Kleinman (1992:190) eloquently writes, it is this affirmation of humanity that is vital to the practice of anthropology:

For when pain is configured as suffering, it evokes intractable, inexhaustible moral and spiritual questions that are worth pursuing to the extent we can better understand human conditions or provide assistance to sufferers, but which are as vulnerable to dehumanizing social scientific accounts as to biomedical ones. And here anthropologists of pain find themselves in an ethical position roughly similar to that of the clinician. For both, it is essential first to do no harm. For both, the moral requirement of engaging people who suffer is to struggle to transcend limited and limiting explanatory models so as to witness, to affirm, their humanity.

239 By contributing to anthropology's understanding of Buddhism, suffering, and schizophrenia, this dissertation helps illuminate the processes by which suffering shapes our sense of self, others, and the world. In doing so, it both witnesses and affirms the suffering and humanity of people with schizophrenia.

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