THE INFLUENCE OF BURMESE BUDDHIST UNDERSTANDINGS OF SUFFERING ON THE SUBJECTIVE EXPERIENCE AND SOCIAL PERCEPTIONS OF SCHIZOPHRENIA by SARAH ELIZABETH ADLER Submitted in partial fulfillment of the requirements For the degree of Doctor of Philosophy Dissertation Adviser: Dr. Melvyn C. Goldstein Department of Anthropology 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 Religion 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. Buddhism, 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. Yangon 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. Colonialism 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 Ne Win Years (1962-1988) 84 5. Contemporary Psychiatry in Burma (1988-present) 87 B. Religious Healing in Burma 92 1. Buddhism and Healing 93 2. Supernatural Healing Methods 97 C. Traditional Healing in Burma 103 1. Indigenous Medicine 104 2. Divination 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 Perception 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 Psychiatrists 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 Myanmar 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