but inadequate role of the passive, melancholic female and her antithesis: that of the deplored voluble, ‘aggressive’, masculinised female counterpart.
When female depression swells to clinical proportions, it unfortunately doesn’t function as a role-release or respite. For example … ‘depressed’ women are even less verbally ‘hostile’ and ‘aggressive’ than non-depressed women; their ‘depression’ may serve as a way of keeping a deadly faith with their ‘feminine’ role (Chesler, 1996: 51).
Wetzel (2000) stands in agreement with Jennie Williams (1999) in arguing that in both the developed and developing world, conditions of oppression affect women living in patriarchal societies, such as Malaysia. These forms of oppression towards women include low status, poverty and exploitation, sexual violence and other acts of human rights violation (Barnes and Bowl, 2001; Wetzel, 2000). Other critiques have noted the relationship between mental distress and the oppression that marriage may impose on women, together with the escalated risk factor connected with the role of motherhood (Ramon, 1996; Ussher, 1991). This has accordingly resulted in a global bias towards a high risk of diagnosis of mental illness for women and their subsequent admission to institutional care.
Long term psychiatric intervention (based upon psychosexual theories) has been inappropriately applied to women throughout the world, when their real problems were poverty, violence and economics (Wetzel, 2000: 209).
Apart from the issue of gender bias, a further issue of interest for this study lies in the ethnic breakdown of admission rates during this period and subsequent decades. For example, in 1900 the Singapore asylums largely held Chinese and Indian migrants who formed the vast majority of inmates (Teoh, 1971). It is claimed that this situation continued over the next century and was comparable with other asylums in Malaya, such as in Penang (Tan and Wagner, 1971). The implications of continuing bias in this regard is considered in this study, in reference to patient admission at Hospital Tranquillity.
In relation to the issue of ethnic preponderance in contemporary psychiatric care in the West, a relatively small but important body of critique considers the issue of mental illness and the impact of migration and that of cultural dislocation, together with the effects of consequential separation of individuals from their supportive networks. Such analyses focus on the significance of ethnic bias of psychiatry in Britain where British-born men from African-Caribbean background have been predominancely diagnosed with schizophrenia (Nazroo, 1997; Rack, 1982). Furthermore, an interesting aspect of the escalated ethnic presence in psychiatric services noted in Britain, and which appears to hold significant import for modern Malaysia, is that subsequent generations are also at greater risk of diagnosis and hospitalisation, despite a level of familiarisation and acculturation in the adopted alien culture (Barnes and Bowl, 2001). This said, Ramon (1996) highlights the issue of class as being a further factor to consider along with ethnicity and migration. She argues that elements such as education and, presumably, upward social mobility can act as protective factors countering the effects of migration and cultural dislocation (Ramon, 1996). Suman Fernando (1995, 1999), however, draws a general conclusion of institutionalised racism encountering cultural difference; while others have considered the phenomenon in terms of actual illness and social stressors. In this vein Ajita Chakraborty (1991: 1208) condemns the ‘value-based and often racist undercurrents in psychiatry’ and goes on to note the fundamental tolerance of mental illness amongst families in India, with the inference that stigma is a persistent effect of Western colonial values. This in turn tends to corroborate the psychiatric assumption that most South-Asian psychiatric patients in Britain have a supportive family network and enjoy what Nazroo describes as a ‘protective culture’, having fewer mental-health needs than other immigrants (Nazroo, 1997: 7). Thus resonating with Teoh’s assumption that separation from ‘stable and emotional family support’ represented a significant risk factor for Indian male migrants in colonial Malaya (Teoh, 1971: 28).
Finally, in contemporary Britain Chinese psychiatric service users have equally been subject to stereotyping, in terms of the assumption that they enjoy a supportive and insular family network, leading to the relative abandonment of carers by the support services (Yee and Shun Au, 1997). In view of the Chinese diaspora and the issue of Chinese asylum admissions in colonial Malaya and Borneo, these latter-day assumptions may contain useful references in understanding the position of Chinese patients in the modern Malaysian psychiatric institution, as represented by Hospital Tranquillity (Kleinman, 1988b).
Back in nineteenth-century Singapore, Gilmore Ellis brought with him contemporary notions of therapeutic care that involved rehabilitative exercises, such as occupational labour; in keeping with British values of the day. These in all likelihood were gender normative activities, and for women revolved around the skills of the good housewife, and which are enacted on hospital wards to this day, as will be discussed further in Chapter Five (Gittins, 1998; Witz, 1992). Gilmore Ellis apparently diverted a considerable amount of Victorian energy and new enthusiasm to improving conditions for the mentally ill commensurate with up-to-date British practices:
In the first year he abolished strait jackets, got 87% of the patients occupied in one way or another, usually at rope-making or weaving in the workshops, instituted a new and better system of record keeping, prosecuted an attendant for ill treating a patient, and arranged for a Chinese Wayang to come and give entertainment (Murphy, 1971: 16).
In Penang, it would seem that such rehabilitative therapies had equally been introduced to patients there. A fascinating insight from a nineteenth century British superintendent who had served at asylums in both Penang and Calcutta stated that the ethnically diverse patients in Penang were far more amenable to ‘voluntary manual work’ than were the Bengalese patients or their Eurasian counterparts, in his experience (Ernst, 2010: 63).
In nineteenth century Singapore even the rudimentary after-care of discharged patients was not neglected; however, despite all these therapeutic improvements, Gilmore Ellis could not prevent a very high death rate from cholera and beri-beri amongst inmates. Acute cases with a rapid discharge rate were not typical admissions, as had been seen in the earlier Singapore institution. Now psychiatric chronicity and physical morbidity were the main characteristics of patients at the new asylum, a situation that would be replicated in the later running of psychiatric hospitals of colonial Kenya in the 1920s (McCulloch, 2001; Murphy, 1971). The high mortality rate caused by cholera and beri-beri epidemics ravaged the internee population. They were brought under control only to be subsequently replaced by syphilis and tuberculosis, so that the death rate was never below 20% and on occasions rose to 50% of admissions. Gilmore Ellis’s response was not complacent, where his own scientific investigations failed, saltwater baths and the curative effects of visits to the seaside succeeded in reducing the mortality rates quite considerably (Murphy, 1971).
In subsequent eras, these fairly benevolent regimes would be overtaken by new forms of treatment such as insulin coma therapy and lobotomy that, as Tai-Kwang Woon dryly notes, ‘did not bring any transient hope to the patients or stirred the enthusiasm of the staff’ (1971: 31). He goes on to note that medication was used to subdue and control patients, and where this failed, restraints in the form of strait jackets were applied. In the case of Hospital Tranquillity treatment included liberal uses of electro-convulsive therapy (ECT), supplemented by sessions of psychotherapy, under the therapeutic regime of the resident colonial alienist of the period.
Gilmore Ellis’s contribution to psychiatric care in Malaya can be seen to have been very much based in the tradition of moral treatment, whereby humane treatment and structured activities were seen to be a highly necessary component in achieving a ‘cure’. Unfortunately these early improvements were not sustained and deterioration in care in association with larger admissions began to take place (Teoh, 1971). In the West the loss of the earlier optimism towards effecting a cure for mental illness caused demoralisation amongst pioneering psychiatric professionals by the end of the nineteenth century (Shorter, 1997). This loss of vision could also be seen to be taking its toll on the standards of care even in the new Singapore asylum during this period. By 1909 Ellis had left
