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Chapter 4 An Adventure in Mental Health Research:
Sarawak, Malaysia (1967-69)
The Initial Offer
Near the end of my stay at Allan Memorial, one of the professors, Dr. H. B. M.
Murphy, a Psychiatrist,
asked if I was interested in joining a group of mental health researchers in British
Guiana. At that point, I knew I could not return to the United States, because I
had to be out of the country at least two years, for immigration reasons.
Therefore, I considered the British Guiana offer, especially since everyone
held Dr. Murphy in such high esteem. An example of what people thought of him
can be seen in the following excerpt from a 1988 edition of SantŽ Culture Health
(Volume 2), written by one of our colleagues (and my great friend), Dr. Karl
Schmidt. He said about professor Murphy:
Honesty, diligence, originality, modesty, reliability, forgiveness:
These were the projections of this great man to me. Nobody has
inspired me more throughout my varied career and none has been
more loyal and forgiving whenever I let him down. The breadth of
his vision and influence on others and myself, on our thinking and our researches
is enormous even though personal meets were rare.
Accepting the Position of Field Psychiatrist
Under the influence of this exceptional man, I therefore started to seriously
entertain thoughts of going to Guiana. Unfortunately, though, because of the
potential political turmoil there, the research trip was cancelled.. I was, however,
soon offered a "replacement" research passage, to an exotic location -to
Sarawak, Malaysia-as field Psychiatrist.
The study there was being done in cooperation with Dr. Karl Schmidt, a
Psychiatrist, who was the director of the Sarawak Mental Hospital. The research
team was to study Sarawak's three main ethnic groups-the Malays, Ibans (Sea
Dayaks), and Chinese-and the research was to last two years (1967-1969).
I accepted this offer, but not before going to the New York Public Library Ñ
for the first time in my life-to research Sarawak. (Although I couldn't yet reside
in the U.S., I was permitted to go across the border and stay in the States for short
periods of time).
The origin of the study and my role in it were described by Karl Schmidt in
the above-quoted issue of SantŽ Culture Health:
With considerable support from Prof. Murphy, we were able to
obtain a large research grant from the F.F.R.P. [Foundations'
Fund for Research in Psychiatry] of Yale University which allowed
us to conduct the epidemiological Sarawak Transcultural
Psychiatric Research Project. . . .Through the efforts of Prof.
Murphy we also obtained the services of Dr. Tom Chiu for a period
of two years. Dr. Chiu and I became life long friends (we also share
the same birthdate!). Dr. Chiu acted as a field and research
psychiatrist, working alongside other expatriate scientists.
Before going to Sarawak, I stayed in New York City for a few months, where
my father, then a widower, was living. Mother had died in Lenox Hill Hospital, in
New York. My parents had come to New York to be near my brother and his
wife, who was giving birth at the time. I recall that my father and I went to see
"Faust" at the old Metropolitan Opera House, before it was torn down. He was
to live for many more years, dying in 1991.
A Brief Background of Sarawak
What was I getting into going to Sarawak? I certainly had been exposed to much
cross-cultural experience in my life, living in the Philippines, America, and
Canada, and being born and raised in China. But what was Sarawak like? And how
would I practice my profession there?
From my library research and talks with others, one of the first things I
remember about the history of Sarawak it that it was once known as the fabled
land of the "White Rajahs." The country was so-named because it was under the
benevolent rule of the English Brookes family for a century, from 1846-1946.
Sarawak was also popularly called "The Land of the Headhunters," because it
was once a warring country with uncontrolled piracy, where headhunting was a
way of life. That ended more or less, in 1841, when the adventurer, from Bath,
England, named James Brookes, was called upon by the Sultan of Brunei to put
down a rebellion by the natives of the state. As a reward for his successful efforts,
he was offered the state to rule. Through his totally relentless commitment to
govern with firmness and benign paternalism, Sarawak flourished.
Thus began the reign of the rajahs, which included Brooke's nephew and his
nephew's son, for the next 100 years, until 1946. At that time, the last rajah,
Charles Vyner, ceded Sarawak to England. Sarawak remained a colony until 1963,
when it joined the Federation of Malaysia, ending one of the romantic sagas of a
ruling family over a land that was foreign, intriguing and above all fascinating.
From the geography of Sarawak, I actually had reason to feel I would be
somewhat familiar with the terrain and culture, since Sarawak is located in
Southeast Asia, perched on the northern border of the island of Borneo, about 250
miles northwesterly of Australia and 200 miles south of China. In 1967, the time I
joined the study, the population was 902,941, divided mainly among the three
major ethnic groups we were going to study-the Ibans, the Malays, and the
Chinese, who collectively composed over 95 percent of the total population.
In the proverbial nutshell, here are a few pertinent facts I learned about them,
in researching my impending trip to Sarawak:
Iban. The Iban way of life had changed little for centuries. They lived in
longhouses on stilts along the upper parts of the rivers. The longhouse was central
to their way of life. One longhouse could have as many as fifty to 100 families,
each sharing a communal hall. In a study of privacy among the Iban, Patterson
and Chiswick found that, although the Iban lived in communal longhouses where
there was little physical opportunity for individual privacy, they used social
mechanisms to obtain privacy. This finding supported the idea of a system of
privacy.
Economically, the Ibans primarily planted hill-rice by shifting cultivation,
caught fish, hunted game, and kept some poultry and pigs. Basic schooling was
only being introduced on a countrywide scale in the longhouses. As a people, the
Ibans were industrious, mainly pagan, and scrupulously honest. Compared to the
two other major ethnic groups in Sarawak, the Ibans were generally more
"primitive" and had the most concrete mental existence, i.e., a mental life almost
devoid of abstract thinking.
Malays. In contrast to the residential arrangement of the Ibans, the Malays
lived in individual houses, which were on stilts, in villages near the river estuaries.
A row of Chinese shophouses often formed the center for an area, with a Malay
village nearby. Also in contrast to the pagan Ibans, the Malays were Muslims.
They largely based their economy on extraction and harvesting, including
methodical fishing and wet rice planting. In addition, many Malays worked as low
scale government servants, which introduced some degree of bureaucratic
mentality into the community.
Chinese. The Chinese were the most modern of the three groups. They lived
in urban areas and on farms near the larger urban centers. Occupationally, they
were mainly traders, artisans and farmers. Their farming methods-centered on
pepper planting and coconut and rubber production-were advanced and intense.
Religiously, they were either Buddhists or Christians, reflecting the colonization
by Westerners. Among the three ethnic groups, the Chinese were the most
educated and had the least concrete mental existence, i.e., they exhibited the most
abstract conceptualization.
The Sarawak Research Project
At the time, I did not know that the research study we were to do in Sarawak
would have such lasting value. So far as I can determine, it stands to date as the
only scientific research that documents the incidence and kinds of mental illness in
Malaysia.
The study was made possible by a grant by the Foundation's Fund to
Research in Psychiatry (F. F. R. P.), based in New Haven, Connecticut.
Stimulated by the director of the Sarawak Mental Hospital, Dr. Karl Schmidt, the
primary purpose of the study was to determine the prevalence of the various
forms of mental disorders among the Ibans, Malays, and Chinese. Sarawak was in
a unique position to provide the opportunity for a fruitful multicultural,
comparative mental health prevalence study, since the three ethnic groups lived in
close proximity yet differed socially, culturally, and in other ways.
The principal purpose of the research was to determine the prevalence of
mental illness in the region where the three distinct ethnic groups lived in relative
harmony. "Relative," because Sarawak, just four years earlier, in 1963, had joined
the Federation of Malaysia. There were still some communist insurgents who
refused to accept Sarawak's federalization. There were burning of Malay coastal
houses and bizarre killings of Chinese children (some were secreted in
refrigerators), all instances of dissatisfaction from both ethnic groups.
Other reasons for the research included determining the kinds of mental illness
among the three groups, and ways of improving the mental health services in the
capital (Kuching) as well as in the outlying areas.
Unbeknownst to me, the preparation for the research, from time of conception
to 1967, had taken two years, including radio and newspaper announcements,
church and government sanctions, and school bulletins. Finally, the special
blessings of a Datu, an important person of high regard and respected elder of the
Malay community, was called upon. His pronouncement was loud, effective, and
encouraging for the entire research effort.
The study was to be based on interviews with members of the three ethnic
groups, using an 80-item questionnaire format. As a result of the extensive
preparation for the study (and blessing from the Datu), the research directors had
obtained agreement for more than 6,000 respondents between the ages of 15 and
59, from each of the three respective ethnic groups, to be interviewed, for a total
of 20,288 interviews. The age range was limited because of accessibility and
logistics.
The following geographical areas, which were thought to represent the groups
in question, composed the sampling areas: Ibans, 40-50 miles away from the
capital; Malays, across the river from the capital; Chinese, in the downtown
capital area.
Welcome to Sarawak . . . Hungry Waters, Fierce Boars,
and (of course) Headhunters!
Finally, I had arrived in Sarawak! Before I barely had a chance to unpack my bags,
however, I and my coresearchers found the enormity of the experience Ñ
including the vastness of the terrain, the dangers from travels to the Malay
Kampongs (villages), and the Iban Longhouses-quite challenging. In fact, it
seemed that our lives were always in danger!
From what? Some of the constant threats from nature were the powerful
waters, which could sweep one away, and the animals, of course-crocodiles,
leeches, snakes, and boars, among many others. The sounds from the boars, in
particular, were so thunderous, that they could almost tear one's heart apart. The
natives knew how to master the menace of the boars, of course, but that was a
skill I was not anxious to learn.
On one occasion, we easily could have been eaten by crocodiles. It was
nighttime and our motorboat had run aground. This situation necessitated that
everyone temporarily abandon the boat and begin to push. Although I was asked
to stay in the motorboat, I decided to join the whole group in the
crocodile-infested waters, to show some kind of solidarity. I'm here today to tell
about it, but it's a situation I would never want to face again! Our research
undertakings in such a foreign land required not only imagination but also common
sense. Respect and cordiality reigned supreme.
Another kind of danger lurked in social relationships-or, rather, our lack of
understanding of all the natives' norms and mores. On one occasion, for example,
the student psychologist from the University of London, who was involved in our
research, decided to invite her husband (from another research project) to join us
on a particular trip to the jungles. As we settled in the night at the longhouse, she
unfortunately declined the invitation to join all the women in our group to go
inside the chieftain's quarters-an Iban tradition.
This refusal set off a ripple of discontent, shock and anger in the whole
community. The following morning, we were informed that her head was spared
because she arrived with a government-sponsored research team. To learn that the
Ibans were still sporadically engaged in headhunting, although it was banned,
became all the more frightening. Obviously, she was insufficiently informed of the
need for cultural sensitivity, which was very much required for this kind of
research.
I came to understand and accommodate such culture-bound behavior on many
occasions. For example, halfway through the Malay interviews, I engaged an elder
hajji to interpret for me. On numerous occasions, in the middle of an interview, at
a specific time at dusk, he would excuse himself and go to a room in the
respondent's house. While the interviews were crucial, I also felt that his need at
that particular moment was more important. He was carrying out, I learned, his
obligations to pray-an important and sacred ritual in Muslim religion. I would
have "lost face," perhaps, had I dismissed him. I would have been an
embarrassment to our whole Malay team as well.
In the midst of this exotic research adventure, so far away from Canada, I was
still having correspondence with individuals from "the Allan" at McGill
University, Department of Psychiatry. One letter I received, from David J. Lewis,
M.D., dated September 26th, 1967, illustrates the curiosity those "back home"
had about the research I was doing, and their desire to participate, albeit from afar.
It read, in part: Dear Tom, . . . Let me ask you one thing. I think as I read your
letter, it said that you were utilizing mental patients and political
prisoners-does that mean that you are engaging them as
interview subjects, or carriers out of interviews? If the latter is the
case, I would be most interested to share your experiences since I
wonder whether these people are not an as yet unrecognized
avant-garde of something that it would take a James Joyce to
recognize at this present time, although it might be quite obvious in
the future looking back; hind-sight is so much easier . . . . Sincerely,
David J. Lewis, M.D.
In the course of the research, I encountered a most unusual so-called
culture-bound phenomenon-Latah. Seldom seen anywhere than among the
Malay women, Latah was reported as far back as 1895. In the 1972 edition of
Psychological Medicine, Volume 2, one can find a good description:
It's characterized by echolalia, echopraxia and command
automatism, taking the form usually of a brisk explosive, verbal
outburst usually following an exciting `happening'. Precipitate
stimuli range from unexpected gestures of another person as slight
unexpected physical contacts to severely frightening events such as
the sight of a snake. Dream content was often overtly sexual.
While somewhat of a novelty for outsiders like myself, the local people
generally brush this manifestation off as the person's "eccentricity." The presence
of mild to moderate severe psychotic disorder was uncovered in 20 cases out of 50
I studied. How wonderful it would have been to be able to pursue this
phenomenon! Soon, however, I was to begin writing my observations up for an
article, which eventually received publication.
Outcome of the Research on Incidence and
Types of Mental Illness
In the two years we were in Sarawak, what did we actually find? The data we
collected were eventually analyzed by computer-and I stress "eventually,"
because we became involved in a "data drama" if ever there was one, to be
recounted shortly.
One thing we learned from the study was how difficult it is to get good
interviews that provide usable data for analysis. Of all the thousands of interviews
we conducted, only 641 individuals met the criteria for inclusion in the study. Of
these, 464 cases were confirmed and 177 were not confirmed. These data are
shown for each ethnic group in Table 1 below.
As you can see from the table, of the 464 cases confirmed, the largest number
came from the Chinese, followed by the Malays and Ibans. One possible reason
for these differences was that there was a uniformly higher educational attainment
among the Chinese interviewers. Another possibility was the accessibility and
familiarity of many Chinese with the main psychiatric facility in the capital,
where they lived.
Table I
Confirmed and Unconfirmed Cases by Ethnic Group |
Total Surveyed |
Total Referred |
|
|
Unconfirmed |
Confirmed |
Ibans |
6,831 |
60 |
107 |
Malays |
6,376 |
81 |
162 |
Chinese |
7,081 |
36 |
195 |
Totals |
20,288 |
177 |
464 |
In general, the outcome of the research did not prove to be exceptionally
revelatory, in the sense that there was no great discovery. In essence, we found
that prevalence of mental illness was similar to findings from prevalence studies in
other nonindustrial countries.
From the diagnostic categories, based on the Diagnostic and Statistical Manual
of Mental Disorders (DSM-II, 1968 edition), the data showed that the neuroses
were the most common psychiatric disorder among the three ethnic groups,
followed by the schizophrenias. These findings for each ethnic group are shown in
Table 2 below.
As Table 2 shows, there was a somewhat uniform distribution of the various
diagnostic categories among the three ethnic groups. Thus it seems that ethnic
groups do not indicate specificity, or culturally determined pathologies.
Table 2
Diagnostic Categories |
Iban |
Malay |
Chinese |
Total |
Neuroses |
40 |
44 |
61 |
145 |
Schizophrenias |
26 |
51 |
56 |
133 |
Mental Retardation |
11 |
24 |
21 |
56 |
Psychophysiologic Disorders |
11 |
9 |
17 |
37 |
Transient Situational Disturbances |
2 |
12 |
15 |
29 |
Organic Brain Syndromes |
6 |
10 |
9 |
25 |
Personality Disorders |
1 |
5 |
10 |
16 |
Paranoid Syndromes |
7 |
5 |
1 |
13 |
Major Affective Disorders |
3 |
1 |
5 |
9 |
Sexual Deviation |
- |
1 |
- |
1 |
Totals |
107 |
162 |
195 |
464 |
The difference is apparently in quantity. It is interesting to note that, in the
original research proposal, the investigators thought that the schizophrenias were
the most common psychiatric disorder. The survey findings showed, however,
that the neuroses were the most common; depressive neurosis ranked first,
followed by anxiety neurosis, for all three groups. Other specific findings worthy
of emphasis were the following: (a) organic brain syndromes were almost
uniformly reported; (b) all three groups reported a total of 29 cases of transient
situational disturbances, with only two cases reported from the Ibans; (c)
headaches and stomach discomfort were common primary complaints for all three
ethnic groups, and these symptoms were the main road toward the medical clinics
and psychiatric facility; (d) many disorders were rare or nonexistent, including the
following: psychiatric disorders relating to alcohol, obsessive-compulsive
neurosis, personality disorder (paranoid), sexual deviation, and affective disorders
(including involutional melancholia and manic-depressive illness). It should be
mentioned here that the affective disorders may have been rare due to depression
being included under the neuroses category, to insufficient history, or to
similarities between somatization disorders and depression (Leighton, 1959).
The study in Sarawak illustrates three main concerns that mental health
professionals working in a multicultural environment should be aware of: (a) the
variation in the prevalence rates of different types of disorders among distinct
ethnic groups, (b) the definitions and classification of disorders, which have direct
implications for treatment, and (c) the relationship between the extent of
modernization within different sectors of the same society and the types of the
disorders among socio-cultural groups residing in the various sectors.
What struck me most, perhaps, was the extraordinary tolerance and patience
shown by the populace toward the mentally ill. A middle-aged Iban widow,
recognized by the people of her longhouse as being mentally infirm, was given a
hut they built for her in the vicinity of the longhouse, so that she could walk
around a spot near her lodging with lighted candle every day at midnight. In that
way, she did not disturb the people in the longhouse as she "performed her
duties" to her dead husband.
At the close of the research project, I saw depression and "crippled thinking"
that, in concept, were very much like that in Western society, although the
manifestation was somewhat different. While patients in the West, for example,
may complain of "wiring" or "electricity in the head," the patients in Sarawak, I
noted, were more likely to describe "birds singing to me." Silence and
somatization syndromes frequently obscured or masked depression. "Keep it to
yourself," a familiar Chinese maxim, was indeed the hallmark of many such pitfalls
in the initial evaluation of the Chinese respondents.
As I look back at the three distinctly different societies living in close
proximity in Sarawak, each carrying out its own peculiar life, I wonder what made
them stay together harmoniously. What ingredients did each ethnic group
contribute to this peace? I never did reach a conclusive answer to this question,
but it would make a wonderful study for a cultural anthropologist.
Towards the end of our research project, I was asked to work in the Sarawak
Mental Hospital for about 4-5 months, and also to prepare some questions for the
Psychiatric Nurses Examination, which the students had to pass to fulfill one of
the requirements for the bachelor's degree. At that time, nearly 30 years ago, I
asked questions and expected answers that reflected my understanding, and the
state of psychiatric knowledge of the time. They indicated what the nurses were
expected to know about psychiatry. For example, I asked:
1. Discuss the present theories about the causation of
schizophrenia.
2. A 20 year old girl, formerly a college student, suddenly left
school for no apparent reason and started to put on excessive facial
make-up and wear gaudy dresses. She tells people that she is a
Russian Princess. Suggest a plan of treatment for this girl, upon
admission.
3. Discuss the role of the Psychiatric Nurse in Community Mental
Health programmes.
4. A seventeen year old boy was noticed one day to wander
aimlessly in the woods and continued to do so for months. He
would stare blankly out into space, as if in deep meditation, for
long hours. His former friends find him non-conversant, aloof and
difficult to mix with. He was, prior to this happening, a
well-mannered boy with a brilliant school record: (a) What are your
impressions? (b) Discuss causation. (c) Does he need treatment of
some sort? If so, discuss. (d) Is shock treatment indicated? If so,
discuss.
5. Describe the various types of depression and give their
symptamotology.
6. What is adolescence? Discuss the problems encountered by an
adolescent.
7. Give and discuss five causes of mental illness not of psychogenic
origin.
As I look back on these questions, I wonder if I would ask the same things
today. I know I would expect different answers to many of the questions.
Psychiatry has changed so much over the past three decades, especially methods
of treatment and theories about the causes of mental pathology, neuroses, and
mood disorders, among other things. I am certain I would require different answers
now about, for example, the causes of schizophrenia and depression, the role of
community nurses, and the characteristic problems of adolescence. Thirty years
from now, I have little doubt that still newer methods of treatment and theories of
mental illness will replace the "conventional wisdoms" in Psychiatry today. Such
is the course of progress in the mental health profession. Or is it merely change?
This is a question that many members of the profession, as well as its critics,
debate fervently and at length.
Towards the very end of the Sarawak project, I received a letter from H. B. M.
Murphy, dated January 8, 1969, informing me that certain occupational plans I
had anticipated were not working out, and that a new position might be available
to me in the States. He said:
Dear Dr. Chiu, . . . I have just heard from Dr. Schmidt that he is
going to Noumea, and on the other hand that the Hawaii people's
attempt to get one or both of you there for some months in order to
write up your research results this summer has fallen through. My
own plans for getting research going in Kuala Lumpur are also not
going ahead as fast as I would like . . . and I therefore started to
wonder what will be happening to yourself. You may have already
plans of your own far advanced, but if not, and especially if you
were expecting to hear something from me regarding Kuala
Lumpur, you may be interested in the following idea.
The University of Vermont, at Burlington, just across the U.S.
border from Montreal, is associated with McGill in our new
transcultural training program, and is nominally supposed to be
carrying half of the work of training any U. S. fellow. . . . Dr. Hans
Huessy is the acting chairman of the department of psychiatry. . . .
He has posts open in his department for fully trained psychiatrists
interested in community psychiatry and he is particularly interested
in getting someone who would share with myself the supervision
and training in the transcultural program. Provided you were
eligible for licensing in Vermont (and I think that he could make out
an easy case to the U. S. immigration department for need you) and
provided you were prepared to do a limited amount of clinical work
in addition to teaching and research, he would probably have a
post with a reasonable salary for you when you finished in
Sarawak, a post which would also give you time to work on the
Sarawak data.
. . . . If you have not definite plans I would suggest that you
write to Dr. Huessy. I do not know what salaries he has to offer,
and conversely I do not know how you yourself stand as respects
the American Board and as respects immigration. If you did go
there, however, and if the Sarawak material were not yet fully
worked out, then in the short run I should be able to help you
analyze it and in the longer run we might be able to collaborate in
new research. . . .Finally, thank you for the Iban bracelet you sent
me earlier. . . It is a most interesting curiosity.
What Now? The Post-Sarawak Turning Point
After Sarawak, I wasn't quite sure where I would work. I wasn't even quite sure
where I wanted to work. Although the University of Vermont was in the back of
my mind, I wrote to a friend, Dr. Richard R. Peebles, a Psychologist, who was on
the staff at the Massachusetts General Hospital, in the Child Psychiatry Unit, for
suggestions. He was my supervisor while I was doing my Fellowship at Harvard.
In a letter dated January 21, 1969, he wrote to me:
Dear Tom: . . . John Lamont says that the demand should be good
enough so that someone with your ability should have no trouble in
choosing the position he wants. Perhaps the American Psychiatric
Association has a listing of current positions open, or could help
you know where to look. . . . Let me know if there are particular
aspects of your training that you would like to have emphasized. I'll
let you know if I hear of anything. . . . I hope you come back to this
area [Boston]. It's a nice place to live in spite of the current social
problems. Best regards from us both-Dick.
Richard was also very gracious in writing me a letter of recommendation to Dr.
Audrey W. Mertz, the Executive Officer of the Mental Health Division,
Department of Health, in Honolulu, Hawaii.
Dear Doctor Mertz: I am happy to be able to give a high
recommendation to Dr. Chiu, both for his psychiatric skills and for
his personal charm and integrity. He works well with colleagues
and is exceptionally sensitive to the problems of his patients. I
supervised some of his psychotherapy cases for one academic year,
and was greatly impressed with his ability to think critically and
objectively about difficult family issues without losing any of his
empathy and compassion for the personal problems of individuals
in the family. Dr. Chiu is also a careful and diligent worker.
About a week later, however, I decided to put out a "feeler" to the University
of Vermont. I wrote to Dr. Huessy, acting chairman of the Department of
Psychiatry, and he wrote back to me, in a letter dated January 30, the following:
Dear Dr. Chiu:
. . . Dr. Murphy had discussed your situation with
me. We are very definitely interested in adding to our full-time
department and are particularly interested in someone with an
interest in Transcultural Psychiatry as we have a training program
in that area.
I have a sneaking suspicion that I must have met you at a party while I was
one of the members of the Visiting Faculty Seminar under Dr. Caplan in
Boston. I am taking the liberty of writing to your references immediately
and will be in touch with you as soon as I have heard from them. Our only
requirement for employing someone is that they hold the ECFMG which I
see you have already had for eight years. Looking forward to further
correspondence with you, I remain, Sincerely yours, Hans R. Huessy, M.D.
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