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Historical overviews of the birth of psychiatry have inevitably expanded to include these developments in the colonies; and the transported evolution of asylums from concentrated sites of colonial activity to macro-scale national assimilation and adaptation. Comparisons often depend upon the numbers of psychiatric institutions, trained staff and budget allocation prior to the postcolonial period, with the exponential growth in these areas since, which is constructed as an unqualified good. Accordingly, we learn that while there were only four, albeit very large, psychiatric hospitals in the Dutch East Indies, by the 1970s this number had doubled in Indonesia (Pols, 2006). Likewise, in Pakistan, since Independence the numbers of psychiatric institutions has grown exponentially (Gilani et al., 2005). Deva (2004) in turn reports similar developments that have taken place in Malaysia, of which more will be said.

Goldberg et al. (2000) provide a useful context by which to measure these apparent improvements, by pointing out that the overwhelming majority of the world’s population live in the developing world and many of these countries have experienced colonialism. Thus, the historiographies of biomedicine have intersected with those of colonial rule; and the latter, as Keller (2001) points out, has been duly strengthened by a Foucauldian analysis of power. Accordingly, the projected mission of British colonialism, for example, that was perceived at the time as fundamentally benevolent and civilising, as well as undeniably profitable, have since been subject to powerful, iconoclastic accusations that have served to sharply refute many of the more benign associations imperialism once boasted of. Thus, the irredeemable evils of empire building have become a guilt-laden, culturally embedded, assumed fact in the contemporary consciousness. Yet such analyses are as captured within a specific socio-historical context, equally as much as that phenomena under study. It is timely to recall then to what extent the greatest admiration, as well as the opprobrium of historians and the informed public, is compelled by sheer fascination when contemplating the mightiest example of administrative, military and cultural hegemony of all: that of the Roman Empire. It is not inconceivable therefore, that emerging revisionist analyses in the ‘post’ postcolonial future may offer new shades of meaning and alternative interpretations for further consideration in our understanding of colonialism and its influences. Thus, as Keller (2001) advises, the more modest study of colonial psychiatry needs to move beyond over-simplistic accounts of racist oppression by colonials, towards a more nuanced and historically situated analysis in order to do this important topic justice.

A valuable corpus of literature on colonial psychiatry has begun to be consolidated over the past few decades, which provides important insights into formalised psychiatric services offered by the British, French and Dutch colonial authorities across Asia and Africa. Such a wide socio-historical-geographical span inevitably leads to rich, multilayered, diverse and textualised accounts that elicit our critical understanding of the processes, practices and principles underlying the establishment of services and their impact upon local communities. These historiographic studies in turn serve to illuminate ethnographic accounts of psychiatric service users, such as this study, where indigenisation has reshaped service provision to fit a postcolonial landscape, and where the historical thread is less distinct but still visible for tracing back to a beginning, if not the beginning.

Colonialism has been credited, albeit with much ambivalence, qualification and reservation, with the establishment of modern psychiatric services in its once occupied territories. Pan-Asia and Africa both saw numerous incidents of industry in the introduction of European psychiatry, albeit unevenly and with markedly different standards of care applied across communities. A necessarily brief tour through the literature reveals the extent of this enterprise to bring modern psychiatric care to the indigenous masses.

The imperial machinery, it is argued, was run through the careful coalition of its essential parts, in which psychiatry and medicine in general had a vital role to play in the consolidation of the Empire, along with bureaucratic administration and the militia (Bhugra, 2001).

Accordingly, Roland Littlewood questions how colonial administrations were served by the rising profession of psychiatry developing in parallel in colonised regions.

We might note, for instance, some affinities between the scientific objectification of illness experienced as disease and the objectification of people as chattel slaves or a colonial manpower, or the topological parallels between the nervous system and imperial order. Both argued for an absence of higher ‘function’ or sense of personal responsibility among patients and non-Europeans (Littlewood, 2001: 9).

In this analysis colonial authorities viewed subject people as being greatly in need of the new science of psychiatry due to their pathologically morbid tendencies, and generally benighted and ignorant condition. These practices were therefore viewed as an essential part of the armoury that an imperial state could utilise as useful propaganda in aiding the ambitions of notably, although by no means solely, the British Empire.

Dinesh Bhugra (2001) points out that the development of asylums in colonial India were predicated on European notions of medical hierarchy, management and care and governed by enlightened, paternalistic and preferably Anglo-Saxon expertise.

The ideal psychiatrist, like the ideal colonial officer or plantation owner, was a ‘father to his children’ (Littlewood and Lipsedge, 1989: 10).

In India we learn that the growth of asylums paralleled historical turmoil, and consequently were built in areas of social unrest with a high colonial presence (Bhugra, 2001). This conflated point is also noted in the more in-depth study by Waltraud Ernst (2010), and is also echoed in accounts of colonial psychiatry from Zimbabwe to Algeria and the Malayan archiepalego. Ernst (2010), however, observes that psychiatric institutions established in the British Raj were primarily there to care for the insane colonial, predominantly army personnel, who had become deranged through a combination of factors, including culture shock, climate differences, homesickness, alcoholism, and the rigours and privations of regular army life overseas, where soldiers were beset with very high disease and mortality rates from a battery of potentially fatal diseases.

While noting that asylum care in India was regarded as generally superior to that offered in the ‘home’ country, Ernst (2010) comments that strict distinctions were observed between colonial patients and their Indian counterparts in terms of comfort, where in case of Indians overcrowding and squalor were rife. However, equally she notes the prevalent asylum policy of this period, extended to Indian inmates, that maltreatment of patients by staff was strictly forbidden, in accordance with the principles of moral therapy. Ernst (2010), however, argues that the overwhelming scale of the local population caused the insane but innocuous ‘native’ to be relegated to a life of highly uncertain provision beyond the walls of the asylum. By contrast, those among the colonial insane who did not recover their wits within a certain timespan were regularly repatriated back to the custodial care of asylums in England.

McCulloch (2001) in turn notes the increase in asylums in the European context and the corresponding growth of patient populations in relation to an analysis of the social control of the working classes. He argues, however, that this has little relevance to the development of the asylum system in the colonies where other issues tended to predominate. Furthermore, McCulloch (2001), accused by Keller (2001: 319) of being an ‘apologist’ for colonialism, goes on to observe that in contrast, the building of asylums in the outback regions of colonial Africa symbolised a wish to emulate the ‘civic virtues’ of distant metropoles as well as expressing a need to control expatriate and indigenous deviancy (McCulloch, 2001: 79).

Lynette Jackson’s (2005) account of Ingutsheni Central Hospital, founded as an asylum in the first decade of the twentieth century in former Southern Rhodesia, offers a graphic analysis of racism in some of the harsh distinctions between the care of white and black patients, particularly in terms of certain forms of treatment, in the period leading up to Independence. Her thesis draws on Franz Fanon’s analysis in pointing towards the trauma of colonisation as providing the seeds of psychic disturbance in local populations, where contact with the colonial world could induce insanity in Africans (Jackson, 2005). This in turn chimes with McCulloch’s view, according to Keller (2001) that the social transition from traditional, indigenous rural economies to colonised, urban spaces generated psychological trauma in the African population. Curiously, Sadowsky (2003: 212) traces back the origins of such viewpoints to, for example, the ‘notorious’ J.C. Carruthers who wrote in the 1950s on the psychic impact of encounters with modernity by local Africans. It is indeed an intriguing peculiarity that such similar arguments have been employed diachronically to both castigate, as well as to justify certain colonial psychiatric perspectives of diagnosed mental health problems in indigenous populations.

Notably, Ernst (2010), Bhugra (2001), McCulloch (2001) and Jackson (2005) find that psychiatric admission of the local population was primarily focused on socially troublesome individuals, rather than the harmlessly insane in both colonial India an Africa. The inference is clearly suggestive of a Foucauldian analysis of the exercise of a power against indigenous grass-roots subversion by a threatened imperial State. However, as Keller (2001) in reference to Ernst (2010) points out, the few numbers of patients detained overall, hardly constitutes an effective custodial curb to social subversion. In this vein, Sadowsky in deconstructing this Foucault-inspired conspiratorial aspect of colonialism, adds the observation:

Although Africans were rarely institutionalized because British officials believed someone to be insane for opposing colonialism, anticolonial sentiments were often taken to confirm that a person already deemed to be acting oddly was, indeed, insane (as already suspected) (Sadowsky, 2003 :213).

Sadowsky goes on to offer an additional critique (2003), arguing that the ‘gung-ho’ colonial confidence towards the introduction of the clearly beneficial trappings of ‘civilisation’, such as roads and railways, were expressed with less assurance when it came to mental health provision in the overtly unfamiliar cultural context that colonial Africa represented.

Khanna (2003) draws our attention to the wave of sympathetic protest by French intellectuals, like the existentialist, John Paul Satre, towards France’s often brutal colonisation of Algeria, fuelled in part by the compelling critiques of Fanon. While not denying the existence of probable mental illness in his Algerian patients, Fanon argued that effective treatment for colonised patients were negated when administered by the representatives of the enforcing colonial power. Thus, Fanon articulated the interrelationship between colonialism and madness, likening alienation from one’s cultural roots, to alienation from one’s self (Vaughan, 2007). In discussing Fanon’s ‘searing indictment of psychiatry’ Keller (2007: 4) notes that diagnosed dysfunction by colonial psychiatrists, both British and French, conspicuously failed to contextualise these in relation to macro oppression. Consequently, a more sophisticated analysis is required to understand colonial psychiatry as both a tool of oppression, and as something that could be beneficial, and even conceivably the means of developing emancipatory mechanisms in the geo-political and cultural context (Keller, 2001).

In contrast to these accounts of oppression by invading imperial powers, the convoluted development of mental health treatment in mainland China offers some extraordinary and disturbing insights. In an interesting account by Kam-Shing Yip (2005) we learn that early psychiatric institutions in the late nineteenth century were established by missionaries, firstly in the Guangzhou area. These early initiatives grew, culminating in formal psychiatric training at the Peking Union Medical College in 1932. However, with the demise of the old dynastic order, and the rise of the new People’s Republic of China (PRC) in 1949, a root-and-branch revolution of mental health services saw the complete rejection of Westernised ‘capitalist’ psychiatry. In its stead a more radical authenticised¹, rather than indigenised, ‘collective action’ was imposed to combat mental illness, now reinterpreted as an individualistic and deviant alienation from established political ideology. Mental health treatment would involve the re-education of the abnormal individual through laceratingly humiliating and excoriating personal criticism by fellow patients and workmates as treatment led by a class-brother/sister psychiatrist with the correct political credentials (Yip, 2005: 108-9).

Kleinman and Kleinman (1999; 1995; Kleinman, 1995) have produced some powerfully compelling accounts of the embodied, psychosocial trauma wrought by the ordeals of Cultural Revolution on individuals since disabled by visceral, unresolved and somatised distress. Collective societal resolution of the more agonising aspects of the Revolution appears to be evaded by a complicit societal amnesia, despite the otherwise complete social transformation of China towards heavy urbanisation and capitalist entrepreneurialism. Today authenticised, culturally grounded therapies like traditional Chinese medicine and Tai Chi co-exist more easily with ‘Western’ biomedical pharmacology, but psychotherapeutic interventions remain marginalised, despite their apparent utility to alleviate some symptoms of trauma (Yip, 2005).