In 1998, the Australian professor of colonial medicine Warwick Anderson warned his readers that ‘[w]e should not assume that the colonial world was a passive receptacle for germ theories or any other form of Western medical knowledge’.[1] Although Anderson meant that the arrival of new medical theories to the colonies led to changes that were often creative and at times unpredictable, his statement could be read somewhat differently. As the receptacle in Plato’s Timeaus, the ‘third kind’ the demiurge needed to realize the ideal Forms, the colonial world had a dynamics and structure of its own that at least challenged the universality claimed by western medicine. This, too, was the case with psychiatry. Faced with the culturally unknown, it became debatable whether diseases like hysteria, dementia paralytica and dementia praecox afflicted the ‘native mind’ in ways similar to the civilized West.[2] But how do you diagnose someone whose language you don’t speak and culture you don’t know? This pebble shortly considers some attempts to solve that problem.
In Nathan Porath’s account of the development of Indonesian psychiatry, a naturalization of psychiatric knowledge could commence only after national independence in 1949.[3] Post-colonial reality provided a space in which Indonesian psychiatry could evolve freely in search of its own identity. Two dissertations written by Raden Marat and Sumantri Hardjoprakoso might serve as examples. In order to complete his studies at the University of Tübingen, Raden Marat questioned if the western treatment of neurosis applied to the Indonesian context as well, and on the other hand, under supervision of the Dutch psychiatrist E.A.D.E. Carp, Hardjoprakoso formulated a psychotherapy based upon an Indonesian view on human nature.[4] Porath maintains that before national independence the development of psychiatry in the archipelago was depended on Dutch medical training in Java and western psychiatry.[5] It should, however, be said that the transfer and use of psychiatry and psychiatric knowledge before 1949 was not exactly what one would call easy and uncomplicated.
One of the problems psychiatrists had to face was the question of diagnostics. Although this challenge might have been present from the very start of mental health care in the Netherlands East Indies, it was only during the 1920s that some physicians started to discuss it in scientific journals. An interesting example of this is an analysis by Dr A. Kits van Heyningen, Officer of Health second class of the Royal Dutch Indies Army who was stationed in Aceh. Accordingly, three factors caused the problems surrounding diagnosis: language, a different psyche, and simulation of mental illness by the Indies population.[6] Kits van Heyningen commenced by mentioning the diagnostic association tests designed by Swiss psychiatrists Bleuler and Jung, and stated that the main objection against the use of such tests in the Indies was that, in general, physicians in the Netherlands Indies ‘speak so amazingly little and very bad Malay’. Since these diagnostic tests were language-based, they did not prove to be very useful. However, even if European physicians spoke Malay fluently, other problems remained. Many different association tests had to be designed because of the hundreds of different languages spoken in the Indies, a task practically unfeasible. Also, and perhaps more fundamentally, Kits van Heyningen claimed that the Malay language did not have a semantic equivalent of the word “associative thought”. Because of this, it was extremely difficult for doctors to ask their patients to do what the tests required even if they themselves did speak Malay.
This last problem was related to another issue singled out by Kits van Heyningen: an almost unbridgeable gap between the psyches of Europeans and ‘Inlanders’. Because of this, he continued, it was sometimes very difficult for European physicians to divide normal from abnormal behavior, and simulation from genuine mental disease, which was obviously important within the setting of a military hospital in Aceh. He had therefore introduced so-called ‘peculiarity note books’ (bijzonderheidsboekjes) to the observation wards, in which the native staff members were supposed to write down daily findings. After all, ‘as racial brothers [they] would recognize the abnormal better than we do’.[7]
However, doctors do not want to rely solely on the notes taken by the nursing staff, and that goes all the more in a colonial setting where that staff was, to a large extent, Javanese. Considering this, Kits van Heyningen noted that some easy-to-handle diagnostic tests were desirable in order to gain a better understanding of the psychology of ‘the native insane’. By suggesting a more somatic approach based on psycho-galvanic phenomena, he hoped to evade the language problems mentioned above. By means of a galvanometer, the physician would be able to measure the body’s electric current under the influence of different psychological processes – ‘[a]lthough,’ he had to confess, ‘one does not really know what is being measured’.[8] Researchers had, however, ascertained that in order to measure some activity of electrical current at all, the psyche needed to be engaged in affective processes. The desired feelings could be evoked by means of association tests, which brought Kits van Heyningen to the conclusion that a combination of association tests and a galvanometer could result in relating ‘words to thoughts’.[9] It would also provide insights into the speed between word and psychical reaction. By means of this sort of investigations, the structure of the native psyche would hopefully be unraveled.
Kits van Heyningen was not the only physician who was interested in developing tools to map the mind of the native and demonstrate its normalities and abnormalities. In March 1923, the Dutch psychiatrist C.F. Engelhard graduated with a thesis bearing the title Research concerning the mind by means of pictures, applied to the Javanese.[10] His main findings were summarized in an article published in the Medical Journal of the Dutch Indies the same year. As opposed to Kits van Heyningen, Engelhard was in much closer contact with the world of the asylum in the Netherlands Indies, and he conducted his research during his stay at a clinic (doorgangshuis) in Surakarta between roughly 1918 and 1923. A former assistant of the German alienist K. Heilbronner at Utrecht Universty – Heilbronner himself had been a major advocate of research by means of pictures – Engelhard became interested in the applicability of this technique to the ‘underdeveloped desa-man’. Like Kits van Heyningen, Engelhard’s goal was to find a practical solution to the problem of diagnosing the Javanese mentally ill.[11] The issue of who and based on what criteria was to be admitted to the mental hospital was probably what contributed to the need for developing such tests. In the ‘Regulations of the care for the insane in the Netherlands Indies’ (‘Reglement op het krankzinnigenwezen in Nederlandsch-Indië’) of 1897, it said that the Landraad, a local native council of aristocracy, could authorize hospitalization. However, as Engelhard would recall in 1948, the indigenous head of the kampong and the Dutch authorities did not always agree on the question if hospitalization was necessary.[12] Possibly Engelhard hoped that accurate diagnostic tests would put an end to these discussions.
Picture tests were based on the idea that forms of representation corresponded to levels of intellectual maturation. The more abstract an object’s representation, or the more complex a combination of pictures, the more developed the intellect needed to be in order to recognize what was depicted. By means of empirical research, one could establish which pictures correlated to what classes of individuals – male/female, young/old, rich/poor – which subsequently made it possible to recognize pathological deviations. For example if eight-year-old boys from blue-collar families, in general recognize a plate that pictures a round object as a football or the moon, and now this specific child under examination thinks it is a petri dish, then this might be a hint of possible deviation. What simply needed to be done, according to Engelhard, was to experimentally develop a series of appropriate pictures that reflected the average Inlander’s mental constitution.[13]
This, however, turned out to be much harder than Engelhard initially expected. Out in the fields of the Netherlands Indies, Engelhard selected both men and women and conducted multiple tests. He asked people to tell him what kind of an object they thought the picture represented, or they had to combine a series of pictures and argue what kind of action was shown. Yet through the eyes of the local population, the whole situation was rather absurd. Most of them became extremely shy and even ashamed, not knowing what to think, much less how to respond. Why was this white physician asking all these questions? An old lady excused herself and told him he should not get angry with her: she had never understood the pictures on matchboxes either, and these were the only illustrations she had ever really seen.[14] In retrospect, Engelhard’s reaction to the entire situation was somewhat confused as well. On the one hand, he does seem to have realized that the representation of objects depends on certain conventions and traditions, which would in part explain the reactions he encountered.[15] Yet, on the other, instead of drawing the conclusion that there had been something wrong with his pictures, he argued that the natives responded ‘just like our children’, reflecting the typical Javanese who – ‘as everybody knows’ – was ‘calm, sober, modest, and who had the slightest inclination to “conquer reality”’.[16] It would take another twenty-five years and a world war for Engelhard to finally resolve this tension in his reaction to his field work, and to recognize that ‘[i]n the past there seem to have been rather a lot of racial psychiatric considerations on the basis of superficial impressions’.[17]
Hans Pols has argued that psychological examinations of, and theories on, the nature of the native mind justified colonial policies by providing a scientific rationalization for European hegemony.[18] It is remarkable how racial prejudice became psychological knowledge published in medical journals even though proper empirical research was lacking. Interestingly, even some contemporaries of Engelhard recognized his dissertation as sloppy science. Take for example a critical reaction to Engelhard’s findings published anonymously by O.H. in Djawa, the journal of the Java-Institute.[19] O.H. remarked that people on the island of Java wrote different poetry, they danced differently, their songs and music were different; wouldn’t their way of representing the world be radically different as well? In order to come to conclusions about the nature of the native mind, one should depict objects in accordance with Javanese tradition. After providing a brief summary of his argument, O.H. asked:
Would it be possible to create test material by means of stylized or picture-like batik art and wayang dolls and groups, in order to conduct research into the mind of the Javanese with material better than Engelhard’s, which would provide an appropriate comparison [between the Western and the native mind]?[20]
If such test material was indeed created, I do not know (and if you do, or if you know who O.H. might have been, please leave a comment below!). Arguments similar to O.H.’s would, however, be repeated throughout the 1920s, especially by a slowly growing group of indigenous physicians and psychiatrists. Although a medical school for educating dokter Djawa was already established in 1851, and the educational program was improved a lot in 1902 when the school was famously renamed STOVIA (‘School ter Opleiding van Inlandsche Artsen’, or School for the education of native physicians), the financial and social position of these Indies physicians was much less favorable than the position of their European colleagues. They received less than half the salary of European physicians and were not welcome in European social circles.[21] During the 1910s and 1920s, when Indonesian nationalism began to take shape, dokter Djawas and Indies physicians associated to improve their position. The problem of diagnostics was taken by them as an opportunity to profile themselves on the Netherlands Indies mental health market.
Like Engelhard, other psychiatrists – notably Feico Herman van Loon and Petrus Henri Marie Travaglino – had applied themselves in reifying the Indies mind, drawing sweeping conclusions from poor evidence. In fierce reaction to their writings, Indies physicians like psychiatrist J.A. Latumeten critiqued its pseudo-scientific character. Their problem was not the mapping of the ‘native mind’ as such. It was an issue of competence. In several publications it was remarked that most of the European physician hardly spoke Malay or any of the other local languages, and they did not understand the archipelago’s many cultures, customs nor history; all of great importance in psychological examination. Because of reasons like these, Kits van Heyningen had introduced peculiarity note books to the psychiatric wards. Indies physicians, on the other hand, took the problem of diagnostics and the developing of a psychology of Indonesians as an argument for the education of Indonesian physicians and the creation of research facilities staffed by Indonesians.[22] Who else was in a better position to diagnose their ills?
Scholarship on colonial psychiatry has had a tendency to focus on colonial psychiatry as discourse, somewhat neglecting its everyday practices and social functioning.[23] Because of this, it has failed to demonstrate the problems and challenges psychiatrists working in the colonial world had to face. It fails to show how, in the colonies, psychiatry had to be reinvented to some extent. Not only did cross-cultural encounters result in a conceptual renegotiation of race, culture, sociology, and biology as causes of mental disease, more practical matters such as how to construct a mental hospital in tropical countries or how to diagnose the indigenous population forced psychiatrists to be creative.
In providing creative solutions, these physicians walked a thin line between anthropological sensitivity and racial prejudice, as is nicely illustrated with the picture research by Engelhard. He did seem to realize that pictorial representation is culture-bound, but nevertheless concluded that the Javanese were child-like and naive. On the one hand, this analysis shows that the production of knowledge is not value-neutral, but that is hardly an original remark. More intriguing – and speculative – is the possibility that the aim of the tests desired by Kits van Heyningen and Engelhard was not to study the native psyche per se, but to have a tool in the social process of establishing who was mentally ill, that is to say, who was entitled to enter the asylum. In the Netherlands Indies, as everywhere else, there was a constant shortage of mental hospital beds, and the doctors needed to be sure that the beds that were available were used appropriately. Moreover, the power of the Dutch in the Netherlands Indies was not absolute, but depended on the cooperation of the Javanese elite. Having an ‘objective test’ might have simplified the negotiation process with the Landraad, or in the case of Kits van Heyningen, might have made it easier to debunk simulation by soldiers who wanted to leave the army.[24] Interestingly, the problem of diagnostics also had a strong social component when discussed by Indies physicians. Here, the issue was a battle of competence and unequal treatment on the medical market. Because of their ethnical background, Indies physicians argued they should be the ones to diagnose their ills. ‘How to diagnose their ills?’ has become the question ‘Why diagnose their ills?’, and for now I will leave you with that.[25]
o-o-o
Image from https://lifevoyagephotoblog.wordpress.com/2013/08/16/wayang-golek/
[1] Warwick Anderson, ‘Where is the postcolonial history of medicine?’, Bulletin of the history of medicine 72 (1998) 522-530, 526.
[2] In 1904, for example, the German psychiatrist Emil Kraepelin, who is often mentioned as the father of modern psychiatry, spent two weeks at the mental hospital in Buitenzorg, the Netherlands Indies, to examine the manifestation of dementia praecox among the Javanese. For his publications on Java, see: E. Kraepelin, ‘Vergleichende Psychiatrie’, Centralblatt für Nervenheilkunde und Psychiatrie 49 (1904) 433-437; Idem, ‘Psychiatrisches aus Java’, Allgemeine Zeitschrift für Psychiatrie und psychisch-gerichtliche Medizin 15(1904) 882-884. At that time, ‘comparative psychiatry’ or ‘racial-psychiatric research’ had already been conducted for more than a century. See: Ana Maria G. Raimundo Oda et al., ‘Some origins of cross-cultural psychiatry’, History of psychiatry 16 (2005) 155-169.
[3] Nathan Porath, ‘The naturalization of psychiatry in Indonesia and its interaction with indigenous therapeutics’, Bijdragen tot de taal-, land-, en volkenkunde 164 (2008) 500-528.
[4] Sumantri Hardjoprakoso, Indonesisch mensbeeld als basis eener psycho-therapie (Utrecht 1956); Raden Marat, Über die Genese von Neurosen in Indonesien und die Übertragbarkeit der europäisch-amerikanischen Therapie auf solche Neurosen (Tübingen 1959).
[5] Nathan Porath, ‘The naturalization of psychiatry in Indonesia and its interaction with indigenous therapeutics’, Bijdragen tot de taal-, land-, en volkenkunde 164 (2008) 500-528, 508.
[6] A. Kits van Heyningen, ‘Psychiatrische expertise’, Geneeskundig tijdschrift voor Nederlandsch-Indië 63 (1923) 48-68, 57.
[7] Ibid., 56.
[8] Ibid., 62.
[9] The question arises if this solution really evaded the problems with association tests, were these problems not simply expanded? Kits van Heyningen was not particularly clear on this point, but I believe his idea was rather simple. As with association tests, the patient is shown a word or a picture, but instead of waiting for the patient’s verbal response (e.g., Tree – Forrest), you measure his or her physical reaction. Because only a physical reaction is measured, you do not have to explain patients what to do.
[10] C.F. Engelhard, Het onderzoek naar de geestesgesteldheid met behulp van platen, toegepast bij den Javaan (Leiden 1923).
[11] C.F. Engelhard, ‘Het onderzoek naar de geestesgesteldheid met behulp van platen toegepast bij den Javaan’, Geneeskundig tijdschrift voor Nederlandsch-Indië 63 (1923) 734-750, 740.
[12] C.F. Engelhard, ‘Psychiatrische ervaringen bij Javanen in Midden-Java (1919-1922)’, Maandblad voor geestelijke gezondheidszorg 3 (1948) 231-251.
[13] Engelhard, ‘Het onderzoek naar de geestesgesteldheid met behulp van platen’, 738-9.
[14] O.H., ‘Een onderzoek naar de geestesgesteldheid van den Javaan met behulp van platen’, Djawa 3 (1923) 132-139, 132.
[15] Engelhard, ‘Het onderzoek naar de geestesgesteldheid met behulp van platen’, 742.
[16] Ibid., 749.
[17] C.F. Engelhard, ‘Psychiatrische ervaringen bij Javanen in Midden-Java (1919-1920)’, 231.
[18] Hans Pols, ‘Psychological knowledge in a colonial context: Theories on the nature of the “native mind” in the former Dutch East Indies’, History of psychiatry 10 (2007) 111-131; Hans Pols, ‘The nature of the native mind. Contested views of Dutch colonial psychiatrists in the former Dutch East Indies’, in: Sloan Mahone and Megan Vaughan (eds.), Psychiatry and empire (London 2007) 172-196.
[19] O.H., ‘Een onderzoek naar de geestesgesteldheid van den Javaan met behulp van platen’, Djawa 3 (1923) 132-138.
[20] Ibid., 138.
[21] Hans Pols, ‘The paradoxical position of Indies physicians in colonial society and the founding of the Association of Indies Physicians.’ Manuscript, forthcoming.
[22]Pols, ‘The nature of the native mind’, 188.
[23] The writings by Waltraud Ernst on asylums in India and Jonathan Sadowsky on psychiatry in Africa should be mentioned as valuable exceptions. Another exception is Hans Pols, ‘The psychiatrist as administrator. The career of W.F. Theunissen in the Dutch East Indies’ Health & History 14 (2012) 143-164. About the discourse-analytic character of historiography on colonial psychiatry, cf. Richard Keller, ‘Madness and colonization. Psychiatry in the British and French Empires, 1800-1962’, Journal of social history 35 (2001) 295-326.
[24] This too can be seen as a social process of negotiation between the doctor and patient, the doctor in need for an objective test to show the patient he knows the patient is simulating mental ailment.
[25] I would like to thank Hans Pols and Ivan Flis for valuable comments on an earlier draft.