Edington on Ng, 'Till The Break of Day: A History of Mental Health Services in Singapore, 1841-1993'
Beng Yeong Ng. Till The Break of Day: A History of Mental Health Services in Singapore, 1841-1993. Second Edition. Singapore: National University of Singapore Press, 2017. 340 pp. $34.00 (paper), ISBN 978-981-4722-40-7.
Reviewed by Claire Edington (University of California San Diego) Published on H-Asia (November, 2019) Commissioned by Bradley C. Davis (Eastern Connecticut State University)
Printable Version: http://www.h-net.org/reviews/showpdf.php?id=53564
In Till the Break of Day, Ng Beng Yeong traces the institutional history of the Woodbridge Hospital, from the early days of colonial Singapore when it was first known as the “Lunatic Asylum” through the postcolonial-era expansion of mental health services and the growth of private psychiatry. One of the stated goals of the book is to “understand contemporary attitudes to and treatment of the insane” (p. 3) and to that end it provides a comprehensive view of the main shifts in the architecture, patient population, treatment regimes, and legal regulations that shaped the development of local psychiatry in its current form. For historians and practitioners of psychiatry in South and Southeast Asia, this book fills a notable gap in the literature by its focus on the Singaporean story, which has been eclipsed by other studies of British colonial psychiatry, most notably of India. Indeed, this book appears as part of a surge of interest in the history of colonial medicine in the region, and the history of psychiatry in particular, yet it escapes some of the main questions that have animated the field in recent years, including concerns about cross-cultural exchanges of knowledge and the role of psychiatric institutions in the broader social and political ecology of empire (and its aftermath). Rather, the book’s interpretative stance and narrative form—which relies on long block quotes from doctors and bureaucrats—tends to reflect the author’s primary training as a psychiatrist rather than historian.
The book begins with the establishment of the colony’s first dedicated institution for the treatment of the insane in 1841. Limited to thirty beds, the Lunatic Asylum provided only the most rudimentary form of custodial care to patients who tended to float from one carceral institution to another. Mirroring trends in British psychiatry, the 1850s witnessed a shift away from mechanical restraints and toward an embrace of moral treatment. Under the direction of Thomas Oxley, the Senior Surgeon of the Straits Settlements and asylum’s director, occupational therapy was introduced as a way not only to humanize (and economize) confinement but also to improve the asylum’s public image. As in other parts of the world, these institutions faced chronic problems of rundown facilities, limited staff, and pervasive stigmatization, which meant patients arrived only at the point of severe mental illness and often sick with other infections.
The British influence on Singaporean psychiatry emerges as a key theme, from the training of doctors to the legal infrastructure of the mental health service. The fact that Singapore adapted insanity laws from India, themselves already adapted from the metropole, is fascinating and merits further study that might help to place the experience of the Straits Settlements, and Singapore in particular, in more distinct relief. Indeed, Singapore, as an important trading hub in the region, was marked by unusual levels of urban density and racial diversity that shaped pressures on the state provision of psychiatric care. In the late nineteenth century, Ng writes, immigration to Singapore was reflected in the “increasing ethnic and cultural diversity of persons seeking mental health care” (p. 153). While the asylum’s population was comprised mostly of Chinese patients, the Malay represented the majority of the general population. This is how colonial doctors explained the underrepresentation of Malay patients, an observation which seems to slide into the author’s own assessment: “It was noted that the Malay race was under-represented among psychiatric in-patients. The reason was probably because Malays were more conservative and preferred to seek native treatment. It was doubtful if the reason was a higher tolerance for mental patients” (p. 149). The fact that these communities may not have viewed people as suffering from mental illness in the same way—as diseased individuals who required expert surveillance in state-run institutions—is not considered, only their preference for “native treatment” and their “tolerance for mental patients.” When Ng writes, “Malay villagers came in time to accept the efficacy of European medicine” (p. 157), we must question the empirical basis on which such a claim is made.
While author does draw attention to “alternative care pathways” (p. 157) provided by indigenous healing traditions, more could have been done to acknowledge the other (layered) pathways which led people to the asylum, namely the social and economic dislocations produced under racially discriminatory tax and labor policies throughout the region. In fact, colonial racism is primarily discussed not in terms of a motivating factor for confinement but rather as a barrier to more effective care. The presentist orientation of the book comes across most clearly on p. 113 when the author writes, “Racial stereotyping adopted by the colonial doctors indirectly implies a failure to tailor treatment plans based on individual needs. The greatest challenge of psychiatry in a multiracial and multicultural society is the heterogeneity of patients and their needs. This heterogeneity poses both theoretical and practical difficulties. The key must be in individualizing care.”
In a way, one could treat this book as itself a historical text that provides insight into the unease of some Western-trained psychiatrists in addressing problems of disease classification—as unstable, historically contingent, and culturally specific. For example, Ng emphasizes how psychiatrists need to recognize the “unique idiom of the patient’s culture of origin,” especially when their “beliefs and practices about disease are not derived from modern science” (p. 164), and that “traditional and culturally based beliefs” should be integrated into diagnostic and therapeutic regimes unless “they seriously interfere with the patient’s treatment” (p. 161). The author further describes the difficulty faced by European psychiatrists in obtaining an “accurate history” (p. 38) from their patients due to translation problems and cultural differences. The causal factors driving patients to the asylum may not be “very reliable” (p. 38) in terms of sketching a patient’s psychiatric background, at least according to colonial doctors, but they can reliably tell us something else about Singaporean society to the extent they touch on experiences of worry, overwork, domestic abuse, pregnancy, and financial hardship. For instance, the author gives a fascinating albeit brief account of the koro epidemic that swept Singapore in 1967 and the hysteria epidemic that followed in 1973. The facts that the former was tied to rumors about pork contamination and vaccine use, and the latter spread among Malay female factory workers, could offer a valuable window onto the city’s social history during this period. They also could help us to understand what psychiatrists at the time saw as the limits of available Western classificatory and diagnostic tools.
The last section of the book focuses on the shift from hospital-based psychiatry to community care after World War II. Ng describes the introduction of insulin coma therapy in 1948 and the later active use of psychotropic drugs, which greatly reduced hospitalization stays. Attention to the role of psycho-pharmaceuticals in guiding the biological orientation of Singapore psychiatry is a real strength of this book, and provides some of its more worrying insights: “The synergism between social management of the patient and major tranquilizer effects is probably the most important aspect” (p. 279). Ng locates the true coming of age of Singaporean psychiatry in the 1980s, marked by a decentralization of psychiatric care into many different services: nursing, psychological service, medical social work, and occupational therapy, as well as the advent of private psychiatric clinics.
Ng mobilizes an impressive number of archival materials—drawn largely from institutional records, medical reports, and the published work and personal communications of doctors—many of which are reproduced at considerable length within the body of the text. As a result, the narrative often feels truncated but also takes on an experimental quality. To the extent this book offers a multifaceted account of the history of a single psychiatric institution in Singapore, spanning the colonial and postcolonial eras, it invites its readers to draw comparisons and connections with other parts of South and Southeast Asia. To the extent it adopts a clinician’s point of view, endeavoring to be sensitive to the needs of populations not operating within a Western medical tradition but nevertheless privileging a Western perspective, readers will need to continually question how distinctions between traditional and modern, local and Western, empiric and scientific, come to be framed in these terms in the first place.
Citation: Claire Edington. Review of Ng, Beng Yeong, Till The Break of Day: A History of Mental Health Services in Singapore, 1841-1993. H-Asia, H-Net Reviews. November, 2019. URL: http://www.h-net.org/reviews/showrev.php?id=53564This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.