INTRODUCTION
There are no arbitrary confinements, there are only arbitrary releases.Footnote 1
In 1931, Dr. Augagneur, the director of the Bien Hoa asylum, located 40 kilometers outside Saigon, quoted these words of Gaëtan Gatian de Clerambault in the introduction to the asylum's annual report. De Clerambault, a French psychiatrist who had worked in the 1920s as the head of the Infirmerie du Dépôt in Paris, was defending his profession against accusations of capriciousness and neglect that forced in some instances the early release of patients. Like the directors of Parisian asylums in the late nineteenth and early twentieth centuries, directors of psychiatric institutions in French Indochina throughout the interwar years faced problems of serious overcrowding and public pressures to both confine and release the insane. Asylum care in Indochina suffered from insufficient space and resources, and came to be marked, out of necessity, by high rates of patient turnover. Even at the height of psychiatric activity in Indochina, in the 1930s, annual asylum reports clearly reveal that the majority of Indochina's insane spent their lives not confined in psychiatric institutions but circulating in and out of asylums, jails, hospitals, poor houses, and family homes.Footnote 2
In this paper I argue that the ways in which people moved in and out of psychiatric care were not arbitrary but instead shaped by complex negotiations between psychiatrists, colonial authorities, and the public, especially families. Confronted with the reality of few experts living in the colony, French bureaucrats and doctors developed mechanisms to regulate the confinement and release of the mentally ill which provided for and indeed depended on the critical participation of families and communities for information, surveillance, and care. Investigating the processes of going in and getting out of the colonial asylum reveals the ways in which lay people participated in the negotiation and exchange of ideas around what it meant to be “abnormal,” as well as in disputes over what it meant to be, in the words of one French colonial psychiatrist, “sufficiently improved” as to return to society.
Debates revolved around not only the mental health of patients but also the capacity of their families to assume their care upon their release, and whether the asylum itself was the most appropriate site for treatment and rehabilitation. I will argue that situating the history of psychiatry in Indochina within exchanges that transcended the asylum's walls provides a critical vantage for exploring contests over the legitimate aims and forms of colonial psychiatric practice, the historical relationship between families and the colonial state, and evolving ideas about what it meant to be a normal productive member of society in French colonial Vietnam.
TRACING A COLONIAL “MICROPOLITICS” OF CARE
Historians of colonial psychiatry have generally dismissed the notion of an imperial “Great Confinement,” and have increasingly considered the field's development from perspectives outside the confines of the institution: in the context of the development of international scientific networks, as a forum for colonial debates over the obligations associated with the civilizing mission, and in terms of how knowledge of the “native mind” served as a guide for colonial policymakers. From this growing body of research spanning India and the Pacific, East Africa and the Maghreb, has emerged a picture of a profession whose science became less a tool for social control than an important means for underwriting the ideologies and structures of colonial power.Footnote 3 At the same time, these studies have tended to conclude with the caution that, in Megan Vaughan's words, “We should not overestimate the role played by professional psychiatry in the history of modern imperial projects.”Footnote 4
While careful to emphasize the limits of psychiatric authority in colonial settings, scholars typically define those limits at the point at which colonial experts lost their hegemony, whether due to cultural misunderstandings, a lack of resources, or active resistance within the asylum itself. Yet scholars have mostly stopped short of asking what the limits of expert authority can reveal about the social histories of the places under consideration and, in particular, about the roles ordinary people played in shaping these histories outside a strictly European psychiatric sphere of control. As a result, these works often miss the ways in which hybrid forms of power and knowledge were produced in spaces where experts continued to exert their influence yet were also forced to engage with local understandings of and practices around insanity. In what follows, I argue that by considering the imposition of limits on colonial psychiatrists as a process of daily negotiation and exchange, we find less the shortcomings of a hegemonic European science than the emergence of a more diffuse, and localized, brand of psychiatric power forged between experts and non-experts.
By considering the movements of asylum patients as the product of everyday interactions between lay people and experts, I depart from the work of scholars who concentrate on how colonial psychiatry provided a new scientific language for framing a discourse of racial difference, and how it figured within a wider biopolitics of colonial rule. Historians have mostly ignored the social histories of the asylums themselves and how they functioned within local colonial political systems. Here I draw inspiration from Peter Zinoman's work on the history of the colonial prison in French Indochina, in which he seeks to “understand the effects of colonialism by reconstructing specific patterns of institutional practice and examining their social and political consequences within the society in which they were deployed.”Footnote 5 Zinoman challenges Foucauldian accounts by arguing that colonial penal institutions, in their daily operation, represented a hybridity of modern and premodern forms of power that co-existed, fostered instability, and produced critical fissures that were exploited by subaltern movements.Footnote 6
If we are similarly attentive to the dynamics of institutional practice, as opposed to discourse, the asylum emerges less as a blunt instrument for the social control and medicalization of colonial society than as a valuable historical site for reframing narratives of colonial repression and resistance. Here I will consider the development of psychiatry in French Indochina as a hybrid field of medical knowledge produced in exchanges between families and doctors, colonial bureaucrats and colonial subjects. I consider Vietnamese families as agents who, in the context of psychiatric care, pursued their own strategies of negotiation, collaboration, and sometimes subversion. Armed with a different set of cultural beliefs and healing traditions, they nevertheless engaged with professional French psychiatrists to find common space for thinking about and discussing mental illness. Families in their letters to asylum directors worked to alternatively inform and challenge the coding of certain social behaviors as “deviant” as well as notions about what counted as psychiatric knowledge as the basis for confining and releasing patients. Studying how colonial experts came to rely on patients' families, neighbors, and relatives highlights the creation of new kinds of spaces for surveillance; instead of treating the institutional and the familial as fully discrete realms, we can begin to understand how they worked to police each other. The ways in which families and communities interacted with colonial psychiatric institutions, I contend, resulted not in the dissolution of psychiatric power but rather in opportunities for its elaboration.
It is important to underscore that these exchanges did not occur between equal partners but among colonial actors with differential access to power and resources, not to mention the patients themselves who were typically excluded from these deliberations. But in debating the suitability of individuals to participate in normal social life, experts and lay people pursued their own strategies in ways that complicate standard narratives of colonial hegemony and resistance. For instance, not all colonial officials agreed on whether to confine certain patients, and the desires of families to take care of the mentally ill at home often clashed with those of their neighbors. Indeed, some families pleaded for the release of family members from the asylum while others challenged the refusal of colonial doctors to exercise the power of confinement. Remarkably, most of these discussions occurred during the 1920s and 1930s, a period of high political drama in Indochina marked by prison revolts and the birth of the anti-colonial nationalist movement. In many ways this is a different kind of story, about how ordinary people used colonial institutions for their own ends, and interacted with colonial experts in ways that helped specify the conditions under which the state could remove individuals from society, both for their own sake and the sake of others.
Recent works in the history of psychiatry have begun to look much more closely at the dynamic between patterns of informal family care in communities and formal medical treatment in institutions. Studies of linkages between the family and the asylum, and increasingly the crucial intermediary roles played by friends, neighbors, and community members, have led scholars to reexamine prior assumptions about the social roles of nineteenth-century asylums. Many, like David Wright, now argue that the confinement of the insane, as well as their discharge and reintegration into the community, resulted from the participation of a diverse array of social actors; not, for example, as a “consequence of a professionalizing psychiatric elite but rather as a strategic response of households to the stresses of social change or economic depression.”Footnote 7 As Joseph Melling writes, the emphasis in current research on the detailed reconstruction of the social and cultural contexts of lunacy provision has enabled us to explore a “micro-politics of care,” which shows bargaining among different actors with unequal power resources and capacities but who could nevertheless exert some degree of choice if not control over their environment.Footnote 8
These studies have brought critical attention to the role of extra-institutional care, and rather than portraying a Great Confinement they insist on the historic permeability of the boundaries between asylum and community. However, few have looked beyond nineteenth-century histories of Western and especially British psychiatry.Footnote 9 In the colonial literature, references to local actors and indigenous understandings of mental illness are used primarily to frame discussions around the cultural relativity of diagnostic categories, yet families rarely figure as key participants in the colonial psychiatric system or as actively shaping the system as it developed.Footnote 10
In tracing the development of a kind of colonial “micropolitics of care,” I draw mainly from patient case files, community surveys, and asylum reports, with a focus on those provinces that comprise what is now known as Vietnam. While colonial asylums in Indochina housed both indigenous and European men and women, I focus on Vietnamese patients, and particularly men, who formed the overwhelming majority of the asylum population.Footnote 11 The first section, “Going In,” discusses the roles that families and communities played in shaping the process of confinement and how their roles changed with the shifting norms of institutionalization. The next section, “Getting Out,” considers letters that family members wrote to request the release of patients, and how these requests were assessed based on determinations of both patients' health and the care-taking abilities of their families. Embedded in these assessments, offered by both doctors and families, are competing notions of what it meant to be normal enough to live in society, and of the nature and function of surveillance outside the walls of the institution.Footnote 12
GOING IN
In 1927, a fifty-seven-year-old farmer named “Cac” was convicted of setting a fire that killed a nine-year-old child and condemned to fifteen years of hard labor. After a psychiatric exam found Cac irresponsible by reason of insanity, he was sent back home to live with his family. In response to a request from the colonial provincial head about the possibility of his internment at the Bien Hoa asylum as a “preventive measure,” the local director of health called for a new administrative inquiry that would look into Cac's “attitude, his acts and his sociability” since he had reintegrated into his village, as well as a medical certificate describing signs of dementia that could justify his internment. The author of the inquiry, conducted in the village of Gia-Hoà in Sontay province where Cac resided reported back saying, “The mandarin let me know that since his return to the village, Cac has lived a peaceful life, without experiencing any new crises, and not doing anything abnormal.”Footnote 13 A doctor's mental exam also found no signs of psychiatric disturbances, but warned that the crises could reappear. Based on these eyewitness and expert reports, the director of health expressed serious doubts about renewing Cac's confinement. Internment in an asylum, he argued, “could only be justified by actual mental troubles, or by default, by a ‘fonds démentiel’ that allows one to conclude the risk of a relapse that could endanger the security of persons or the public order.”Footnote 14
This episode highlights how lay accounts were as important as expert opinions in shaping decisions to confine the mentally ill. In particular, the power to intern patients depended on the assistance of families and communities, who could provide doctors with critical information about long-term behavioral patterns and the specific circumstances surrounding a recent “crisis.” In the 1930s, when French psychiatrists working in Indochina began to speak about the virtues of preventive care and the need to create a clientele for psychiatric services, the role of the family was reshaped. The idea of a “fonds démentiel”—literally, a demented foundation or background—signaled not only a shift in the norms of institutionalization but also a growing concern among doctors to identify early warning signs so as to avoid confinement entirely, a process in which the family was expected to play a major role. The concern here is therefore to situate the process of confinement within a social landscape marked by a diversity of actors that contributed to shifting colonial ideas about what it meant to be “abnormal,” and to demonstrate the extent to which expert practices relied on the intervention of the public.
Mandated Placement
Before the first asylum was opened in Cochin China in 1919, the colonial state relied almost entirely on families and communities for information and surveillance of the mentally ill, with only the most extreme cases sent to special pavilions in hospitals or repatriated to France.Footnote 15 In 1887, the administrator of Thu Dau Mot province wrote to the director of the Interior Service complaining of the lack of expertise and the continued absence in Cochin China of any decree prescribing the legal process of confinement, “Since the beginning of the year three lunatics have already been sent to Chô Quan Hospital…. It is impossible for me, given the absence of a doctor, to testify as to the mental state of the patients that I send to Chô Quan; I am obligated to bring back the testimony of their families, their neighbors and the authorities of their village.”Footnote 16 Investigations were often prompted by the concerns of community members, as in one 1912 case when it was reported, “This individual is a continual source of anxiety, his neighbors are in effect obligated to exercise on him a continual surveillance in the fear that he will set fire to the village and would be very happy to see him locked away.”Footnote 17 Given the scarcity of experts, the observations of notables, in addition to those provided by the police, attained their own kind of authority, prompting one police commissioner to declare, “It appears to be superfluous to submit [the patient] to a medico-legal exam.”Footnote 18
This practice of “enquêtes,” or administrative inquiries, continued throughout the asylum era as procedures for internment became increasingly formalized. In 1918, the Bien Hoa asylum was established outside Saigon along with the colony's first legal regulations around psychiatric care. In 1930, the French law of 1838 regulating asylum care was officially extended and adapted to Indochina. This law included provisions for a psychiatric assistance system that grew to include a network of psychiatric services in major hospitals and, in 1934, the establishment of a second asylum in northern Tonkin. Asylums received both European and Vietnamese patients, who were segregated into pavilions according to their race, gender, and the severity of diagnosis. In charge of these services were French doctors who had either received specialized training in psychiatry in France or had earned their degrees in tropical medicine and worked up through the ranks of the colonial medical service. In 1934, the Ecole de Médecine in Hanoi added psychiatry to its curriculum as part of the advanced training of Vietnamese doctors who came to staff the psychiatric assistance program and eventually assumed control once the French left Vietnam in 1954.Footnote 19 A staff of nurses, guards, and coolies assisted doctors with the daily care and surveillance of patients, the administering of medicines, and the translation of patient demands into French.
As in France, there were two principal ways people could find their way into an asylum: either a “placement ordonné,” or “mandated placement” requested by the administrative authorities, or a “placement requis” initiated by the patient's family, relatives, or friends. Each required a medical certificate confirming an insanity diagnosis, which was issued only on a temporary basis. At the end of six months, confinement could become permanent depending on the patient's medical progress. Psychiatric expertise became routinized as part of the internment process, which worked to expand the legitimate terms of confinement. The 1930 law, for example, extended the grounds for confinement under a placement ordonné, from disturbing public security, tranquility or decency to include more medically grounded justifications for those who risked their “own security or possibility of cure.”Footnote 20
Local investigations to determine what happened to provoke internment represented a key first step in initiating a placement ordonné. Following an incident, the police commissioner would call for a “small inquiry in the quarter … if an inoffensive mad person, recommend stay with the family. If not sure, send to hospital for an exam.”Footnote 21 In this way, non-experts continued to play a powerful role in framing diagnosis and the grounds for confinement. In some instances, anticipation of possible objections by families and other colonial officials led doctors to adopt an essentially defensive posture when pursuing internment. As the governor general urged in 1928, in order to avoid “any later complaints,” it is “indispensable to establish for each patient whose internment is initiated by public authority an order of placement expounding the motivating circumstances which make it necessary.”Footnote 22
These “motivating circumstances” were established by community surveys that inquired after the mental state of the soon to be, or just recently, admitted patients. Distributed by asylum directors to local notables as a routine part of the confinement process, survey questions in the 1930s followed a newly standardized format:
(1) Do you find (person) abnormal? If so, since when?
(2) Has he or she committed any eccentricities? In the affirmative, what kinds?
(3) Is he or she capable of working?
(4) What is their conduct toward the other habitants in the village and the members of their family?Footnote 23
The answers to these surveys provide a rare glimpse into how families and neighbors, in being asked to offer their own impressions of the mentally ill in their community, contributed to the development of colonial psychiatric knowledge. In a 1934 letter accompanying a survey of local inhabitants, one asylum director asked, “Have you heard people say in the quarter that Phuc is abnormal? Interrogate neighbors on this subject.” And “Have you yourself ever noticed any eccentricities by this individual, and if so, which kinds?” In response, Tin, the chief of Phuc's quarter in Hanoi, said that his neighbors insisted on his good conduct and claimed that he never violated the law. However, Tin shared his own impressions of an “allure anormale” that contradicted observations by Phuc's neighbors, suggesting they might have tried to protect him from the asylum: “[He] breaks into the houses of his neighbors without motive; left school; wanders all day in the streets; when there is a procession or a vaccination doctor in the quarter, he pretends to be very knowledgeable even though he has no idea. And finally, from time to time, he plays tricks on his parents as one does with small children.”Footnote 24 This idea of an “allure anormale” highlights the kinds of eccentric but innocuous behaviors that the community had coded as deviant but clearly learned to accommodate.
For those “lunatics” who routinely antagonized their community, the results from the inquiries left no room for interpretation. Acts of violence, theft, or arson represented the most common reasons for families and communities to seek confinement for the offending patient. A 1926 report from the chief of security in Bac Lieu province found that, according to the local population, Andre G. was considered “cracked, he is without profession, injures anyone who refuses him charity and will ride in a rickshaw for hours and for payment, hits the coolie.” A métis abandoned by his French father, Andre had become such an object of terror in his community that one doctor insisted on his confinement in an asylum rather than imprisonment because “weakened or disabled in the head, Andre is resistant to sanctions as is shown by the numerous times he has been their object.”Footnote 25 In some cases, clear conflicts emerged between a patient and their community, shedding light on the strategies that each pursued in his or her representations to colonial authorities. In response to the notables of one village, whose report declared that “Hoc” had been “always crazy” for at least the previous three years, the doctor noted the inconsistency with the statement by the patient, who countered, “that besides those periods which he had told of, he stayed absolutely normal.”Footnote 26
Families were also in a position to offer specific information that psychiatrists used in making their diagnoses. Questioning the family and neighbors of the patient both before and during a crisis was important because, as one French psychiatrist pointed out, “It is the element that we are missing.”Footnote 27 For example, the father of one patient described a turning point when his son began to suffer from strange episodes. He provided quite a detailed account of what French doctors later deemed epileptic fits, which “began only three years ago, suddenly when Hang had a bizarre crisis, sat on the ground, swaying his body, his legs trembling and in the end declared himself a God.” Neighbors and communal authorities later confirmed that Hang had indeed been “caught by madness.” They reported that these crises occurred every month or two, during which Hang, possessed by spirits, would run wildly down the street and unfailingly attack passersby.Footnote 28
Doctors clearly took lay views of symptoms and behaviors seriously and incorporated them into their own diagnoses. While Hang's psychiatrist later recorded that Hang displayed no symptoms during a twelve-day period of observation, he nevertheless emphasized the regularity of the fits reported by the communal authorities and diagnosed Hang as a “para-epileptic” with a probable cerebral infection. Cases like Hang's also reveal the points of consensus that emerged between families and doctors regarding the presence of mental disability that required responsible oversight. Hang's father, for instance, reported that he would notice the onset of symptoms warning of an impending “crisis” and was entrusted by his neighbors with Hang's surveillance until the period of danger had passed. He also periodically cut his son's long unruly hair as a way to “refresh his head,” revealing that while beliefs in the causes and remedies of mental illness may have varied, the notion that illness was rooted in the brain and that “abnormal” status derived from public displays of anti-social behavior provided common ground for making claims about “insanity.”
Colonial psychiatrists clearly became frustrated, however, when they believed families willfully fed them ambiguous or misleading information,
We have only been able to receive rather vague information on the acts and movements of our subject, watched over by the members of his family since the moment he was returned the last time until the day he was found guilty of the crimes that he is now accused of. How did he comport himself throughout this one-year time lapse, exactly what did he do? It is difficult to know, since we believe that it would be childish to absolutely believe the words of people who lie by nature and who, moreover, have a reason to hide more or less the truth. It might be better to believe entirely what the accused has to say himself.Footnote 29
Despite their doubts as to the quality of information they received, the frustration evident here nevertheless underscores the extent to which psychiatrists depended on those who knew the patient best. It also reveals how families and neighbors sometimes did all they could to obstruct the efforts of colonial authorities from sending patients back to the asylum. In one extreme case, on the evening of the 6th or 7th of February of 1909, a patient's own family kidnapped him in order to prevent his confinement in a psychiatric ward at Chô Quan hospital. By the 9th, despite leads from local notables, he had yet to be found.Footnote 30
Requested Placement
By the 1920s, the seeming reluctance of families to bring in their mentally ill for care became a major concern for French colonial psychiatrists, who worried that they only received patients once they were beyond hope. French experts attributed the hesitation of families to a popular stigma against mental illness and imprecise notions that the “mad” were less gravely ill than they really were. Scores of colonial texts from the period remark on the superstitious and “credulous” nature of the Vietnamese people, who were said to explain mental illnesses in terms of divine retribution for prior sins.Footnote 31 As one provincial chief explained, “According to native beliefs, the cause of madness is entirely spiritual, such as the poorly chosen site for ancestral burial grounds, the unfortunate orientation of the family tombs, the breach of diverse rites or forms of worship, all causes that indispose the spirits and lead them to pursue the guilty individual.”Footnote 32 Mental illness implied not only a condemnation of the individual but also an indictment of the honor of their family as a whole, which was charged with the duty of caregiving.Footnote 33 “For these reasons,” as one 1903 report stressed, “families probably will not voluntarily consent to entrusting the insane to the administration in order to place them in a special asylum. They refuse to believe that our doctors can cure them.”Footnote 34
Reinforcing these views was the unfavorable image of asylums propagated in the local newspapers that likened them to prisons, and their personnel to prison guards “preoccupied only with guarding as many patients as possible.”Footnote 35 According to one doctor, concerns over exposure to the other mentally ill patients in the asylum prompted many Vietnamese to declare, “To be enclosed here and not become completely mad!”Footnote 36 And, as another stated simply, “Prima facie the thought of a long confinement frightens families.”Footnote 37 As a result, the asylum was envisaged as a place of last resort, “All of these prejudices, these inaccurate critiques have created a frame of mind of which the principal result is that confinement is only envisioned as a final measure. A number of patients have waited until the last moment when it is too late and … [their illness is] often irreparable.”Footnote 38
Concerns that the majority of the mentally ill remained out of reach, especially those in isolated rural regions, continued to plague colonial psychiatrists throughout the 1930s. Yet some began to express hope that the population had grown more accustomed to the necessity of psychiatric care.Footnote 39 For these optimists, the increasing relative numbers of placement requis indicated an apparently “profound modification in the indigenous mentality toward the insane.”Footnote 40 A 1934 report observed that in the province of Bac Giang, out of sixteen internments that year, fourteen originated with the families and only two were ordonnés. In all other provinces, the proportion was reversed. The proximity of the asylum and a firmer understanding of its purpose were thought to be significant factors in encouraging families to present their family members for care. One psychiatrist hoped that as knowledge and awareness increased more families would demand placement rather than keep the insane in their villages under “lamentable conditions.”Footnote 41
One psychiatrist was especially surprised that “the indigenous population has understood more rapidly than we would have believed the goal, the point, of the asylum and we are more and more frequently receiving visits from family who come to demand the formalities necessary for internment, bringing patients in for an opinion and, after cure, maintaining relations with medical personnel in order to continue the required treatments. Also, patients who were given their liberty have solicited their own readmission.”Footnote 42 For doctors, the contact with families was invaluable as a “source of precious information.” Their participation revealed, “Annamite families, even of modest classes, are neither more nor less limited in their inability to understand than European families—I say even, much less. With a little patience, it is always possible to obtain useful information, and it is exceptional that families fail to surrender to our reasons when we explain the necessity of an internment or a prolongation of hospitalization. Little by little, they constitute a veritable clientele of service: those with intermittent crises are brought to us periodically by their families at the first sign of a relapse.”Footnote 43
With the creation of a clientele for psychiatric services, French psychiatrists in Indochina hoped to shift the focus of treatment from long-term asylum care to early prevention and an “open door” model. This turn came as part of a growing international movement for psychiatric reform that spread throughout France, England, Belgium, and Germany, as well as to the United States, Canada, Argentina, Japan, and Norway starting in the late nineteenth century.Footnote 44 With mounting concerns over asylum overcrowding and accusations of negligence toward patients, psychiatrists began to experiment with alternative forms of patient care that relied on the family, and the incorporation of new uses of space and the environment into treatment regimes. In France, the League of Mental Hygiene, founded in 1920, campaigned for major reforms to the asylum system based on a more flexible conception of mental illness as an avoidable and curable disease. Under the direction of Edouard Toulouse, the League advocated for comprehensive services that highlighted prevention and rapid treatment as well as an expanded role for psychiatry in society.Footnote 45
For psychiatrists in Indochina who closely followed the efforts of metropolitan reformers, and those of the Dutch in neighboring Java, the principles of mental hygiene inspired the development of the colony's own psychiatric assistance program. They worked to provide patients with care before the onset of acute psychiatric illness, and stressed the rehabilitation of the chronically ill through labor and “life in the open air.” Asylums were organized as large agricultural colonies where patients could work the land on the path to healing and eventual liberation.Footnote 46 As an essential complement to the asylum system, Indochina's first outpatient clinic was established at Chô Quan hospital in Saigon in 1928, followed by the expansion of similar services in major hospitals throughout the 1930s, including those specifically geared toward the treatment of “abnormal” children.
This more flexible and dynamic approach to mental illness also projected the cosmopolitan attitude of colonial psychiatrists who sought to participate in the growing international movement around mental hygiene and, in some instances, to position themselves as more progressive even than their metropolitan counterparts.Footnote 47 A 1926 report authored by the director of the Bien Hoa asylum, for example, boasted that Indochina's psychiatric services made patients in the colony the envy of those in metropole. He noted that with the exception of Madagascar, France's African colonies continued to lag far behind. Even in Tunisia, where Antoine Porot's clinic opened to much acclaim in 1911, innovations arose, but only in the context of the treatment of European patients. While considered a crucible for colonial mental health reform, Algeria did not adopt a more comprehensive system targeting indigenous communities for another two decades. Instead it was Indochina that in the 1930s earned the praise of international onlookers for having made the “most serious efforts” regarding psychiatric assistance in all the empire.Footnote 48
The 1928 creation of a neuropsychiatric clinic in Saigon thus borrowed much of its early design from open services attached to psychiatric hospitals in Paris.Footnote 49 Whereas the asylum received chronic cases that took years to resolve, this open service assured triage and treatment en cure libre for milder cases as well as those who demanded more immediate care. Not only did the service encourage the early detection of mental illness and prevent more serious forms from developing, but it also reduced costs associated with confinement and assured those “petits malades” a more rapid “social recuperation.” Between 1928 and 1934, the clinic doubled its patient load while decreasing the average length of treatment to just fifty days. The service also reduced by more than half the number of confinements in the asylum by hospitalizing those who could be cured more quickly. The numbers of patients leaving the service for reasons other than internment, such as cure, improvement, or repatriation, also jumped from just two in 1928 to 110 in 1934.Footnote 50
As clients of psychiatric services, families were asked to more actively participate in psychiatric care. For French psychiatrists, this required the Vietnamese share basic understandings about mental illness as something that could be prevented and cured under the proper surveillance of experts. The organization of an “open service” was deliberately aimed at shifting the perspective of those families who continued to “hide their lunatics, drag them from pagoda to pagoda, from sorcerer to sorcerer, before bringing them to us in such a lamentable state that all our methods are ineffective and there is nothing more to do from a therapeutic point of view.”Footnote 51 While some family members remained reluctant to present patients for care, others adopted a more insistent role, even challenging those experts who refused their requests for confinement.Footnote 52
What the French took to be an evolving agreement over the existence of mental illness does not imply that the French and Vietnamese held similar beliefs about the etiology of mental diseases or the appropriate cures—far from it. While Jonathan Sadowsky, in his work on colonial Nigeria, understands this “overlap” as demonstrative of the universal validity of psychiatric disorders, he also stresses ways in which agreement nevertheless continued to be framed in Western terms and served as a powerful means to control socially deviant populations.Footnote 53 Here I am concerned more with how this “overlap” created a common space for negotiation over care. While the categories of “normal” and “abnormal” continued to be framed in Western terms, I want to bring attention to the fact that the content of these categories critically relied on the kinds of information Vietnamese were willing or thought relevant to tell French doctors.
The rise in the numbers of patients treated at Chô Quan Hospital therefore raises important questions about the impetus driving the growth of psychiatric services in Indochina. Were families truly becoming more accustomed to psychiatry as the French suggested, or were there other social forces at work such as the financial crush of the depression of the early 1930s that prompted families to confine the insane? Did the expanding availability of open services generate their own demand, or did the growing demand reflect a more profound transformation in the perceptions of the local population? Throughout the interwar years, Vietnamese families increasingly resorted to institutional-based mental health care when traditional healers were ineffective, or in the event of the failure of asylum care, recommenced their search for alternative therapies. This dual uptake of both Western biomedical and local healing practices reflects the complex and dynamic patterns of therapeutic pluralism in colonial Vietnamese society, as observed by historian Laurence Monnais in relation to pharmaceutical use.Footnote 54 In the context of mental health care, therapeutic preferences shifted with the availability of new forms of treatment in ways that served to broaden rather than replace precolonial strategies for the management of mental illness.
As psychiatric activities diversified and expanded from the treatment of acute mental illness to the identification of underlying abnormalities, a greater reliance than ever was placed on the participation of families and communities. Families continued, however, to pursue their own strategies in ways that both facilitated and constrained the ability of colonial psychiatrists to identify and care for the mentally ill.
GETTING OUT
Families also played an important role in determining patterns of discharge in Indochina. Confronted with the pressure to treat more acute cases, psychiatrists depended on family resources to support temporary or permanent releases for those patients deemed “sufficiently improved.” Once their family agreed to assume responsibility for their care, the patient was repatriated to their home village. Under the 1930 law, this practice became regulated as a “sortie définitive” when the patient was declared cured and released from the asylum or, more often, as a “sortie provisoire” when the patient was subject to a six-month probation outside the asylum. The patient would be placed under a “sanitary” or “medical surveillance” of either weekly or monthly visits by the local doctor who administered medicine, kept track of the patient's progress, and eventually recommended a sortie definitive or reintegration back into the asylum.Footnote 55 Pierre Dorolle, a French psychiatrist and specialist in tropical medicine, emphasized in 1937 that this period was to be viewed not as a break with the asylum but rather as an extension of it: “The congé d'essai [test leave] therefore does not suspend completely the effects of internment from the point of view of restrictions on individual liberty.”Footnote 56
Dorolle praised the 1930 legislation for permitting premature exits from the asylum, “even before cure,” which worked to protect the interests of those chronic patients who would not otherwise benefit from a long confinement. He lauded the innovative quality of the “sortie provisoire” for lending psychiatric assistance in Indochina “a more distinctly medical character.” The legislation also allowed the patient, their spouse, friends, or family members to put in their own request for release and, if denied, to petition the decision to a tribunal for a second expert opinion. Examining letters by family members requesting release, and the responses they received, reveals how the “sortie provisoire” became a flashpoint for extensive negotiations between families, communities, doctors, and colonial authorities. These included competing definitions and assessments of the patient's ability to live in society, of which medical diagnosis formed only one of many considerations, as well as the ability of their families to care for them. Whereas confinement allows us to look at how the abnormality of patients became established through a range of both lay and expert opinions and strategies, the process of discharge raises a different set of questions about what it meant to be normal enough to live in society and the nature and function of surveillance outside the walls of the institution.
Letter Writing
French doctors often claimed in their reports that the Vietnamese were humiliated by the presence of mentally ill family members. The archive of patient case files, however, reveals large numbers of family members, both men and women, who petitioned for their loved ones to be returned home. As David Wright argues, letters by families in psychiatric archives, though little explored, provide rich source material for uncovering those subtle negotiations inherent in the discharge process.Footnote 57
Letters followed a particular format in which families pledged responsibility for the future actions of the patient, enumerated their caregiving qualifications, and stressed their affective ties to the patient.Footnote 58 Family members reassured doctors about the kind of care the patients would receive at home, and most importantly how they would protect them and others from danger. In 1887 one parent wrote, “I engage to watch over my son very closely and to avoid any mishap if he once again falls mentally ill. I will engage, moreover, to keep him at my house at Phuoc Ly where I live and not let him come to Saigon.”Footnote 59 Regarding his “personal surveillance,” one father assured doctors that he would not let his son near any firearms and would allow him to be cared for by the doctor at the medical assistance service in Ninh Binh, where he worked.Footnote 60
In their pleas for release, letter writers stressed their qualifications as responsible caregivers, including declarations of loyalty and devotion to the colonial administration. Many invoked the support of local notables with ties to the administration to bolster their case; for example, “I come here today to request you allow me to withdraw my son from this health establishment. The notables have certified that I am a good father and capable of properly feeding him.”Footnote 61 Access to local elite networks represented an important boon, especially to indigent families, as they advanced their petitions.Footnote 62 Others took more extreme measures. In Cholon in 1927, three brothers of a woman treated at Bien Hoa wrote in their request for her release, “We have reserved for her a small house in the form of an asylum on our property, well aerated, with a garden, in the country, and we give your our formal assurance that the public will not be worried or disturbed.”Footnote 63 Some even argued that their homes possessed important advantages over the asylum, for “the country air and family joy will contribute largely to hastening the cure.”Footnote 64 These arguments for home care relied on declaring the strength of affective ties while also warning of the risk of emotional harm to both patient and family as the result of a prolonged separation. The petitioners quoted above made the following personal plea to colonial administrators: “[Because of] our brotherly … love, we will fall into the same state as the person of interest, which is to say to suffer from the same mental troubles because of the separation,” and this would mean the health of the patient would never improve.Footnote 65
When requests for release were refused, families sometimes continued to negotiate with asylum directors, but around specific aspects of the patient's care. One woman, after multiple failed requests for her husband's release from an asylum, asked that, should he not be discharged, that he be moved into the “paying wing” where he would be provided with better care.Footnote 66 In another instance, before the Voi asylum was opened to the public in 1934, one “panic stricken” family asked the governor of Tonkin to prevent the transfer of a patient to Bien Hoa in the south. They requested “the favor of leaving us, in Hanoi or in the province of Tonkin, our unhappy Man, where he will rest locked up until his death; we only demand the near presence of his family—so that we can have news and bring him whatever is necessary, and on his death, to arrange the necessary ceremonies that are demanded by our Buddhist religion.” Although Man was eventually sent to Bien Hoa, a visit by his wife to the asylum a year later secured the presiding doctor's permission to have him transferred to a hospital closer to home.Footnote 67
The sense of panic that suffused some letters led psychiatrists to write to families to reassure them about the release of the patient concerned. In 1927, the director of Bien Hoa wrote to the governor general in response to a request for a patient's release, “His family can remain calm. I am trying to discharge as many patients as soon as their state no longer presents any danger to society or to themselves. Thirty-six patients have been released since the 1st of January 1927 versus only thirty all of last year.”Footnote 68
While at the moment of admission the inability to work secured the abnormal status of the patient, it was regaining the ability to work that emerged as an important prerequisite for release. To qualify for a sortie provisoire, the patient most often had to demonstrate that their symptoms of mental illness had gone away, which did not necessarily (and often did not) mean that they had been officially “cured.”Footnote 69 This was particularly true for those harmless or “calm” patients suffering from chronic diseases with no hope of a full recovery. Doctors writing in patients' files often associated the disappearance of symptoms with observations such as “he is calm, a good worker.”Footnote 70 In Indochina, where asylum labor played a major role in patient therapy, the ability to work was seen as critical evidence of improvement in the patient's condition. Conversely, those unable to work were often found ineligible for release.Footnote 71
The ability to labor fueled other practical concerns over the patient's capacity to “make a living by [their] own means” upon leaving the asylum.Footnote 72 This emphasis on self-support was not motivated solely out of concern for the patient's welfare; as the local director of health in My Tho province argued in 1920, “Many epileptics earn a living: this disease does not lead to hospitalization for life and perpetual care with costs to the Colony.”Footnote 73 For those households that lost a principal breadwinner to the asylum, petitions for release were also linked to broader strategies concerned with the family's financial survival. In a 1921 letter requesting the discharge of her husband, Le Thi Mai wrote to the asylum director asking for his “return home where he has left the heavy weight of eight children who have become very miserable since the absence of their father who is their sole support.” She was successful, yet the asylum director pointed out that her husband would never be able to provide for his family and had to be kept preoccupied with household chores under surveillance by his wife.Footnote 74
In letters to asylum directors, family members offered their own opinions about the patient's condition and at times asserted that their loved ones had, in fact, improved enough to come home. Families made claims based on either eyewitness accounts from asylum visits or written communications with the patient. The director of the Voi asylum observed in 1934 how families closely monitored confinement: “It is certain that families are interested in their patients. Since the opening of the asylum, 325 visitors have come to Voi. What is more, a correspondence has been established between the asylum and families who frequently demand news. Even after they leave the asylum their families continue to write to let us know what has become of the patients and if they have readapted to normal life.”Footnote 75 Exchanges of information, whether with the patients themselves or with the asylum staff, provided families with the opportunity to make their own determinations about patients' conditions. In 1921, one woman petitioned the release of her husband writing, “My husband lost his reason suddenly after being sick for two months. The notables considered him to be insane and he was sent to the asylum in 1919. But as soon as he arrived … his reason came back to him. The proof is that my sister went to see him two times….”Footnote 76 Others relied on written accounts received from the patient, “Judging from the tone of letters that my husband sends to us, he has a lucid spirit and consequently harmless for his entourage. I must add that I will engage to assume all responsibility of the acts of my husband.”Footnote 77
These family assessments did not always square with those of experts and sometimes generated significant conflicts. Rather than ignore family protests, doctors would often incorporate them into defenses of their diagnoses. In the just-cited example, the psychiatrist at Bien Hoa in crafting his response cited verbatim the family's claims: “Although it actually appears that he is in a normal psychological state, I cannot share the opinion of VO-THI-NGU (mother of the patient) when she writes ‘…vi no thiet manh da lau roi….’ or that of TRAN-TAI (husband of the patient) who writes: …‘now she is cured.’” The psychiatrist draws on language typically used in case files to accuse one of the petitioners, Tran-Tai, of himself being “incoherent” and of “presenting himself with an attitude that ripples with insolence, demanding the immediate release of this patient.”Footnote 78 In responding to challenges mounted by family members doctors at times became exasperated and tried to reassert their expert authority: “The petitioner writes in talking of her son, ‘Nay no thiet manh roi…’ he is now completely cured. That is an assertion without foundation. Ky has received since his admission to the asylum … only one visit, from his brother, and this happened nearly four years ago, that is, two months after his admission. I do not suppose that this visitor possesses the sufficient psychiatric knowledge for him to appreciate the cured or stabilized condition of our patients….”Footnote 79
By quoting the original Vietnamese in their replies, doctors demonstrated the extent to which they took seriously attacks on their expertise even as they skewered the conceit of the petitioners. Yet in translating these demands into French, and emphasizing the distinction between the “appearance” and reality of mental illness, their responses highlight how these debates continued to be framed in Western terms that limited the scope for negotiation. Families thus engaged in forms of protest that ranged from challenging the decision to confine to questioning the knowledge upon which such judgments were based. Ultimately, however, it was asylum directors who held the authority to determine the risk of the patient to the community, making recourse to police powers in order to enforce their professional opinion. The spaces of overlap that emerged between experts and non-experts therefore proved both shifting and profoundly unequal.
While psychiatrists faced opposition from families regarding their decisions to prolong confinements, they also sometimes encountered resistance from colonial officials to their decisions to release patients. When patients had a dangerous history, even if their symptoms had disappeared, local authorities feared that the disease would manifest itself at a later point and the “lunatic” might again threaten the security of their community. In 1925, the prosecutor general in Saigon used the case of one patient to warn of a broader pattern in which “the existence of these individuals is a vast cycle where prison and asylum alternate with phases of liberty when they commit minor offences, misdemeanors, and crimes which lead to a new confinement.” The discharge of the patient in question, he asserted, would simply recommence “the conflict between the Medical Administration and Judiciary Service in another form.”Footnote 80
Family demands for release must thus be situated within a broader constellation of concerns that included those of not only psychiatric doctors but also colonial authorities who sought to protect public safety. These concerns over public safety surely responded to the growing political unrest in interwar Vietnam, which included an increasing number of strikes due to worsening economic conditions, and also the massive repression that followed such incidents as the Yen Bay prison uprising and Nghe-Tinh Soviets of 1930–1931. These events perhaps explain why the colonial police force might have felt more eager and emboldened to maintain order in the streets, while institutional overcrowding and mounting financial pressures on asylum directors may have encouraged the release of patients before their full recovery. Communities, meanwhile, who had long developed their own mechanisms to preserve social order, were faced with new social, economic, and political pressures that they had to consider when deciding whether to petition for the discharge of the mentally ill from colonial institutions.
Assessing Families as Caregivers
Requests for patient release were not approved until it was determined whether the family was in a position to take appropriate care of the patient. Family members were expected to look after the patient until they were cured and pledge responsibility for any violent acts that might occur in the event of a lapse in surveillance.Footnote 81 Those patients considered potentially dangerous would often still be released provided family members took extra steps to ensure “a rigorous surveillance”Footnote 82 and to watch over them “day and night to prevent any sort of incident (fire, suicide).”Footnote 83
Given the burdens associated with guarding patients, psychiatrists investigated families, including their household income and personal habits, to determine if they were adequately equipped to provide care. Historians of Indochina have explored the ways in which the colonial state policed the intimate lives of families, especially in the realm of sexuality, but determining the capacity of families to meet the basic needs of their own sick responded to a different set of concerns about the social organization of Vietnamese family life.Footnote 84 As Hilary Marland argues, this practice of assessing the quality of family care allows us to see how the state entered the entire household of the “lunatic.”Footnote 85 In 1922 the president of the Municipal Commission in Cholon confirmed that Nho, the brother of a patient, lived in a hut bordering a rice mill where he earned 24 piasters per month.Footnote 86 His salary was found sufficient to provide for the needs of his sister, who was subsequently released into their parents' care.Footnote 87 The location of the family home itself could play an important role. In 1924, the release of a woman to her daughter was approved because her “home is found just next to the police station, which allows us to believe she will be sufficiently guarded.”Footnote 88 Scrutiny extended as well to the personal habits of family members. For example, in 1921, the head of the Security Police in Saigon described the brother of one patient as “thirty-five years old, father of a family, a well-behaved and punctual worker at the Imprimerie Commerciale…. When summoned to my office he renewed his assurance that he will watch over his parent and urgently warn the authorities if he notices any sort of relapse.”Footnote 89
Refusals based on poverty were most often motivated by similar concerns: if the family was unable to take adequate care of the patient, he or she would return to begging and vagrancy, risking relapse and a return to the hands of the colonial administration.Footnote 90 In a 1925 report to asylum officials, the administrator of Can Tho province described a set of petitioners as “very poor. They live … in a miserable hut of the value of $6.00. Nguyen Van May cultivates a hectare of rice belonging to Van-Dat-Lieng and only takes 60 units of paddy with which he feeds and takes care of his mother…. It is therefore impossible for the family of Duong to come take the patient from Bien Hoa and care for him.”Footnote 91 Only if Duong was found “capable of working and assuring his own existence” could he be released. This example demonstrates that it was not only wealthy families that requested release; families from a range of income levels appealed for the return of patients, which, in certain cases, would mean taking on a significant financial burden.
Doctors grounded their refusals in not only low family income levels but also the type of care they thought the patient would receive at home. In one case, a psychiatrist determined that a patient, in the end, was “not a lunatic in the proper sense of the term.” Yet the doctor worried that he was “a weak spirit, unfavorably influenced by mystical ideas and by the religious life that he has adopted over the last nine years. Will probably give release on a trial basis but he must return to his family and not the pagoda.”Footnote 92 In fact French psychiatrists continued to compete with indigenous healers well into the 1930s, even as the colonial state worked to increasingly restrict the practice of traditional medicine and promote widespread and exclusive recourse to Western medical care.Footnote 93 In 1932, one psychiatrist worried about the “misdeeds of sorcerers in the psychopathic domains,” complaining that the “majority of the insane do not come to asylum until they have been dragged from pagoda to pagoda, sorcerer to sorcerer.”Footnote 94 These sorcerers or “spirit mediums” were accused of not only promoting a spurious brand of medical treatment but also for igniting underlying forms of dementia and even inducing states of mental illness that did not exist before. Another psychiatrist suggested that these “superstitious instincts profoundly anchored in the spirit of the natives,” especially tenacious in the countryside, would become “surchauffé,” or “overheated” by sorcery practices. The unfortunate subject, suspended in a kind of excited delirium, would then slide all-too-frequently into a dangerous form of insanity.Footnote 95 At special risk were the sorcerers themselves, who, in the course of their professional practice, would fall into a state of such “progressive excitation” and become “so strongly saturated that [they were] more or less under its influence.” The craft of spirit possession was considered singularly ill suited to “maintaining the equilibrium of one's mental faculties,” which was why so many of its practitioners often fell “victims to the demands of their profession.” (In 1928 alone, seven sorcerers were reported to be confined at Bien Hoa.)Footnote 96
French psychiatrists would routinely describe sorcerers and their clients as, at the time of “possession,” “momentarily deprived of reason.” What colonial experts saw as evidence of an underlying psychosis for the patients' families signaled a state of being taken over by a supernatural force. There emerges here a shared notion of not existing as one's true self, but with different explanations that demanded different responses. Psychiatrists noted in some case histories that patients themselves protested the terms of their confinement by explaining their irregular behavior as derived from genies or spirits, not mental illness. One patient claimed in 1921, “A genie (white tiger) had entered him and gave him the supernatural power to cure the sick and to supervise the notables.”Footnote 97 The file of another patient noted, “Thai sees genies … from time to time in the form of men (doctors and nurses), these genies talk to him and declare that he will be liberated soon….” Thai was diagnosed as a megalomaniac and the file reported his tales of great accomplishment, including curing a woman suffering from beri beri in just five days.Footnote 98
The medical language used here is striking and suggests one reason French medical authorities felt threatened by sorcerers who continued to hold sway over local populations, and why patients' claims to medical expertise may have been taken as evidence of their insanity. In any case, it is apparent that despite French pronouncements to the contrary families and communities continued to view sorcerers as an important source of cures for a range of ailments, from mental illness to epidemic disease. In 1928, one asylum patient, a father of three and the guardian of a small but well-trafficked pagoda, was described as possessing no intellectual capacity and in the grips of senility. Nevertheless, he was reported to have held a “certain influence” over other villagers among whom he had earned a reputation as a healer. During a violent outbreak of cholera one summer, parents delivered him their children in order to be cured. Despite condemning his supposed powers as pure superstition, the French doctor writing in his case file stressed that this sorcerer trusted completely in his own curative abilities and that he did his work with “conviction and fervor.”Footnote 99 While colonial officials commonly portrayed sorcerers as charlatans who took advantage of a credulous and backward population, many colonial psychiatrists were fascinated by those who, they felt, truly believed in what they were doing. In at least one instance, a French psychiatrist seemed almost seduced by the deep conviction of a patient he described as possessing “the allure of a prophet, with long floating wavy hair, piercing eyes, an aspect of ‘freedom,’ but one that is absent…. During the period of observation he presented no crisis or related symptom, spoke little but carried himself with an illuminated air, indifferent to what happened around him except for when we attracted his attention.”Footnote 100
The Absence of Families
While the relationship between doctors and families could prove problematic, the very absence of families generated a sense of crisis within Indochina's psychiatric assistance program. In 1937, Yves Chatel, the governor of Tonkin, told of the “serious inconveniences” posed by patients who occupied places that were needed for others requiring immediate internment. He cited the Voi asylum, which was built to accommodate three hundred patients but instead housed 424.Footnote 101 In August 1939, a Commission charged with Voi's oversight deplored the presence of “those abandoned, who uselessly encumber the rooms of the asylum and risk becoming human wreckage.”Footnote 102 Sometimes families refused to take patients back, but more often asylum directors and colonial administrators were simply unable to locate any family members at all, even after multiple attempts and, in more desperate instances, after testing broader family networks. In many cases, abandoned patients were simply hired on to work as coolies at the asylum.Footnote 103
Indeed the inability or unwillingness of some families to care for their own became an important cause for concern among colonial officials, especially following the onset of the financial depression in the early 1930s. Here we see evidence of how those social bonds of mutuality and obligation on which the care of the mentally ill traditionally depended begin to fray. In 1930, Rene Robin, the governor of Tonkin at the time, reported that the custom of villages providing aid to the less fortunate had declined in recent years. He observed that this communal custom, while not properly encoded in Vietnamese law, nevertheless formed an important part of oral tradition. But, as Robin underscored, “This imprecision of charges of assistance imposed on the communes does not allow a clear discrimination between the respective duties of the family, village and the administration.” Instead, he observed that villages had developed the irritating habit of discharging all obligations toward their “miserables” by directing them to the provincial hospital and even to the offices of the colonial administration. He conjectured that the recent upswing in vagrancy, especially in cities, could be traced to the negligence of communal authorities and the inhabitants themselves. It would therefore “be convenient to remind them of their obligations towards the infirm and indigent, and to exactly spell out their responsibilities…. Still I do not think it is necessary to enact a new regulation. Simple respect for customs must suffice.”Footnote 104
In fact no legal text obligated families to take charge of patients ready for release. At the same time, it was unlawful to prevent patients from leaving the asylum after they had been certified as “cured.”Footnote 105 This posed a distinct challenge to asylum directors. In 1925, a patient was approved for release but his wife was found ineligible to care for him. Legally, however, it was imperative that he be released without any delay or else, as the director of Bien Hoa's director warned, it would constitute “an arbitrary detention.” Here we see the formal limits of the practice of assessing families' ability to care for their loved ones. The local director of public health also cautioned that the family could not be used as an excuse: “I do not believe that it is possible to argue the precarious situation of the family for keeping him at the asylum.” He feared “an eventual accusation of sequestering, for which, if I were to say nothing, would make me appear to be an accomplice.”Footnote 106 The case was ultimately referred to the prosecutor general for review in order to absolve the medical service of any responsibility. As with confinement, fears of accusations over the refusal to release patients generated pressures that dictated changes in psychiatric practices. Psychiatrists became caught between their anticipation of pushback from non-experts (whether other colonial administrators or families) and the very real problem of what to do with the population of cured patients with no homes to return to. Proposals to create separate asiles colonies, villages of mostly cured patients placed into makeshift “families,” while debated seriously in the late 1930s, never came to fruition.Footnote 107
Examining the complexities of the discharge process reveals how the decisions to release patients were grounded in both judgments of their condition and the care they would receive outside the asylum. But even as the households of patients became objects of expert oversight, so too did families exert their own judgments of French psychiatrists, in some instances by turning to traditional healers instead. Earlier we saw how areas of overlap between French and Vietnamese understandings of mental illness formed a common space for establishing the abnormal status of patients as the basis for confinement. In the context of discharge, a different kind of overlap between the spaces of the family and those of the institution succeeded in generating new opportunities for surveillance beyond the walls of the asylum. Questions of exactly how to police those recovering from mental illness in the community—what that oversight should look like and with whom it should be entrusted—and whether patients were ready to reintegrate back into “normal” social life continued to test the limits of expert authority.
CONCLUSION
Families and communities played a critical role in shaping psychiatric practices in French Indochina throughout the interwar years. They provided information that assisted experts in forming their diagnoses, contributed to colonial ideas about what constituted valid grounds for patient confinement and release, and supplied crucial forms of surveillance and care in the community. Families were active participants in psychiatric care in ways that disrupt our notions of the colonial asylum as a closed setting where patients rarely left, and as run by experts who enjoyed broad and unquestioned authority. In short, colonial psychiatric authority was far less hegemonic than one might suppose. The power to confine or seek treatment for those perceived to be “abnormal” continued to grow throughout the interwar years with the expansion of psychiatric services in asylums and major hospitals, and new forms of community surveillance. But rather than see this as a process that flowed inexorably from the colonial state, I have considered here how families and communities pursued their own strategies that profoundly shaped colonial ideas about the meaning of deviance and the therapeutic possibilities for addressing mental illness. In these ways, a focus on the movements of patients and the roles of families and communities in mediating these movements blur distinctions between asylum and society, the institutional and the familial. For historians of Vietnam such a perspective offers a new window into the social relationships among and between families, communities, and the French colonial state throughout the early decades of the twentieth century.
For historians of medicine, the relationship between the asylum and the community also offers an important site for investigating the production of knowledge and power in colonial settings. As the symbol of colonial psychiatric authority, the asylum serves as the natural point of departure from which to examine what French doctors took to be their mission as well as the challenges they faced in realizing their ambitions in daily institutional practice. But such a perspective misses the emergence of more fluid, dynamic spaces where doctors were forced to confront alternatives to the brand of care they offered. I have argued that everyday exchanges between French experts and Vietnamese families signal not only small erosions in the authority of colonial psychiatrists, but also, and more significantly, the emergence of a new, more diffuse kind of psychiatric power. This power tied together the authority of European science backed by a repressive colonial state to the social norms of local communities that prescribed the bounds of individuals' conduct and the obligations and duties of families charged with their care. Grasping the full extent of colonial psychiatric power, and the resistances it faced, only then becomes possible when we read patient case files for what they can tell us about life outside the asylum as much as life inside its walls.
