Clinical history

A. Patient Identification

“Nyoman” is a 53-year-old Balinese rice farmer. He was born in a small rural village located at the center of the southern Balinese rice bowl—a densely settled part of Bali and one of the most agriculturally productive areas of Indonesia. The village is about 30 kilometers north of Bali’s capital city of Denpasar. Nyoman still lives in his natal family compound. He is married to a woman who is a member of his clan (dadia), with whom he has two adult children. His wife works in the market selling religious offerings. Nyoman has worked all his life in the fields, farming several hectares of rice land. Occasionally, he also works as a construction laborer.

The first author (R.B.L.) first met Nyoman at his home in 1996. Nyoman was a participant in the second author’s (L.K.S.) 12-year follow-up study of 113 cases of acute-onset psychosis, based on hospital admissions at Wangaya Government Hospital in Denpasar. Nyoman was initially hospitalized in early 1984. L.K.S. followed him up, along with the other patients, several times over the next year and a half (1984–86) and then again at 12 years. This research was part of a wider World Health Organization study on the course and outcome of acute psychosis in the developing world.

During 1996–97 and 2003–2004, R.B.L. conducted nine home visit interviews with Nyoman, his wife and extended family, and members of his hamlet (banjar). While Nyoman’s first language is Balinese, he is also fluent in Indonesian. The interviews were conducted in both Indonesian and Balinese. R.B.L. is fluent in Indonesian, and a field assistant, who was present at three of the interviews, helped translate from Balinese to Indonesian as needed. This history is based on the original case notes, which included an inpatient observation, evaluation, and interview in 1984; the subsequent home interviews in 1984 and 1985; and the follow-up interviews in 1996–97 and 2003–2004.

B. History of Present Illness

Nyoman traces his illness back to 1965, when, at the age of 21, he witnessed the massacre of several fellow villagers. The killings were part of a military bloodbath that swept across Bali and other areas of Indonesia in response to a purported communist-backed coup attempt in September 1965 (Robinson 1998). Between 80,000 and 100,000 Balinese, or approximately 5–8 percent of the population, were killed between December 1965 and March 1966 (Cribb 2004). Nyoman described to R.B.L. how military and paramilitary (tameng) forces purportedly belonging to the Indonesian Nationalist Party (PNI) entered his village looking for suspected members of the Indonesian Communist Party (PKI) and other left-wing organizations. Several villagers participated in the hunt. Nyoman remembers the accused villagers, including several of his family members, being marched off to the cemetery (kuburan). He remembers trailing the procession with some of the other villagers at a safe distance. Suddenly, he said, he felt an overwhelming sense of terror. He felt that someone might hurt or kill him, even though he had not been singled out for execution. He quietly left the group and climbed a tree near the kuburan. From the branches of the tree he witnessed the accused being systematically macheted to death. Since that time he had never spoken about the incident with anyone, including those members of his village who had also witnessed the massacre. This was understandable, since the perpetrators were still living in the region; several of the squad members were village officials and even teachers.

Nyoman’s long-standing problems with social withdrawal and fear appear to have begun after witnessing the massacre. In a 1997 interview with R.B.L., he said that he was very terrified by this experience, which he said weakened his life force (Balinese [Bal.] bayu). He said that his ongoing problems with feeling his heart beating rapidly began at this time. He also felt an “inner pressure” (Indonesian [Ind.] tekanan batin), which he felt was weighing down his body. For months after the massacre he said he had difficulty eating and became very thin and withdrawn. He said his eyes felt like they were deeply sunk in his head. He remembers being jumpy and easily startled, and experiencing periods when he felt his mind go blank. He had difficulty falling asleep, and nightmares revolving around themes of being chased and people being butchered frequently interrupted his sleep.

Nyoman described how he became very afraid of social gatherings and avoided public places and events after the massacre. He withdrew from the common social activities of his banjar and stopped participating in community work projects. He often had “quiet” or “closed” (Bal. nyebeng) social presentation. However, Nyoman said he does not feel frightened or anxious (Ind. cemas, Bal. nyeh) when guests come to his family compound. He only gets the fear-related feelings when he has to go out in the village for social or ritual events. These problems continued to disturb Nyoman in the years following the violence, but he never sought treatment or medical care.

In 1974 he accidentally ate some eels he had caught in an irrigated rice field that had been sprayed earlier that day with endrin, a potent organochloride insecticide. He became very ill, experiencing continual vomiting and severe stomach pains for several days. He became confused and felt constantly dizzy. His symptoms lasted for six months. During that time he withdrew socially even more, rarely leaving the house except to work in the rice fields.

Nyoman married a member of his dadia in a cross-cousin arranged marriage in 1980. His wife gave birth to a son the following year. In 1984, when his first child was three, his wife gave birth to their second son. She had a difficult labor and delivery, and lost much blood. The infant died one month later. Nyoman described this as his most difficult time. He cried continuously for several weeks. He had trouble sleeping. He also became very fearful of other people. He had continual thoughts that other people were carrying knives and axes and plotting to kill him. When he had to appear at public events or places, he would always bow his head and never look at people. If there were many people around him, he felt that his chest was tightening and he felt very weak. He felt that his eyes absorbed the images of the people around him and that those images entered his brain.

At that time he also began seeing small, black figures, which he believed to be spirits known as the wong samar, literally the “indistinct people”1 (these spirits are discussed further in Section B.2, under Cultural Formulation, below). Nyoman first saw the wong samar after cutting the grass in the rice field. He said the creatures were wandering over the grass and hiding in stagnant water. At first they made noises that he could not understand. Gradually, the noises solidified into words with meanings attached. He felt the figures were competing with one another to enter his head and take possession of his body. When entering his head, they would ask him, “Why don’t you take care of yourself? Will you take care of us?” They also gave him advice, such as telling him to take medicine when he was ill and how to use the herbs, amulets, and special articles of clothing that he received from traditional healers. He would hear other figures vying with each other over who was going to enter his body. Some were wong samar; others were related Balinese spirits, such as Gamang Pemali. He thought that there was something in his mind that attracted those spirits to entering his body. After they had settled in his head, they stopped speaking. He could only hear the ones on the outside who continued to talk.

After the wong samar entered him he would feel his body become heavy. He believed that the wong samar entered his nerves (Ind. saraf) and absorbed his bayu so that he felt weak. He stated that he felt continuously confused, nervous, and restless because he could not stop the images and visions of the wong samar from reoccurring.

When these spirits possessed him he would desire to stay home or go to remote places to be alone. He believed he should not walk when the sun was high because that is when the other Buta Kala (spirits of the underworld distinct from the wong samar) can prey on people. He avoided social contact by hiding in such places as remote rice fields or in the deeply cut canyons that crisscross the Balinese landscape. He knew that the spirits stayed in these quiet places. At times he seemed to seek out a relationship with the spirits, by going to their suspected dwelling places.

He would sometimes leave his home for days at a time. When he returned he explained to his family that he had been taken into the wong samar world and that he had been forced to marry a beautiful wong samar woman. Whereas the spirits he classified as wong samar were small and black, the woman he said he married looked like a normal human, except she floated an inch off the ground and her upper lip was flattened. It is a common Balinese belief that wong samar sometimes take these human forms in order to mix with the human society and find victims who are weak, such as the very young, the very old, and people who are ill.

Nyoman’s experiences with spirit beings gradually waned over time, and he described long periods where he would not see or hear them. However, during the national election campaigns in 2002–2003, when Indonesia elected its first-ever democratically elected president, the spirits returned. This time they were asking Nyoman to rejoin the Communist Party. In response Nyoman would wear a camouflage jacket and military helmet, and would sleep in his family temple courtyard. He believed these actions prevented the spirits from entering his body and forcing him to return to the PKI.

C. Psychiatric History and Previous Treatment

Although Nyoman had been experiencing significant distress and symptoms since the 1965 massacre, he did not seek any treatment until after the death of his infant son in 1984. This event appeared to exacerbate his condition, particularly his inclination to withdraw socially. When he ultimately refused to leave his room to go to work, family members brought him to a traditional healer (balian) in a distant banjar. This balian lived in a very isolated village in a mountainous region northeast of Nyoman’s village. According to the balian, whom R.B.L. interviewed in 2003, Nyoman’s illness was caused by witchcraft, the result of ill wishes of unspecified village members (Bal. pepasangan). The balian also noted that Nyoman’s nerves were weak (Ind. Lemah syaraf). Nyoman spent one month in the balian’s compound. This healer, who is a balian usadha—one who reads and interprets sacred ethnomedical texts inscribed on palm fronds—prescribed herbs to be administered as a body rub and as an herbal drink. He and his wife and family also gave advice and psychosocial support to Nyoman. The balian usadha believed that Nyoman had a variant of bebainan. Bebainan is a common explanatory model for sorcery-induced illness that is specific to Bali (Suryani l984). People undergoing bebainan experience a sudden sense of blankness, loss of desire or will, and confusion. These are often accompanied by dysphoric somatic conditions, such as stomach or headache. Victims often cry uncontrollably, shout or scream, become mute or silent, or incessantly talk angrily to themselves. On occasion this is combined with violence.

Because of Nyoman’s worsening condition, and the belief that in addition to sorcery Nyoman’s illness was caused by his weak nerves, the balian brought Nyoman to the Dutch-built state mental hospital in Bangli, 30 kilometers northeast of Denpasar, saying that he would recover more quickly there. Nyoman was given chlorpromazine, 50 mg three times a day, trifluoperazine, 5 mg three times a day, and a multivitamin. The voices of the wong samar gradually decreased in frequency and prominence, until after about one week they had become “hazy and unclear.” He was hospitalized for three weeks and then discharged.

After Nyoman was discharged, he stayed at home for one week. It is unclear whether he continued taking the medication while at home. His symptoms returned and his family took him to the Wangaya Government Hospital in Denpasar, which had a small inpatient psychiatric unit. There he entered into Suryani’s study. According to the initial intake notes he appeared dazed or expressionless (Ind. melamun, Bal. bengong) and appeared to have a vacant or forgetful demeanor. He often appeared confused or panicky (bingung) and had disturbed thinking (Ind. pikiran terganggu,Bal.kenahe sing luwung). He reported that he often felt breathless (sesak napas) and dizzy (Ind. pusing, Bal. pengeng). He was diagnosed on the basis of the PPDGJ (Pedoman Penggolongan dan Diagnosis Gangguan Jiwa), the Indonesian diagnostic manual, which is based on the ICD and the DSM. The initial diagnosis was Paranoid Acute Problem (298.30). A subsequent diagnosis, which was made at the one-year evaluation, was Schizophrenia Paranoid type (295.3).

Nyoman was hospitalized at Wangaya for one week. He was given trifluoperazine, 5 mg three times a day, and an unspecified dosage of trihexyphenidyl to reduce the dystonia and akesthesia brought on by the trifluoperazine. Nyoman said he thought the medication from the Bangali state mental hospital was more powerful than that of the Wangaya Hospital, as it reduced his symptoms more.

After his discharge, he returned to work as a farmer and occasional construction laborer. He reported that he took his medication for only a brief period after discharge, and then stopped because of its lack of local availability and unaffordable price. Periodically, he was able to engage in community activities that took place in the banjar meeting space (bale banjar), but often had difficulty in his social relations. He continued to have difficulty sleeping and to have both visual and auditory hallucinations. For several years after his second hospitalization he would go to the general hospital to receive medication. Sometimes he bought the medicine at a local pharmacy or the puskesmas, a small community health center usually staffed by nurses and a general practitioner, with other specialties rotating on a weekly or monthly basis. He also continued to consult numerous balian over the years.

D. Social and Developmental History

Nyoman was the third of five children born to a Balinese rice farmer. He does not remember any serious illnesses in childhood. He was not able to finish high school because of financial problems and went to work in the rice fields. In 1996–97, at the time of R.B.L’.s interviews, Nyoman still lived in his family compound with his wife and children, as well as his mother, his father, and a paternal aunt. During the relatively rare periods in which Nyoman does not see and hear spirits he is active in the neighborhood congregation, particularly the seka gong, or local village gamelan orchestra. This group often performs at other places. During one interview his son and his niece were observed practicing for a dance performance where Nyoman’s orchestra would play.

Regarding his arranged marriage, when R.B.L. interviewed Nyoman’s wife in 1997, she said that before their marriage she had heard about his propensity to isolate himself socially and that he had some type of mental problem. (She referred to his condition using the modern term penyakit jiwa, literally “psyche/soul illness,” most likely because she was talking to R.B.L. in Indonesian, and she had some familiarity with biomedical terminology in light of her husband’s two prior hospitalizations.) She said she had not wanted to marry him because of the stigma associated with marrying such a person. In 1980 she was forced to visit his compound with her family to make arrangements for the marriage, but she ran away. She was found and her family convinced her to accept the marriage. The reason why she was forced to marry him is unclear.

Nyoman’s wife, who seemed quite dissatisfied with the marriage and Nyoman’s behavior, was able to corroborate many aspects of his narrative. She said he was always quiet and did not often engage in casual conversation. She said he would get stuck on a subject and that was all he would talk about. When he did talk it was always about the spirit beings and how they were involved in his life. She found this subject repetitive and boring. His wife feels that he will never recover from his condition. Nonetheless, Nyoman feels that he has a good relationship with his sons and that he communicates well with them.

E. Family History

Nyoman said that, as far as he knew, there was no history of psychiatric illness in his family.

F. Mental Status Exam2

In appearance, Nyoman is small and thin, with a deeply etched and sun-darkened face. His expression during interviews was alert, although at times he seemed apprehensive and preoccupied. While he appeared a bit disheveled at these times, there was nothing unusual about his hygiene given his occupation as a rice farmer. He made eye contact in a culturally appropriate manner, although from time to time he glanced at R.B.L. in a fleeting, furtive, and slightly wary way. He spoke in an understandable, if occasionally pressured, manner. He presented his personal history in a spontaneous fashion in response to R.B.L.’s questions. He organized his narrative with sufficient detail and consistency. He seemed most interested and attentive when we discussed his relationship with his spirit beings and the efforts he has made to care for them or make them leave him. He spoke candidly and openly about his relations with his spirits. His speech would only become a bit pressured when he struggled to describe their world and how he participates in it. He said he has been living in two worlds (dua dunia), the world of his family and community and the world of the spirits, for the past 15 years.

His speech was clear, engaging, and thoughtful. While his speech reflected his preoccupation with the spirit world, R.B.L. noted no impairments in his language functioning reflecting disordered mentation. There was no evidence of loosening of associations, tangentiality, or derailment.

His anxiety seemed proportionate to the interview situation. He would begin the interview with a more guarded stance, but then would open up and disclose aspects of his life. He seemed to understand the normal social graces and expectations of being polite to guests that Balinese culture requires. He would bring in a rug for us to sit on, and then would offer us snacks and tea as the interview progressed. He was pleasant and affable to interview; he cooperated and responded without hesitation to questions about his life and condition. Nyoman seemed to enjoy the interview experience, and would gently chide R.B.L. if we had not come a previous time as promised. He and R.B.L. formed a close and friendly relationship over time.

He stated that he had never disclosed to anyone else his experiences of witnessing the massacres in 1965. He had an accurate recall of details of his previous treatment efforts, and described at length the various efforts the balian have undergone to rid him of his spirit beings. His attitude toward these spirits, however disturbing they may be to him at times, was one of acceptance that they will be with him in the future.

G. Course and Outcome

Nyoman had a history of social withdrawal and nonpsychotic symptoms from the age of 21. During his third interview with R.B.L. in 1997, Nyoman revealed that the symptoms began in 1965, after he witnessed the massacre of some of his fellow villagers. The symptoms worsened in 1970, at age 30, following the accidental ingestion of rice-field eels that had been sprayed with an organochloride poison. Psychotic symptoms emerged in 1984, at age 40, following the death of his infant son. Currently his symptoms are largely in remission, subject to exacerbation following stressful triggers (e.g., the election campaign in 2003–2004). Pak Nyoman reported that he would occasionally return to the local puskesmas for antipsychotic medication, particularly if he had trouble sleeping due to the spirits returning.

H. Diagnostic Formulation


Axis I


Schizophrenia, Paranoid type, Episodic with inter-episode residual symptoms


Posttraumatic Stress Disorder: chronic

Axis II


No diagnosis

Schizoid personality features

Axis III


Toxic effects of substance chiefly non-medical as source—other pesticides, not otherwise classified

Axis IV


Problems related to the social environment: moderate

Axis V

Highest past



GAF = 55


GAF = 55

I. Differential Diagnosis

Nyoman was provisionally diagnosed with schizophrenia on the basis of the following DSM-IV-TR criteria: delusions resembling thought insertion, auditory and visual hallucinations, and delusions of a persecutory nature. His social functioning is also significantly impaired and both his active symptoms and his overall illness have persisted for decades.

Nyoman clearly has a passive reception of a somatic sensation imposed from an outside agency. For example, if he sees the shadow of a vehicle passing by, he feels that the vehicle’s shadow can crush his shadow. Afterward he feels sore and uneasy. He always feels that his mind “pulls” (menarik) or “absorbs” (menyedot) things into it. If he sees a chicken or a lizard, he feels it is pulled into his mind and can stay there a long time. He may grow scared because the image does not disappear. This seems to indicate a type of “thought insertion,” in that Nyoman always feels that objects are being pulled into his mind, and then he cannot “stop them from appearing” in his thoughts.

But the story regarding Nyoman’s hallucinations, delusions, and negative symptoms is more complex. He has what appears on the surface to be auditory and visual hallucinations. He occasionally sees, but more often hears, the many types of spirits and voices, from different places, that interact with him and with his other spirits in different ways. They have voices like people. He also has visceral or somatic hallucinations related to his visual and auditory ones. The latter can be linked to his more primary hallucination regarding his participation in the spirit world. While the spirits are in his body he feels that they absorb his bayu, which he believes causes him to become weak. When he feels them entering his body, he believes they lodge in his nerves and make his body feel heavy and cause his skin to become thicker.

Whereas many hallucinations/delusions of schizophrenics in Western industrialized countries involve very negative images and commands, however, for Nyoman the spirits’ main command is that he needs to take care of them and then they will not disturb him. The nature of these hallucinations is actually ego-syntonic. At times it appears that he welcomes the intrusion of these spirits into his mind and body. He gives his body over to the spirit beings and says to them, “It’s up to you that you enter my body ... do it ... serve yourselves ... go ahead ... I do not care.” He said he is not scared of the wong samar because he already has good relations with them. He is very much convinced of the reality of these and other spiritual beings.

Nyoman also has a sense of control over the form and content of the hallucinations. For example, he has formed a relation with the barong, a good and protective spiritual figure represented by a dragonlike mask. The barong often has a particular temple devoted to it within the central village temple. The spirit of the barong can possess people for short periods of time, both in temple festivals and in theatrical performances such as the Calonarang. Nyoman feels that he is able to pull the barong into his mind when he goes to the temple on auspicious days, such as wage or kliwon on the Balinese calendar. The barong also enters his body whenever he takes part in community work activity dedicated to temple maintenance or other religious duties. As the barong enters him, he feels his body get lighter and his pains disappear. When particular wong samar spirit beings are disturbing him, he feels he can call on the barong to act as a protective spirit and make them leave his body. He believes the barong offers him a form of protective medicine.

A diagnosis of paranoid schizophrenia appears to be warranted given that Nyoman has delusions and hallucinations with a relative preservation of cognitive functioning and affect, and that these delusions and hallucinations are organized around a coherent magicoreligious theme. His hallucinations share the characteristics of a psychogenically based disorder rather than an organic one. They are fleeting and transient, with the hallucinations being shadowy and misty and occurring in shades of grey. Nyoman said that he could see or feel them even during the interview, but he did not act as though he really saw or felt them (e.g., he never responded or spoke to them during the course of the interview).

We have several reservations about making such a diagnosis, however, as some of its associated characteristic features are problematic in this situation. Although Nyoman appeared shy and at times anxious, both while being observed in the village and in the interview context, this demeanor did not seem to be coterminous with affective flattening and avolition, which are prominent negative symptoms of some forms of schizophrenia. His speech production was normal, grammatical, and semantically appropriate and could not be classified as alogia. While his range of activities was restricted when he was actively “delusional,” he had a range of volitional activities adequate for his roles in his banjar.

Nyoman’s other negative symptoms (his social isolation and loss of interest in the social world) seem clearly attributable to his involvement with the world of spirits and, as such, should not be considered outright a symptom of schizophrenia. Most Balinese believe in the existence of these spirits, and have relationships with them in the form of religious offerings, often on a daily basis. Healers are frequently possessed by these spirits and utilize them to diagnose and treat illnesses and to repair and redress familial and other social problems (Connor et al. 1986). Individuals can become possessed by the spirits in religious and ceremonial contexts (Belo 1960). Nonetheless, Nyoman’s relationships with the self-same spirits go far beyond what is culturally normative in terms of his social withdrawal. They would not be, in the DSM nomenclature, “culturally sanctioned,” e.g., taking place in a normative culture context, such as a magicoreligious ritual or symbolic healing performance.

It is significant that many of Nyoman’s symptoms began after he was poisoned with pesticides. Ingestion exposure to an organochlorine such as endrin is known to have a neurotoxic effect, causing sensory disturbances, headaches, dizziness, mental confusion, and psychosis (Donkin and Williams 2003). This could account for the late onset of some of his psychotic symptoms. However, he would not fit the criteria for substance-induced psychotic disorder, because while some of the features of his larger clinical picture (e.g., confusion, social withdrawal) began or were exacerbated following the pesticide exposure, his delusions and hallucinations only began after the death of his second son, almost a decade later.

In addition, even Nyoman’s poisoning with endrin can be questioned as an actual cause. In 1965 there was gossip that spread among the members of the local subak (the irrigation society that controls water flow for rice fields in the watershed) that subak members who were also members of the BTI (the Barisan Tani Indonesia), a group affiliated with the PKI, were spreading excess endrin in the irrigation channels to poison the subak members who were not affiliated with the PKI. Endrin was also—like Baygon is today—famous as a cheap and effective method of committing suicide (Santikarma, personal communication). It seems significant that Pak Nyoman only got sick upon hearing that he had potentially been poisoned. It is possible that he was not actually poisoned but had an acute fear or panic response, given the multiple meanings and triggers that endrin represented.

Nyoman also has the cardinal features of chronic posttraumatic stress disorder (PTSD) with psychotic features. He witnessed an event in which some of his fellow villagers and family members were brutally macheted to death, which frightened and horrified him. From that time he has had persistent symptoms of increased arousal and associated physiological reactivity, as indicated by tachycardia, difficulty concentrating, confusion, and dizziness, and he has had nightmares and other persistent sleep disturbances. In terms of avoidance and numbing criteria, given that several of the perpetrators of the 1965 massacre were members of Nyoman’s banjar, his reluctance to frequent public places, engage in village activities, and socialize may be attributable to a sensible or healthy response to the highly fraught political and social history of his immediate surroundings.

A diagnosis of PTSD with psychotic features would encompass some additional aspects of Nyoman’s illness experience and his subsequent relationships with spirits. By comparison, among Cambodian refugees who experienced the numerous traumas associated with the Khmer Rouge regime, a prominent cultural pathoplastic shaping of PTSD symptomatology is visitations by ghosts and other spirit beings (Sack et al. 1995). It is conceivable that there is some connection among Nyoman’s initial traumas in 1965, the reactivation of loss, fear, and sadness as a result of losing his son in 1984, and his subsequent experience of the spirit beings. In the Balinese case, however, most people (and they numbered in the hundreds of thousands) who witnessed horrific things in 1965 did not develop such close relationships with wong samar.

In addition, there is clearly a dissociative possession component to Pak Nyoman’s clinical picture. For example, his relation with the barong spirit is similar to the interactions that persons with Dissociative Identity Disorder have with a protective alter, as opposed to his relation to the more distressing forms of spirits that he believes attempt to inhabit his body.

Cultural formulation

A. Cultural Identity

1. Cultural reference group

Nyoman is a Balinese Hindu. He grew up and has lived his entire life in a small village located at the center of the southern Balinese rice bowl—a densely settled part of Bali, and one of the most agriculturally productive areas of Indonesia.

2. Language

Nyoman speaks Bahasa Bali as his primary language. He is also fluent in the national language, Bahasa Indonesia.

3. Cultural factors in development

The influence of Balinese culture on Nyoman’s development are discussed under Social and Developmental History (Section D, above) and Family History (Section E, above).

4. Involvement with culture of origin

In the past generation Bali has gone through massive changes, not the least of which is its transformation into Indonesia’s premiere cultural tourism destination. Nyoman’s village is situated on a major road linking a number of tourist destinations. There are no major “tourist objects” in his village, so relatively few people stop there. Thus, geographically and figuratively, village life bridges vast changes brought on by electrification, nationalization, the impact of mass media, and globalization, on the one hand, and rural time, which is marked by a complex ritual calendar, adherence to village customary law (adat), and the daily and cyclical routines of wet rice irrigation, on the other.

B. Cultural Explanations of Illness

1. Predominant idioms of distress and local illness categories

Members of Nyoman’s community have different and varying perspectives on what has been troubling him over the years, but it is significant that in R.B.L’.s discussions with family members, neighbors, and other community members of his banjar, Nyoman was specifically not referred to as crazy/mad (Ind. gila, Bal. buduh) (L. Connor 1982). Although madness in Bali is deeply intertwined with magicoreligious elements, there is a clear distinction between those who are buduh and those who channel spirits for healing and spiritual power (Ind. sakti, Bal. kesakten) (H. Geertz 1994). Regarding the latter, traditional Balinese categorizations differentiate among spiritual possession, spirit channeling, and psychic distress caused by angry spirits (Ruddick 1986). Often these categorizations include symptoms that Westerners would see as both “physical” and “psychological.” In general, definitions of what constitutes madness involve extremes of behavior, such as running away or refusing to be restrained (Bal. nglumbar), having unintelligible or nonsensical speech (Bal. ngemigmig), and leaving the village and wandering the roads in a disordered state (L. H. Connor 1982).

Nyoman did not engage in the disordered actions that typified “insane” behavior, characterized by ngamuk (Ind. mengamuk), that is, by being loud, violent, or disruptive (Browne 2001). Given his two hospitalizations in Bangli and Denpasar, his family was well aware that biomedical practitioners perceived Nyoman as being mentally ill.

Although villagers seem to feel that Nyoman has a particular relationship with the spirit world, this does not necessarily define him as mad. Of perhaps greater relevance is Nyoman’s social withdrawal, which interferes with his ability to perform his community work obligations. One villager told R.B.L. that Nyoman was not crazy, that his only problem was his particularly intense and ever-present involvement with the spirit world. On the other hand, it is significant that Nyoman’s wife perceived him to be mentally troubled at the time of their arranged marriage in 1980, which took place years before his auditory and visual hallucinations began.

Several of his fellow villagers classified him as buduh kadewan-dewan, literally “madness from the gods,” or what L. H. Connor (1982) refers to as “blessed madness.” Connor notes that people with this label often experience it on the “margins of settled society” and often wander far from their villages to remote locales. The illness is usually precipitated by an event such as the death of a close kin or marital problems. However, Nyoman’s case differs from Connor’s examples in that many of her case studies used this experience to become healers. The disorder would disappear after purification and consecration ceremonies, neither of which Nyoman underwent.

Thus, opinions about the cause and type of illness varied across family members, village members, psychiatric treatment providers, and healers. Nyoman’s “madness” or “social withdrawal” seems to be a matter of debate or ambivalence among his family, neighbors, healers, and physicians. In addition, the ways in which Balinese categorize “mental illnesses” are also highly contested and subject to historical change, as in, for example, Nyoman’s wife’s usage of the modern biomedical term penyakit jiwa.

Nyoman himself described his illness as “ngeb,” which has two distinct, but related, meanings and presentations in Balinese culture. Ngeb is an illness caused by witnessing something horrific, frightening, or bizarre, such as the devastating cholera epidemic that swept through Bali in the 1920s. Seeing spirits, such as the wong samar, causes another variant of ngeb. As a result of these frightening or horrific experiences, sufferers put themselves in a self-imposed exile characterized by “muteness” (membisu) and lack of participation in the social world. Nyoman’s ngeb began with the witnessing of the massacre in 1965. Following the death of his infant son, his initial ngeb was compounded by visual and auditory hallucinations of the wong samar world.

Whether or not ngeb is an illness is certainly contested among the Balinese. Many contrast ngeb with illness, as in, “Tiang ngeb kewala ten gelem” (“I’m ngeb, I’m not ill”). While psychiatrists may refer to ngeb as mental illness, ngeb is also quite resonant with a the Balinese practice of puik (Mead and Bateson 1942; C. Geertz 1973), intentional silence and social avoidance, or a kind of social commentary koh ngomong (literally “fed up of speaking”) (Santikarma 1995). Given the above, the illness category of ngeb does not correspond with or translate neatly into a DSM diagnostic criterion.

Nyoman’s ngeb should also be considered in historical context. The events of 1965 had reverberations for decades (Dwyer 2004; Dwyer and Santikarma 2004). After the bloodbath and massacres of 1965 ended, the New Order regime of former president Suharto (1966–98) led a campaign to officially frame these events in a certain way and to stigmatize, ostracize, and blacklist those who were perceived as supporting the communists. This included not only former PKI members, but also their extended families. A “clean environment” policy (lingkungan bersih) legally banned family members of the PKI from the civil service and the media and from participation in civil society organizations, such as NGOs. Family members also had limited access to other civil rights, such as the “good behavior letter” (surat kelakuan baik) necessary to obtain a passport, a university scholarship, or permission to move from one district to another. Until Suharto’s fall in 1998, any public discussion of the events of 1965 that was at variance with the official government version was forbidden, and those who engaged in it were jailed or “disappeared.” Individuals with ngeb arising from 1965 can thus be seen as mute witnesses against the domination (Ind. kekuasaan) and control that the Suharto regime imposed on Indonesia following its ascendancy in 1965 (Santikarma 2003). It is significant that Nyoman has several friends who are similarly characterized as ngeb, and avoid social gatherings. His closest neighbor has symptoms very similar to his own, is also classified as ngeb, and also witnessed the events of 1965.

In this context it is extremely significant that, while it seems obvious to outsiders that Nyoman is a victim and survivor of a politically based massacre, bordering on genocide, he is viewed by members of his community as being a perpetrator or instigator of the events of 1965, because he was a sympathizer with the communist party. Only in 2004 could his brother say that Nyoman himself had been forgiven by villagers for causing the “disorder” of the events of 1965.

2. Meaning and severity of symptoms in relation to cultural norms

Having complex relationships with spiritual beings, including seeing and hearing them, would be prima facie evidence of a “bizarre delusion” as diagnosed by most psychiatrists in Western countries. But there is a strong cultural context for the “normalization” of Nyoman’s seemingly visual hallucinations around the wong samar. Numerous spirits and ghosts are believed to inhabit rivers, graveyards, ravines, and Banyan trees (Howe 1984). These have various names (wong samar, roh jahat, tonya, memedi) and have different attributes. This type of complex spirit taxonomy is common throughout Southeast Asia (Ebihara 1968; Keyes 1977). Illness is often seen as a punishment for offenses against the many spirits that inhabit the village and surrounding countryside. These spirits are believed to cause illness or emotional or interpersonal problems when they have not been sufficiently propitiated with offerings or are made upset by buildings placed improperly or by a ceremony done incorrectly or not at all (Lemelson 2003a). Given the complexity of the Balinese ritual calendar, this is almost inevitable.

The wong samar, the spirits with whom Nyoman is most engaged, are a potent class of spirit beings that have linkages to Balinese history, mythology, and culture stretching back at least 700 years. During the migration and wars in the Majapahit era, a semimythical leader from Java, I. Macaling, brought an army of spiritual beings called “wong samar” to conquer Nusa Penida, an island off the coast of southern Bali. The wong samar were involved in a variety of spiritual battles, but finally were defeated. It was believed that the wong samar lived on in the spirit world after the battle, and that if the wong samar were treated with proper religious respect and offerings, people could avoid illness and death. This clearly provides a cultural framework for understanding why Nyoman’s primary experiential relationship with the wong samar is framed in terms of caring for them, propitiating them, and allowing them to possess him given their high status and his need to be subservient to them.

While it may seem bizarre that Nyoman became married to a spirit, in Bali it is believed that people can take wong samar as wives. They are reputed to be affectionate and loyal spouses, who desire to make their husbands happy. However, if the husband does not pay proper attention to them, they can become angry and bring misfortune and illness. Thus Nyoman’s hallucinations involving the wong samar’s needs to be taken care of and given proper respect have a deep cultural basis. Indeed, most of Nyoman’s beliefs about the wong samar (e.g., they have flattened upper lips, they float an inch above the ground, they live in canyons or remote rice fields) and other spirit beings, such as the protective barong, are widely shared and accepted as fact by many Balinese.

It is also understood that those involved in the spirit world, like Nyoman, will have a different presentation due to their relationships. In Bali, spirits are seen to have a relation to certain states of mind and emotional feelings. This is seen in naming practices for states of dysphoria or anxiety. Anyone overwhelmed by emotional distress or displaying violent feelings or actions can be said to be possessed by demonic spirits (kasurupan kala) (Hobart 1997).

Finally, Nyoman’s sense of living in two worlds speaks to some of the fundamental and commonly cited binary distinctions in Balinese culture: the buana alit (lit. “little world”) and buana agung (lit. “great world”) and the Niskala(lit. “the unseen world”) and Sekala (lit. “the visible world”). Others have referred to Sekala and Niskala as “natural” and “supernatural” domains, and buana alit and buana agung are usually glossed as “microcosm” and “macrocosm” (Eisman 1990). These worlds interpenetrate and influence each other. Balance needs to be maintained between these domains or illness is perceived to result.

Given the above, could Nyoman’s experience be seen as an extended form of positive spirit possession? There is a culturally normative context for possession states to be associated with spiritual beings associated with strong spiritual power (kesaktian) such as the barong or the wong samar. But Nyoman’s relationship with these spirits goes far beyond what is culturally typical. While his relationship is not culturally bizarre (e.g., like the notion that the CIA has implanted transmitters in one’s head), the degree to which he has withdrawn from society due to his involvement with the wong samar is particularly stigmatizing and disabling.

3. Perceived causes and explanatory models

A number of common explanatory models are understood by the Balinese to underlie disease causation and mental illness, and are utilized in complex ways in Balinese traditional healing. With differing degrees of importance, humoral theories, hot-cold dichotomies, biomedical models, possession, sorcery, magic, violations of religious and moral norms (including the improper enactment of rituals), and spirit intrusion, imbalance, or disharmony in the patient’s environment all have a place in Balinese folk theories involving the causes, symptomatology, treatment, and outcome of illness (Lemelson 2003b). Currently, complex notions of stress and its influence on health pervade the common discourse.

Nyoman believed that his ngeb began by his witnessing of the massacre and the shock/startle (Ind. terkejut, Bal. makesiab) that, as a result, weakened his bayu, or life force (Wikan 1989). This fits well with the notion that illness may be precipitated by accidents, shocks, or fainting fits resulting from emotional disturbance. Throughout insular and mainland Southeast Asia,bayu is seen as present in all matter, both living and dead (Keyes 1977; Laderman 1991). However, it is a force that is sensitive to disturbance and can be depleted through startle, fear, or other disturbance of balance. Bayu needs to be gede (strong or large) to maintain health. Nyoman felt that his continually weakened bayu accounted for the predilection of his spirit beings to visit him. Bayu can be affected by emotional states such as sadness, and a cluster of symptoms—such as weakness, heaviness, and feeling empty—indicates that the bayu is weak or gone. This is often seen as the result of black magic. When asked if he believed that someone was doing sorcery that caused his problems, however, Nyoman responded in Indonesian in a way that suggested either ambivalence or difficulty expressing himself in that language, “Tidak mungkin tapi kemungkinan ada” (‘Definitely not, but the possibility exists’).

Nyoman also cited an astrological cause for some of his problems. He stated that he was born in the thirtieth week (Wuku Wayang) of the Balinese calendar. This is considered an unfortunate time to be born, as children are more likely to have numerous social and emotional problems with others due to the inauspicious timing of their birth.

4. Help-seeking experiences and plans

Nyoman only sought out psychiatric treatment when his suffering became intolerable following the death of his son in 1984. Why didn’t he seek psychiatric or other forms of help following his witnessing of the 1965 massacre, given the severity of his distress and symptoms? This could be partially explained by the Balinese cultural emphasis on emotional regulation and de-emphasis on the expression of negative emotional experiences and states (Wikan 1990; Jennaway 2002). However, perhaps more important is the dangerous political nature of these experiences, as discussed above. That said, Nyoman did consult and was treated and cared for by traditional healers (balian)3 many times in the previous 30 years.4 Balians are traditional healers whose activities include healing of illness plus specialization in religious ceremonies, sorcery, and counsel of bereaved family members through the channeling of deceased relatives’ spirits, as well as advice and charms for attracting or keeping lovers (Connor et al. 1986). Balians view madness as having various causes, such as inherited factors, congenital influences, the “grace of god,” ancestral or divine curses, bewitchment, and sorcery through introduction of small bebai or creatures into the victim’s body (Lemelson 1999).

Nyoman recounted how one balian attempted to cure him with holy water or oil (tirta), which he would suck out of Nyoman’s nose. Another balian, an herbalist, gave him a spicy mixture (boreh) to be slathered on his body. Another had him make colored rice offerings (segehan) to be put at the entrance to his house as an offering to the house spirit. He also gave him a belt of a witch (leyak), called penestian. When Nyoman put on the belt he felt as if he was being pulled toward the temple. Still another balian advised Nyoman to throw the belt away in a ceremony on the beach, where he would give a rice offering in the shape of demonic deity Rangda. The balian also gave Nyoman a mantra, which he was to utilize when he gave the offering. The mantra was addressed to Durga, the god of the underworld: “Those who disturb me, go away, far to the bottom of the sea, I give you this serving.”

C. Cultural Factors Related to Psychosocial Environment and Levels of Functioning

1. Social stressors

The main social stressors were Nyoman’s persistent visual and auditory hallucinations revolving around the spirit world, which caused him to withdraw socially. Balinese village life has a complex ritual and ceremonial calendar, with temple festivals, holy days, and regional festivals occurring on a weekly or, at times, daily basis. Inability to participate in this life would be seen as a major role failure, and would subject one to stigmatization and gossip.

2. Social supports

Nyoman lives in an extended family compound, organized patrilinearly and patrilocally (C. Geertz and H. Geertz 1975). He communicated regularly (if too infrequently, at least according to his wife) with the family and neighbors who would stop by to visit him in his family compound. His immediate social support network appears to be sufficient and supportive of his daily activities and minimal social participation in various roles. This relative adequacy is underscored by the fact that Nyoman is married, has children he can communicate with and care for, and has not been ostracized or labeled in a highly stigmatized way.

The events of 1965 not only penetrated deeply into his intrapsychic life, but also affected his social support network . At the time of the 1965 violence, Pak Nyoman was the only male in the house responsible for nindihan natah (defending the family home) when it was attacked by the tameng. His younger brother was away at school in Singaraja and another brother was living in Sumbawa. Pak Nyoman took this all very hard because he also saw his older sister forced to marry one of the most vicious of the paramilitaries after 1965. This man is now his brother-in-law. Family members clearly linked this relationship to the continuing tekanan or weight of his fears.

Another neighbor also believed that a good part of the reason why Pak Nyoman was so troubled was because it was his second cousin (mindon) who encouraged the tameng to attack Nyoman’s home because the cousin wanted to take the land. She stated that the people you are really afraid of are your family members (the ones who know you well enough to inform on you) rather than strangers or the state. Both violence over land reform (Robinson 1998) and anger and resentment toward close relatives over their role as informants (Dwyer and Santikarma 2004) are common themes related to the events of the September 30th movement (Gerakan tiga puluh September) in Bali.

3. Levels of functioning and disability

A number of cultural factors make Nyoman’s social isolation and lack of participation in village life disabling. Social participation in a sociocentric society like Bali is expected on a relatively continual basis. In Bali, individuals are fully integrated into extended families, clans, work or interest groups, irrigation societies, and hamlet associations, as well as being identified by caste (Jensen and Suryani 1993), and the sense that one is being observed and judged by one’s “consociates” is particularly intense. In “face-to-face societies,” where behavior is intricately observed by everyone around and privacy is minimized in personal and social life, people feel even greater pressure to participate socially and manage the social presentation of social behavior through “emotion work” (Hollan and Wellenkamp 1994). If one does not participate, a number of negative personality descriptors, such as “arrogant” (sombong), can be applied, with highly stigmatizing results. The fear of witchcraft and poisoning increases the emphasis on polite and frequent social interactions. These pressures compounded Nyoman’s isolation and oddity.

Bali is also famed as one of the most ritually regulated societies in the world, with a high degree of religiosity as manifested by the daily offerings given to the gods and spirits, the incredibly complex ritual calendar, and the extensive temple systems. Given the centrality of religious ritual performance, complexity, and action in everyday life, the ever-present expectations for sociality and social engagement, and the responsibilities of hamlet members, Nyoman’s social avoidance, fear, and disengagement become all the more debilitating.

D. Cultural Elements in the Clinician–Patient Relationship

It is significant that Nyoman, as other patients in the outcome study, did not seek psychiatric or biomedical care after the initial psychotic break and hospitalization. In Nyoman’s case, because he was not defined as “mad,” his phobic symptoms and continual hallucinations would not be culturally defined as something that would enter the purview of a psychiatrist. It was only when he was unable to fulfill his minimal role obligations toward work and family following the death of his infant son, and as a result of his ensuing, possibly psychotic, depression, that he was brought to a psychiatric hospital.

Personally, R.B.L. found Nyoman to be an engaging and interesting man, and R.B.L. looked forward to the interviews. When in 1997 Nyoman first disclosed to R.B.L. the nature of his experiences and trauma, particularly the events of 1965, R.B.L. felt honored that he would confide such information to him. Toward the end of the fourth interview, Nyoman received a visit from a neighbor of approximately his same age whom he had known for many years, and Nyoman invited him to be part of the interview. They began to discuss the events of 1965, and for the first time Nyoman disclosed what he had experienced during that period to a member of his village. R.B.L. felt this was a courageous step for Nyoman. In follow-up interviews in 2003–2004, the family and village members were much more open about the events of 1965 and had lively discussions concerning the memories and meanings of those horrific times.

Nyoman later told R.B.L. that his experience of the wong samar world had lessened significantly after his original disclosure to him. As part of the research project, we had encouraged Nyoman to return to a recently opened puskesmas near his village and receive antipsychotic medication, which he gladly did. When R.B.L. returned for an interview several weeks later, Nyoman was not at home. His wife said it was the first time he had engaged in community work for temple maintenance in many years. Whether this was a result of the medication, the disclosure of his trauma and its potentially cathartic effects, the natural course of his disorder, or part, all, or none of the above, is difficult to say.

In the years following the fall of the New Order regime, the political climate in Indonesia surrounding discussion and debate of the events of 1965 has changed considerably. The press regularly covers debates over the events of this history and its meaning, and there is a fledgling and problematic movement to redress the human rights violations and genocide through the formation of a National Truth and Reconciliation Commission (Komisi Kebenaran dan Rekonsiliasi Nasional) (Dwyer 2004; Dwyer and Santikarma 2004). It is not surprising that it is in this context that many of Nyoman’s symptoms receded, only to be reactivated under the pressures and memories that political campaigns evoke.

E. Overall Cultural Assessment

Nyoman presents a complex clinical picture, with a complex etiology and personal history, set in one of the most culturally “dense” societies in the world. His illness and his adaptations to it exist on multiple levels.

In one sense, his complex relation with the spirits can be seen as a compensatory mechanism to cope with the overwhelming grief and sadness at the loss of his child. His relations with the spirit world provide a culturally acceptable and understandable mode for managing his socially avoidant and anxious states. This is overlaid on a personal history of severe trauma. Of course, it seems clear that the biological diathesis model (e.g., a vulnerability to psychotic states, suggested by the diagnosis of schizophrenia) is relevant here, as many other Balinese suffered similarly in 1965 without a similar progression into delusion, social isolation, and spirit possession.

By focusing only on Nyoman’s clinical symptoms, or on a psychodynamic, defense model of his symptomatology, however, we lose extremely important aspects of the social and historical context in which these symptoms are embedded. A unidimensional diagnostic formulation is wholly inadequate in this case. This is a man whose symptoms and suffering have a complex etiology, stemming from being poisoned with a toxic agent, suffering great personal loss and tragedy, and witnessing a horrific act of political violence. His disability is compounded by the complex interaction of Balinese notions of hierarchy, which help to create anxiety about authority and social presentations and emotion management. These are further compounded by a national political culture that, until the fall of Suharto, made expressing distress and remembering 1965 a politically and socially dangerous, if not fatal, behavior. Nyoman’s social avoidance and isolation, as defined by ngeb, have their origins in witnessing a trauma that, until recently, had a schematized and politically monolithic construction in Indonesia’s historical memory, and a fear-inducing and stigmatizing enactment on a daily level in village life.

Suppression of these social memories took place at all levels of Indonesian society and was supported by notions regarding the negative effects on mental health, economic development, and Indonesia’s national status of discussing these traumatic events. This is compounded by a cosmological context that leads to further suppression of social memory. Ngeb has been viewed (Santikarma 2003) as a means of political protest that can take two forms. One is the muteness that acts as a form of a resistance against political authority, in which the memorializing and even recall of a specific traumatic event, caused by state terror, has been suppressed. The other meaning of ngeb is a fear of memorializing or resisting cosmological authority, which it is believed causes the community to risk natural disasters, such as epidemics or volcanic eruptions.

Nyoman’s case clearly fits, if not wholly, into this historical frame. However, his complex psychiatric and individual history cannot be simply subsumed by relating it only to this historical model and context. Given the multiple models of illness causation, the differing and, at times, changeable definitions of madness, and the many forms of healing available, it is a complex task to relate these to Nyoman’s personal experience. He drew on these models, and was shaped by them and by his historical context, and this multilayered interaction helped create a complex illness picture that does not provide an exact fit with a neat historical determinism or the categorical strictures of the DSM.


  1. 1.

    In Balinese taxonomies, the wong samar spirits are differentiated from the deified ancestral spirits (Bal. leluhur). One does not normally have ongoing relationships with wong samar, whereas one has ongoing, rather clearly-defined relationships with ancestral spirits, as well as other spirits, such as the buta kala, who inhabit one’s space.

  2. 2.

    The mental status exam is based on the data collected by R.B.L. in 1996–97.

  3. 3.

    Numerous categories of balians, with various types of roles, statuses, and knowledge, exist. Healers are sought for both their knowledge and their spiritual power (sakti) (H. Geertz 1994). Because balians are able to draw on spiritual or mystical powers and energies, and some (covertly) deal in black magic, they are generally respected and feared. However, many will deny that they have anything to do with black magic (guna-guna, ilmu hitam, magik).

  4. 4.

    It should be stressed that the traditional and the medical systems are generally complementary, and not antagonistic, in Bali, in opposition to many other parts of the developing world. In general, many of the balian stated that they are willing to work together with doctors and that they will refer to doctors for somatic illnesses, particularly when severe pain or disability is involved. Balians have been invited to the psychiatric units to perform religious and healing ceremonies.