Photo 8.1
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Ni Ketut Kasih

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1 Story Summary

Ni Ketut Kasih is an elderly widow with a kind face who lives in a small village in Central Bali. She is the proud mother of four children, and the beloved grandmother of twelve grandchildren. When she is not helping her family around the house with chores such as sweeping and cooking, she may be socializing with other women down by the river, meditating, or reading.

Ketut has lived her whole life surrounded by the complex rhythms and requirements of the Balinese ritual calendar, with temple observances, holy days, and village and regional festivals occurring on a weekly or, at times even daily, basis. Tourists flock from all over the world to witness these Balinese ceremonies lush with sensory delights—filled with the fragrant smoke of incense, the colorful offerings of fruit and flowers, often with artful gamelan music and temple dances performed amongst ornately carved architecture and a crowd dressed in their golden-threaded best. However, for the Balinese themselves, these rituals are much more than a spectacle; they are a spiritual mandate and social requirement, which demand a great amount of labor and sacrifice on the part of those who practice them. A large portion of ritual duties and responsibilities falls particularly heavily upon Balinese women who not only often contribute financially, but also must spend countless hours crafting offerings by hand.

For many decades now, Ketut has had particular difficulty with the stress surrounding ritual obligations. She anticipates ceremonies far in advance of their coming, repeatedly questioning family members about the state of their preparations. Ketut has been renowned in her village for the speed and mastery with which she can prepare offerings, and this has contributed to her status as a ritual specialist and ceremonial leader. However, in her worry that her family will not be able to fulfill their ritual obligations, Ketut will be unable to sleep. She finds her mind crowded with thoughts as she remembers the stresses of her childhood, when her father was taken as a prisoner of war and she was forced to abandon school to help support her family. Sometimes the worries get to be too much and Ketut will have a “fit.” She might disappear, leaving her family to wander to distant places, or act out in strange and disturbing ways such as disrobing in the market or challenging others to a fight. When her family feels that Ketut requires assistance beyond what they can provide, they take her to the state mental hospital or they provide her with medications prescribed for these episodes of behavior and emotional disturbance. Ketut usually recovers quickly and experiences long stretches of peace before another ritual or financial obligation evokes more worry and another episode of illness.

Ketut’s reaction to family obligation stressors and ritual requirements raises questions about the purpose ritual serves and the cost that it carries for the individuals that prepare for and perform them. Her case provides an example of one unique schema of stress wherein cultural obligations, traumatic historical events, biography, and neurobiology overlap to trigger cyclical episodes of mental illness. In doing so, it illuminates personal constructs of distress and the binding associations that make certain burdens unbearable.

Ni Ketut Kasih was born the eighth child in a family of twelve. Her father was a weapons specialist who had fought the Japanese during World War II. Then in 1947, when Ketut was still a little girl, he defended his people against the Dutch in Indonesia’s struggle for independence. He was captured during a mission and interred in a camp for prisoners of war, apart from the family for months until he was finally able to escape. Ketut’s mother was sick at the time, and there was no money for school fees. Ketut was forced to postpone her hopes for education in order to care and provide for her family. She worked as a seamstress and a peddler, selling small items to help raise money for her family’s food and ritual needs. After her father was reunited with the family, Ketut was able to attend elementary school. She happily remembers these carefree days when her only obligation was to study. However, because of ongoing financial difficulties, she was forced to abandon her education after completing the sixth grade.

Over the years, Ketut became a successful small businesswoman, selling fish that she herself would transport to market from coastal Jimbaran in a big battered Colt truck. In early 1965, there was a crisis in the fish market, portending the larger national crisis to come, and Ketut was left with significant debts. Her family could not help her because they themselves were struggling due to the violent upheavals of that time; a purported communist coup had led to a takeover by Suharto’s New Order regime, and in Bali thousands of people were killed or imprisoned in the waves of violence, suppression, and surveillance. Ketut’s uncle and cousin were killed, she witnessed massacres of fellow villagers, and hunger and stress led many of her family members to fall ill. After this difficult era, Ketut’s family arranged a marriage for her with a distant relative. Ketut felt upset that she did not get to pick her own husband, but she did not dare resist; soon after, the feelings of anger diminished and she settled into a companionable and loving relationship with her husband, Pak Mangku.

Ketut gave birth to the couple’s first child, Wayan, in 1969 three days after a ritual ceremony. This precipitated the first of many episodes of “inner sickness” that Ketut would experience over her life. She did not want to claim her son, refused to breastfeed, and exhibited episodes of disassociation and disorientation, acting as if she could not remember who she was. She was ill for about three and a half months, during which time her family sought a variety of treatments. Her father searched all over south Bali for a traditional healer who could provide relief. He found one who said that the problem stemmed from a crack Ketut suffered to her skull as a child, and prescribed a mix of sticky rice and betel leaves to be applied to the damaged areas. The family also sought treatment from their spiritual advisor who conducted religious purification healing ceremonies. He recited a prayer, and gave Ketut oil to drink after which mucous came pouring out of her mouth and nose, a commonly recognized sign of recovery in Indonesia. Ketut returned to her normal self within a month of this treatment. Ketut lived her life fairly free of incident after this episode for over fifteen years. She gave birth to three more children and took care of the household while selling staples at a small food stall in the nearby market.

Then in 1986, Ni Ketut Kasih attended a large-scale family ritual marking both the wedding of her brother-in-law and a tooth filing ceremony, a Balinese rite of passage. She arrived at the ritual and suddenly began to weep, felt weak, and was unable to greet her relatives until she finally collapsed. She was taken to see psychiatrist Dr. I Gusti Putu Panteri, was prescribed Thorazine, and recovered within eleven days. She soon relapsed again, however, at which point her family brought her to the psychiatric ward at the regency public hospital.

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Ni Ketut Kasih evaluated by her psychiatrist, Dr. Panteri

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Over the following decades, Ketut would relapse and be hospitalized more than 35 times, sometimes briefly, sometimes for a month or more. When she recovers she can be without incident for months, but her relapses can be severe. She and her family both believe that in every case the triggers for her episodes are the emotional burdens posed by ritual events and family obligations. Ketut says their onset is marked by a feeling that her family is facing a challenge or event that they will not be able to handle. Her husband says that at these times, especially when the family is in fact unable to contribute financially to village or temple rituals and therefore unable to fulfill their ritual obligations, Ketut feels greatly disappointed.

Ketut says she can often tell when a relapse is coming. She is often unable to sleep a day or two before she gets sick and will be sensitive to the sound of the wind or the rain falling on leaves. She may be bothered by physical symptoms, feeling like there is a hole in her head that is filled with rice and sand or that she has been stabbed in the chest with a bamboo stake. Alternatively, she may feel empty, as if she has already lost consciousness. She will become unable to see her own shadow or imagine her own face when she was young, unable to remember a time when she was happy. She feels afraid of her husband and worries about making mistakes, and at the same time, she feels suspicious of friends and neighbors, thinking that they may secretly want to do her harm.

Once her “fit” is in full effect, Ketut has a lot of energy. She wakes up very early in the morning or in the middle of the night and may disappear, wandering far from the house. Sometimes her energy takes the form of industrious spiritual labor where she makes many offerings for the Gods—even more than usual—and talks a lot about the invisible world. At times she may disrobe in public, evoking the Balinese style from a previous era where women wore only a sarong with their breasts exposed. Ketut may also express feelings of anger or aggression, occasionally throwing things, striking out at family members or challenging them to a physical fight. There have been a number of occasions where Ketut has experienced epileptic seizures during these periods of extra energy and unusual behavior.

Ketut and her family find pharmaceuticals to be effective in responding to her symptoms and restoring her usual calm demeanor. She has been prescribed chlorpromazine in the past, and up until the present takes two antipsychotic medications including other phenothiazines (such as trifluoperazine) tablets or if she is hospitalized, a monthly intramuscular fluphenazine injection. She also has prescription for Haloperidol, which her family administers if her symptoms start to flare up, and takes a daily routine of an antispasmodic such as trihexyphenidyl to manage the stiffness, tremors, spasms, and extrapyramidal effects of the antipsychotics.

In accordance with the Balinese conceptualization of health, Ketut and her family also continue to attend to the spiritual as well as the biological aspects of her well-being. After years of struggle tending to her responsibilities as a village ritual specialist (B.B. pemangku), which she assumed after the death of her husband, Ketut’s family has relieved her of the burden of this activity as well as the responsibility for preparing offerings, unless she so chose to participate. Her children and grandchildren assume the responsibility for the family’s other ritual requirements, sometimes even receiving help from other villagers, in an attempt to protect Ketut’s peace of mind. From time to time Ketut will still experience an episode of disordered behavior, emotion, and thought, but taking the empathetic view that anyone can become overly stressed, the family actively rejects any stigmatization of her symptoms, instead calmly taking each episode as it comes.

2 The Beauty and Burden of Balinese Ritual in Ni Ketut Kasih’s Cycles of Illness

Ritual plays a large role in Ketut’s illness experience by acting as a powerful trigger for anxious, manic, and disordered states. While ritual can serve various positive functions in a society, such as providing a regulated symbolic system to express shared emotional states and maintain societal equilibrium, it may have a collective and personal darker side; Freud once called religious ritual a “universal neurosis” used to repress and displace a given society’s antisocial impulses and taboo desires (Freud 1934). In any case, ritual—in the Balinese case in particular, the preparation of voluminous offerings to be used during ritual—serves as a meeting point where familial and community relationships, the schedules and customs of preparation that influence day-to-day routines, and personal feelings and associations come together.

Bali is known as one of the most “ritually dense” cultures in the world. The Balinese ritual calendar is two hundred and ten days long and full of cyclical events. The ritual year is marked by the twin rituals of Galungan, when departed souls are invited back to earth to be honored, and Kuningan ten days later, when they return to heaven. There are temple ceremonies every full moon (B.I. bulan purnama) and every fifteen days (B.B. kajeng kliwon), as well as annual temple anniversaries known as odalan, which must be held both for village temples and private family temples. In addition, every thirty-five days there are honor days, such as Tumpek Landep, the day where all metal goods are blessed and offerings are made for kitchen implements, garden tools, metallic parts of machinery, and vehicles. There are also other holy days, such as Nyepi, the day of silence, and Hari Raya Saraswati, honoring the goddess of knowledge. Of course, there are also large-scale rituals to mark important life cycle events, which in Bali include a series of ceremonies for newborns, including the forty-two-day ceremony to ensure safe development, the three-month ceremony where the baby touches ground for the first time, and the hair-cutting ceremony; puberty rituals; the tooth filing ceremony at adolescence to extinguish “animalistic” tendencies such as lust and greed; the wedding ceremony; and a series of funerary rituals including the Ngaben, or a Balinese cremation.

An integral element of Balinese ritual is the offerings (B.B. banten). In the film, Ketut and her family refer to the practice of ngayah, “committing oneself to God through making ritual offerings.” This concept suggests that the emphasis in preparing offerings is not solely the tangible end result, but the devotional process manifested in the finished product. This devotion is expressed and displayed not only through offerings made at special occasions, which include towers of arranged fruit and baskets of flowers, but also through canang, the daily offerings that women craft and leave at important areas in the house and local environment, such as at doorways or intersections. These offerings made from leaves, flowers, sliced fruit or pieces of rice, coins, and incense are rich with symbolic meaning referencing Hindu deities, the life cycle, and philosophical theories of value and balance.

Beyond the purely aesthetic, offerings can be seen as result-oriented, “pragmatic interventions which aim to change the state of affairs in this world, to bring about material well-being and prevent suffering” (Geertz 1991). This pragmatic approach to ritual offerings is supported by local beliefs about the high cost of making a ritual mistake. In traditional Balinese logics of illness and healing, a wide variety of personal and family ills—from a headache to a slowly healing broken leg to an argumentative husband to a meager harvest—are frequently interpreted as having their source or etiology in forgotten or improperly performed rituals. Those suffering will often consult with balian, traditional healers and ritual experts, to determine what has gone wrong and which corrective rituals are required to effect cure. Many families go into to debt to ensure a ceremony is performed in a timely and appropriately appointed manner in order to prevent such ill effects.

Therefore, in making offerings and performing rituals properly, individual Balinese women take responsibility for the well-being of themselves, their families, and their communities. The extensive female networks of labor and communication and the female leadership in organizing sometimes hundreds of family members involved in ritual preparations—plaiting leaves, cutting fruit, and molding rice—may speak to the valued and important role women play in Balinese spiritual life. However, knowing that the Herculean task of making offerings is always and only relegated to women, it may also be interpreted negatively as some Balinese choose to call it, “ritual slavery” (Lemelson 2011).

While this may seem extreme, understanding the required physical labor, time, spiritual and emotional investment, and monetary resources required to make offerings and fulfill family obligations combined with the overdetermined significance of ritual in Balinese family and community life, makes it clearer how ceremonies may become not just culturally elaborated festivities, but also culturally marked stressors that might strain pre-existing vulnerabilities or precipitate an illness episode.

Indeed, it has been ethnographically demonstrated that ritual obligations are a common stressor in Bali and throughout Indonesia. Hollan and Wellenkamp, working on Sulawesi (Hollan and Wellenkamp 1994, 1996), singled out ritual as “one of the most significant and emotionally charged” aspects of adult life because there is often so much at stake personally and communally. The many things that need to be taken into consideration to make a ritual run smoothly, combined with the many feelings and memories and associations rituals evoke, is commonly understood throughout the archipelago to lead to “too many thoughts.” It is also commonly understood that if these thoughts become too overwhelming or the stress of them goes unmanaged, mental illness may result. Ketut notes:

If there is a ritual that is coming … two days before I already have those symptoms again …When there is a ritual, two days before I already can’t sleep… because I’m thinking about problems that are going to come in another two days.

3 Chronologies of Trauma, Culturally Inflected Emotions, and Social Support

It becomes a complicated and ironic fact of Balinese life that ritual activity, which is intended to promote and protect the purity and balance of the community, can also cause significant psychological pressure for an individual. In Ketut’s illness narrative, they become causal stressors for episodes of mental illness particularly because they also evoke a formative episode in Ketut’s childhood wherein she was dealing with a combination of pressures that were truly overwhelming. This originary experience was shaped by cultural, historical, and personal circumstances.

Ketut remembers being forced into a role of premature responsibility because her father was absent from the household and her mother was sick. Ketut suggests that the help she was expected to provide was too advanced for her age, saying, “At home, I shouldered the burdens. The burdens of my parents, I took them on.”

This childhood experience differs from the cultural ideal: for the Balinese, as perhaps in most societies, childhood is supposed to be a relatively carefree time. In Bali, children are considered vulnerable to spirit attack, and therefore must be protected and indulged. Children may make demands on their parents and are humored by their older siblings. Furthermore, because they are not yet “aware” the way adults are, children are not held to the same strict rules of conduct (Bateson and Mead 1942; Jensen and Suryani 1992; John 1953). Ketut still identifies with and longs for this carefree time, when she remembers having a “happy” face, telling herself, “That’s your face from when you were young, that’s what you were like when you were young, because in Bali when you’re young you’re happy.”

The loss of her father put an end to this culturally designated period of relative ease. This was a time of personal difficulty for Ketut, where she was certainly experiencing a cluster of emotions including confusion, feelings of sadness and pity for her suffering father, and anxiety to know that he was gone and not knowing when he was going to come back.

Given that Ketut’s father was imprisoned and taken from the family in the process of fighting for Indonesian independence, Ketut’s story cannot be separated from Indonesia’s history of colonialism and national development. When Ketut was a child, the Dutch had colonized parts of Indonesia for centuries, although the Balinese had successfully resisted Dutch rule until 1908. As a revolutionary Indonesian nationalist movement was growing, the country was swept into World War II. The Japanese invaded and defeated the Dutch in 1942. They were at first welcomed as liberators who would unite Indonesia with the rest of Asia. Indonesia officially declared independence in 1945, but the country remained under Japanese rule and conditions rapidly deteriorated. Many people died of starvation due to extreme shortages of food and many Indonesians were mistreated as laborers and comfort women. When Allied Forces defeated the Japanese, they agreed to return Indonesia to Dutch rule. In 1946, the Dutch took Bali and other outer islands and the war for independence lasted until 1949. The entire nation was affected by these political struggles; Ketut’s immediate and extended family network of support were among the hundreds of thousands strained under these conditions.

Research in the neurobiology of stress has provided insight into the seemingly atypical chronology of trauma, where past and present distresses are folded into one another and certain memories repeat with a perpetual sense of urgency. Culturally, personally, and historically determined frameworks of interpretation intertwine and interact with emerging sensations, thoughts, or emotions in a complex loop that creates meaning for the person experiencing them (Hacking 1995). Various sensations, emotions, and interpretations are linked together through conscious or unconscious association and through neurophysiologic pathways. Embodied memories, cultural metaphors, historical trauma coalesce into personal schemas or scripts of stress that frame and interpret current sensation and experience. Past experience, which may re-emerge as flashbacks, re-experiencing events, or traumatic memory, may link physical sensations with distressing emotions. For example, for a survivor, a fleeting sensation of dizziness may recall the dizziness of malnutrition she experienced during wartime, and thus simultaneously evoke emotions of terror or grief. In a correlative process known as “kindling,” if a physical sensation is repeatedly experienced in the context of distress, then future distress will become likely to evoke these sensations as a stress response. So if this same survivor feels sad, she may also soon start to feel dizzy (Hinton et al. 2008).

In Ketut’s case, present family obligation stressors are amplified by Ketut’s personal history of trauma and responsibility. Each newly emerging stressor recalls her past formative experiences of stress, confounding present anxiety with the past anxieties of worrying about her father and having to assume responsibility for her family. Furthermore, the ritual and economic burdens Ketut was forced to take on in the household were folded into the emotional and physical stressors of war: both the socio-historical milieu of anxiety and violence, and the physiological responses to hunger and starvation may have amplified her stress at that time.

Other associational processes may shape emotion and sensation as they occur. These processes can amplify, mute, or generate new sensations. One is the loop of anxiety and attention; certain feelings or sensations are unpleasant and cause high alert, yet constantly scanning for, thinking about, or attending to such feelings may cause them to intensify. Significant factors determine what feelings or sensations deserve such close attention, including ethnopsychology, traumatic memory, and self-image. Different emotions and sensations have different saliency for different cultures, and cultural context will determine the comparative normativity or pathology of certain sensations or emotions. Feelings of shame or embarrassment are particularly laden feelings in Balinese culture; therefore, the presence or threat of shame is likely to lead to heightened attention. A self-image built from such cultural frameworks, past events, perceived innate qualities, and interpersonal relationships will further affect how an individual interprets his or her own sensations or emotions.

Many of the emotions that become disturbing to Ketut when she is having an episode are very common idioms of personal and interpersonal distress salient to Indonesian cultures in general and Balinese people in particular. In a psychocultural context that prizes harmonious interpersonal relations and a smooth personal demeanor, these emotions not only articulate distress, but also evoke distress. Particularly upsetting are feelings of shame or embarrassment, feelings of suspicion, and feelings of anger.

There is a large literature on the role of culture in shaping emotions, and many scholars have commented on the significance, depth, and nuance of shame, or malu, in Indonesian cultures (Heider 1991, 2011). Malu (B.B. lek) may in some contexts be similar to the Western understanding of shame, a sense of losing face when unable to uphold norms or requirements or unfavorably compared to others, and so on. So, in this way, shame is a result or a reaction, a negative state associated with embarrassment and guilt. But malu may also connote an active preventative process of managing emotions internally to prevent one from becoming ashamed. To know a sense of shame is to acknowledge the capacity of your behavior to offend or destabilize others, and therefore knowing and displaying proper “shame,” which in this context may mean deference or a regulatory self-consciousness, may become a sign of maturity or a sense of pride. Indeed, children are complimented when they are mature enough to “know a sense of shame.” Clifford Geertz (1991) interpreted the Balinese sense of shame as a kind of stage fright, an anxiety over the possibility of social awkwardness, insult, or poor role performance in the constant negotiation and renegotiation of status. While malu itself is clearly not a singular “cause” of her episodes, Ketut herself notes the power it has over her equanimity, and clearly associates feelings of shame as a significant stressor for her as when she says, “If I have too much shame I go crazy.”

Another mental state associated with Ketut’s episodes is that of suspicion. When she is starting to feel unwell, it is stated that Ketut starts to feel that “this world is a world of treachery,” questions the seemingly innocuous motivations of guests who come to the house, and feels afraid that people outside of her immediate family plan to harm her. These feelings are somewhat corroborated by her family, who suggest Ketut may have fallen ill because other people were jealous of her.

Whether or not one can posit that Balinese culture is governed by a “paranoid ethos” (Schwartz 1973), there is a pervasive belief in black magic and a corollary sense of fear or suspicion that arises particularly in the contexts of illness or misfortune. It is often the onset of illness or otherwise abnormal behavior that indicates a person has been the victim of black magic or witchcraft. Black magic can come in many forms, sent through telepathy, poisoned food served by a family member, the touch of a witch (Wikan 1990), or in the form of projectile needles, bullets, pins, or other implements. Black magic, along with ritual error, may be one of the most commonly invoked explanatory models of illness in Bali. The reason for use of black magic is usually revenge against a direct offense or jealousy of others’ good fortune, and extended kin are the most frequently accused (Wikan 1990). This vernacular understanding of black magic as a causal factor for symptoms of mental and other illness provides a clear explanation for why Ketut would feel suspicious when she starts to feel ill, and why rituals, involving meeting with the aunts, uncles, and in-laws, who might harbor secret mal intent against her, would be cause for fear or worry.

Finally, the expression of anger is also seen as being in direct relationship to mental illness. Ketut’s family often feels she needs to be medicated at times when she expresses anger and aggression. Certainly while aggression can be upsetting in many cultures, it may be even more so in Bali. In the early ethnography of Bali, Margaret Mead, who had a particular interest in childhood, analyzed childrearing tactics that she felt specifically trained against the expression of anger (Bateson and Mead 1942). The prohibition against anger is active for all members of Balinese culture, but may particularly apply to women who are supposed to be decorous, graceful, and deferent. Because of these restrictions on behavior, if and when someone does reach the point of noticeably expressing anger, it signals that something has gone terribly wrong. While the correlation may not be as direct as equating being visibly angry and being crazy, the embodied loss of control and detachment from social norms that expressions of anger display may be a very powerful indicator for the Balinese that a person’s emotional states are unmanageable or that he or she has lost touch with the Balinese reality.

Considering the interaction of experiencing, expressing, and interpreting negative feelings raises the interesting question: Do these negative feelings trigger the onset of mental illness because they are so upsetting to the person having them, are they interpreted as mental illness because they are so outside the idealized norm, or does the complex interplay of personal subjectivity and cultural context construct the phenomenology of mental illness? Or does the sociocultural demand for smooth demeanor during times of stress add additional pressure to an already high-pressure situation?

Variations on these core questions have been central to the project, the psychological anthropology, particularly between domains of culture and personality, and what the relationships between these two and how and in what ways does personality and its adaptive capacities function as a primary, intermediate, or intervening variable (Kardiner et al. 1945; Kardiner and Linton 1974). Ni Ketut Kasih’s story provides an “experience near” and “thick” description through which these complex relationships can be explored.

Ni Ketut Kasih’s decades-long experience of mental illness provides a longitudinal perspective on mental health within the family system. In a complex but compelling interaction, Ketut’s family is both stressor and strength through her life course. It is clear that extended family relationships can act as a stressor in a sociocultural context like Ketut’s. Contact with this extended family elicits feelings of responsibility to adequately represent and support family members and ancestors, shame if rituals are improperly carried out or cannot be afforded, and anger or jealousy over economic differences amongst the kin network that then must be suppressed.

However, perhaps more significantly, Ketut’s immediate family provides a buffer of support. They do this primarily by actively resisting labeling Ketut or defining her by any stigmatizing diagnosis. While she at times describes herself as mentally ill (B.I. sakit jiwa), her family adamantly does not call her mad (B.I. gila, B.B. buduh). Despite the fact that she has been institutionalized many times, the family chooses to normalize Ketut’s experiences of dysregulation. They say, “Crazy, in Indonesian it’s ‘crazy.’ In Bali it’s ‘crazy.’ But we don’t make assumptions like that. We see our mother as having too many burdens on her thoughts, and anyone can experience that. Relatives of my mother still say, ‘This woman is sick like this because she indeed has many burdens.’ There isn’t a problem.”

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Ni Ketut Kasih in the warm embrace of her family

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In avoiding conflating Ketut’s symptoms with her Self, her family emphasizes the temporary or transient quality to her illness, leaving plenty of room for her many periods of stability and lucidity and underscoring a sense of continuity to Ketut’s daily life. While she does periodically spend time in psychiatric care, the family does not stigmatize the kind of illness she suffers from, instead treating her mental illness like any other illness. Therefore, she is not institutionalized indefinitely nor identified as ill when she is in fact feeling better. The family does not focus on their mother’s diagnosis but rather her observable condition—if she is doing well she is treated as such, if she is not doing well they take her to the hospital for care, and the moment she seems recovered they bring her home.

Furthermore, the family shares responsibility for her care. In collectivist and interdependent societies, such as those found in Indonesia and Bali, the kin network and environment are considered profoundly significant in determining the behavior or outcome of any individual. Therefore, if one person’s well-being is threatened, responsibility is shared in terms of both etiology and cure. Ketut’s son says “we make efforts for her to recover,” emphasizing the collective investment and effort of the family unit. This effort is visible in actions like staying awake to guard or monitor Ketut if she is having a spell of energetic sleeplessness during the night. The family also engages in a kind of collective prevention, protecting their mother from potential triggers and searching for ways to keep Ketut in a balanced state. Even extended family and non-kin villagers who know Ketut sometimes provide assistance. For example, if she has wandered away or gone to the market during an episode, they help bring her home.

The family also shares responsibility for Ketut’s tasks when she is unable to carry them out. For example, when Ketut’s first son was young and she was dealing with her illness, he lived with and was cared for by his grandfather. Kin and villagers adapt to Ketut’s shifting needs and capabilities, affording her duties when she can handle them and easing such expectations when she cannot. Illustratively, Ketut was still given important ritual responsibilities, such as being a counselor for village religious issues and being a temple priest, even after episodes of illness. However, now her son has taken over these duties because he feels more capable. He explained, “I have a wife, there is already someone to help me, and I advised her so that my mother doesn’t take on those burdens again… so that we young people take that responsibility, that it’s now our burden. Mother should just be calm, like that. That’s what I told her to do. The important thing is that my mother is healthy.”

It may be that in the interdependent family structure that is prevalent in much of the developing world, this approach of communal responsibility and collective care may seem less out of the ordinary than for families in the West, who, for example, for reasons of increased mobility may live far away from their networks of support. In Ketut’s case, shared care, and a separation between symptoms and identity due to such things as spiritual attribution, supports her periodic recovery and ongoing integration in the family. Further cause may be because such communities have more flexible or accommodating expectations for their members, and more opportunities for ill people to actively contribute and feel productive.

4 Seeing Beyond a Sparkling Face

When Ketut is met at the community clinic in Central rural Bali in 1997, (a shot seen immediately after the title card, at the opening of the film) she seemed the epitome of an elegant, “sparkling” Balinese woman so well captured in Unni Wikan’s classic account (Wikan 1990). However, the façade started showing some cracks upon the initial psychiatric interview with Dr. Panteri and her daughter that day. It became clear that underneath the laughing, polite banter there was a current of disturbance, something “off” in the culturally typical account one would expect of a Balinese woman in her position. Then, in the course of the interview, it emerged that she had been hospitalized for psychiatric problems a number of times in the previous two decades, a clear indicator that hers was not the “typical” life course of someone in her position. Ketut and her daughter agreed to be filmed further in their house compound.

This allowed for a more extensive interview to be conducted with Ketut, her husband, and several of her children. At this point, the focus was both getting to know Ketut through gathering her life history and understanding her challenges and experiences by doing basic clinically oriented interviews as to her psychiatric diagnoses, and hearing her family’s accounts of her history, summarized above.

One thing that was evident was the warm and open attitude in Ketut’s family about her condition, and their willingness to share it with a foreigner and associated film crew. At no time was there reluctance or hesitation about them narrating and interpreting her story, and the story of the family. Indeed, both her husband and children seemed extraordinarily protective when they spoke for and about Ketut.

After these initial meetings in 1997, while local collaborators occasionally got updates from Ketut and her family, Ketut was not formally interviewed again until 2008. The long lapse of time was due to involvement in other projects, and in fact at that point, Ketut was not going to be included as a participant in the emerging Afflictions series. It was only as Afflictions evolved that a role for her began to emerge; however, in 2008 just what aspects of her story might be focused on or what role she might have in a film was only slightly theorized.

Ketut had quite visibly aged in the preceding years. In addition, she seemed quite withdrawn when the team showed up with a small camera crew, presenting a very different social face than when she was first shot in 1997. Her countenance was sad and frightened, and she did not want to come out of her darkened bedroom. Given this, Ketut was not asked to make an entrance or participate in the film project. Instead, extensive interviews were conducted with her grown children and family. In addition, remarkably, her father was still alive, well into his late eighties or early nineties, and seemed compos mentis. A fascinating interview unfolded about not only his experience in World War II and Indonesia’s war of independence from the Dutch (1945–1949), but also how both the wars and the intense privation and suffering experienced all through Bali played an influential role in Ketut’s childhood. The confluence of his story and the obviously warm and supportive environment that the family had created to support Ketut in her illness became touchstones for the emerging story of Ritual Burdens (Lemelson 2011).

It was interesting to see how Ketut’s attitudes and ideas about the film project changed over time. The original interview took place in 1997. The family was visited intermittently to film over the following decade, between 1997 and 2008, and renewed a more in-depth relationship and filming schedule with the family from 2008 to 2010. This long research period had been punctuated by rather severe episodes of mental illness that had often required Ketut to be hospitalized. At various points she had clearly decompensated, and during one visit was not even able to leave her room to participate in an interview. On other occasions she was able to more actively participate, even though her physical appearance and social presentation were markedly affected by her illness, and over more than a decade of filming increasingly displayed the ravages of time.

Some of these ravages are due to the natural course of aging, and having lived through traumas that have left their mark on Ketut’s countenance, but some of these ravages are specific to the course of the treatment of her mental illness. Ketut is being treated with long-term antipsychotic/neuroleptic medication, which is most useful in treating schizophrenia. Ketut does have some symptoms that overlap with schizophrenia, in particular feelings of paranoia; however, as explained above these feelings may be culturally more normative rather than a clinical symptom. Furthermore, schizophrenia is usually characterized by many symptoms Ketut does not exhibit, such as the positive Schneiderian first rank symptoms of delusions and hallucinations. While it may seem that she has some of the negative symptoms of schizophrenia, such as affective flattening and social withdrawal, these seem more reactive in nature and related to a sense of fear and paranoia rather than a primary illness marker of schizophrenia or related thought disorder.

The diagnosis of bipolar disorder, raised in initial meetings by her Balinese psychiatrist but not reflected in much or her treatment, may more accurately reflect Ketut’s condition. Bipolar causes unusual shifts in mood, energy, sleep patterns, and the inability to carry out day-to-day tasks. Those with bipolar disorder will experience unusually intense emotional states that occur in distinct periods called “mood episodes,” euphoric or overexcited manic episodes, or extremely sad or inactive depressive episodes. Sometimes, a mood episode includes symptoms of both, hence known as a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.

Bipolar illness is usually treated with a mood stabilizer, such as lithium (Martin 2007). However, lithium treatment is more difficult to implement than an antipsychotic because its dosage and prescription require the monitoring of lithium carbonate blood levels. Currently, the only laboratory in Indonesia available for these blood tests is in Jakarta, making such monitoring expensive and inconvenient. Antipsychotic medication is effective in its behaviorally inhibiting effect, but does not necessarily ameliorate the core causes or symptoms of bipolar disorder. Meanwhile, antipsychotics, due to their effects of dopaminergic production and uptake physiology that leads to low levels in the central nervous system, causes side effects that lithium does not, including that of tardive dyskinesia, which leads to uncontrollable twitching of the mouth and eyebrows. Tardive dyskinesia, after its initial onset, can be irreversible. These side effects are visible throughout the film, and unfortunately as visible and continuous markers of difference are deeply stigmatizing in her community, they have also led to long-term physical effects of stiffness and pain in her jaw, causing her much distress.

5 Last Encounters

In 2010, a polished rough cut of what would become Ritual Burdens was completed. Ketut and her family were shown the film to get their reactions and feedback. Her family clearly and enthusiastically gave their permission for the film to be screened in a variety of different contexts. They were very supportive of the larger mission of the Afflictions project and valued the process of honestly documenting and representing their mother’s experience living with ongoing mental illness (although, as discussed, they purposefully rejected the explanatory model of “mental illness” in favor of indigenous ideas about “burdens” and “stress”).

But there was another burden on the film project. The final screening with Ni Ketut Kasih in 2013 came at a cost. In the early sequences, she seemed to enjoy seeing footage of her younger self and of her husband, who had passed away a number of years earlier. However, as the film went on, Ketut grew increasingly upset and requested that the screening computer be turned off, as watching herself age, struggle with episodes of illness, and exhibit the side effect of her tardive dyskinesia on-screen proved too painful for her to bear. It was overwhelming to see herself, younger and seemingly happier, and to think of all she had missed in life.

Ni Ketut:

I’m confused, sir, I’m confused if I remember.

And then:

Son:

Why are you crying? Hey.

Daughter:

Mother, you shouldn’t cry, Mother.

Ketut:

I’m stressed. I’m stressed (continues weeping). Oh No! Stop!

At this point the film was stopped, but it was some time before Ketut stopped crying. Her family noted how sad she was, remembering the past and all she had lost. Ketut then asked for her medicine, so she could “forget and go to sleep.” Her family got it for her, Ketut went to her bedroom, and the lead author and crew said goodbye one last time to Ketut and her family.