One hundred-fifty million people suffer from different types of mental illness in the developing world, where psychiatric treatment is often limited or non-existent. With such daunting statistics, one would expect their recovery rate and outcomes to be deficient. But, the World Health Organization, in a landmark, decades-long research project, found that the mentally ill living in non-industrialized nations actually fare better than their industrialized counterparts where biological approaches to mental illness prevail. On a population level, the mentally ill—including schizophrenics–return to their homes and their jobs more quickly, are hospitalized less frequently and experience less severe symptoms, overall.

In 1996, armed with a Fulbright scholarship, I went to Iive in Bali and Java, to research the circumstances behind these startling findings, along with the more general question of the relationship between culture and mental illness. At that time, I interviewed many patients. As an anthropologist, I was not only interested in their diagnosis, illness and treatment, but also in their goals and values, in how their illness impacted their self-perception and self-esteem, and how they were regarded and understood by their family and community.

In subsequent years, I returned to Indonesia many times to film mentally ill men, women and children (forming long-term relationships), to record their struggles and defeats and moments of happiness and transcendence. “Afflictions: Culture & Mental Illness in Indonesia,” the first film series on the lives of the mentally ill in the developing world, was born out of this footage.

“Afflictions” evolved into six short films. With the probing and detailed eye of the video camera, the films look at an equal number of Indonesians who suffer from schizophrenia, Tourette’s syndrome and anti-social personality disorder. The narratives are at turns informative, disturbing and even heartwarming.

As the stories unfold, it becomes clear that it is neither their psychiatric diagnosis nor their illness, per se, that is the most troubling to the mentally ill. Rather, it is the response of their family and community to their condition and the depth of their struggle to forge identities that they believe to be valued and valuable.

The “Afflictions” films shine a light on societal issues impacting the experiences—the suffering and the wellbeing–of the mentally ill, some specific to the Indonesian culture and others with global application. Balinese religious symbology, Dutch colonial occupation and Indonesian historical events play a role in the their stories. At the same time, universal concepts rise to the surface: home placement can be more beneficial than institutional care; urban living impacts disease onset and outcomes; and treatment modalities that integrate psychiatric and outpatient treatment can be the most effective.

In the end, it is my hope that the findings clarified and made accessible in “Afflictions” help shape the care and treatment of the mentally ill in Indonesia, in other developing nations and around the world.

Interview with the Director

1)    What inspired you to create the “Afflictions: Culture & Mental Illness in Indonesia” film series?

According to the seminal studies conducted by the World Health Organization (WHO), the prognosis for patients diagnosed with severe mental illness is significantly better in developing nations than industrialized nations. On a population basis, those in the developing world experience less severe symptoms, fewer subsequent episodes and greater job retention than their western counterparts. This finding is counterintuitive for many reasons, including the greater monetary investment by the west in research and treatment and the economic and cultural barriers to new modalities in psychiatric care in developing nations.

2)    How does “Afflictions” break new ground?

“Afflictions” is the first film series on mental illness in the developing world. It is also the first film series to look at the long-term care and treatment of mentally patients in a developing nation and to illustrate the likely reasons for their outcomes.

3)    What was the filmmaking process?

As an ethnographic filmmaker, I began the process with a strong vision of what I wanted to investigate, but without pre-conceived notions of the outcomes. I initially interviewed more than 100 potential subjects, culled from clinics, village surveys and personal referrals, and selected six diverse, yet representative cases on which to focus. After lots of hours in the editorial bay, as the research and the overall narrative fell into place, I worked with my crew to arrange additional interviews and activities to fill out the stories.

4)    How did you build trust with the films’ characters?

In addition to my work as an anthropologist, I am a trained clinical psychologist and spent several years interviewing and assessing the mentally ill and providing psychotherapy. I learned techniques that I have brought to conducting interviews as a documentarian, including: a nonjudgmental and supportive attitude; a proclivity for remaining silent—especially during long, uncomfortable pauses—to allow my subjects to work through their anxiety and discomfort; and most importantly, the patience to address issues multiple times until the truth becomes apparent to the camera.

5)    What was the most challenging “Affliction” film to direct?

“Family Victim,” which looks at the life of a troubled and rebellious young man, was perhaps the most challenging film to direct because its subject–Estu Wardhani–is the son of professional colleagues. It was difficult to depict the truth of Estu’s story while at the same time remaining sensitive to his family’s need for privacy and to their desire to protect their reputation.

6)    Why did you choose film rather than the written word as your medium? 

Although longitudinal studies have been written about mental and neuropsychiatric illness in developing nations, there haven’t been any films about the topic. Because of the all-encompassing nature of cinematic language, many of the issues central to achieving better patient outcomes can be expressed more succinctly and directly using a visual medium. In addition, cinema allows audiences to directly and emotionally understand the complex factors that impact the lives of the mentally ill, while introducing a different and unfamiliar cultural setting in which these stories unfold.

7)    Why is “Afflictions” timely and relevant?

One in 17 Americans live with a serious mental illness and 450 million, worldwide, suffer from a mental or behavioral disorder. It’s a serious global problem that has been supplanted, on the one hand, by concerns about HIV/AIDs, TB and malaria and, on the other, funding shortages. While definitions and diagnoses vary from nation to nation, mental illness has important cross-cultural similarities.

“Afflictions” uses the medium of film to emotionally move mental health policymakers and practitioners, patients and their families. It strives to educate them about other points of view and to inform them about what they can do to improve outcomes for the mentally ill from all socioeconomic backgrounds.

8)    Why is “Afflictions” pertinent to the highly anticipated DSM update?

In the west, serious mental illness is increasingly viewed through the singular lens of biomedicine, as demonstrated by the contents of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM). The APA is currently making final preparations to release, in May 2013, the manual’s first major update in nearly two decades.

“Afflictions,” in contrast, is inspired by Harvard psychiatrist and medical anthropologist Arthur Kleinman’s groundbreaking work about the importance of bringing an ethnographic perspective to psychiatric research and practice. The “Affliction” films illustrate the complexity of mental illness, and depict how history, globalization and urban living impact its course. Most importantly, “Afflictions” elucidates how families and society understand, label and treat mental illness makes an enormous difference in patient outcome.

9)    Why did Dr. Lemelson choose Indonesia as the location?

Indonesia is a psycho-culturally fascinating nation that sits at the confluence of traditional and modern ways of living. It has attracted many researchers over the years and, as a result, offers a strong foundation for ethnographic study. Indonesia is also an emblematic developing nation, and its research findings are applicable to other developing nations.

“Afflictions” is Dr. Lemelson’s second body of work in Indonesia. The first, the feature documentary “40 Years of Silence: An Indonesian Tragedy,” examines the impact, on four families, of General Suharto’s mass killing of between 500,000 to 1,000,000 suspected communists in 1965-66.

10) How can I see the “Afflictions” film series?

“Afflictions: Culture & Mental Illness in Indonesia” is available for purchase by individual viewers at der.org, amazon.com or at elementalproductions.org. The film is available for educational and institutional purchase at der.org.

11) What is Elemental Productions next project?

Elemental Productions is putting the final touches on “Ngaben: Emotion and Restraint in a Balinese Heart, “ a short film about the funerary practices in Indonesia and “Standing on the Edge of a Thorn,” about a families struggle with poverty, mental illness and the sex trade in Java. Elemental is also currently in postproduction on a feature documentary about gender, violence and kinship in Bali and in preproduction on a short film series about mental illness around the world.