Most studies of shame have focused on stigma as a form of social response and a socio-psychological consequence of mental illness. This study aims at exploring more complex Javanese meanings of shame in relation to psychotic illness. Six psychotic patients and their family members participated in this research. Ethnographic fieldwork was conducted in Yogyakarta, Indonesia. Thematic analysis of the data showed that participants used shame in three different ways. First, as a cultural index of illness and recovery. Family members identified their member as being ill when they had lost their sense of shame. If a patient exhibited behavior that indicated the reemergence of shame, the family saw this as an indication of recovery. Second, as an indication of relapse. Third, as a barrier toward recovery. In conclusion, shame is used as a cultural index of illness and recovery because it associated with the moral-behavioral control. Shame may also be regarded as a form of consciousness associated with the emergence of insight. Further study with a larger group of sample is needed to explore shame as a ‘socio-cultural marker’ for psychotic illness in Java.

1. Accepted Manuscript
Title: SHAME AS A CULTURAL INDEX OF ILLNESS
AND RECOVERY FROM PSYCHOTIC ILLNESS IN JAVA
Authors: M.A. Subandi, Byron J. Good
PII: S1876-2018(17)30816-X
DOI: https://doi.org/10.1016/j.ajp.2018.04.005
Reference: AJP 1400
To appear in:
Revised date: 13-3-2018
Accepted date: 1-4-2018
Please cite this article as: Subandi MA, Good BJ, SHAME AS A CULTURAL INDEX
OF ILLNESS AND RECOVERY FROM PSYCHOTIC ILLNESS IN JAVA, Asian
Journal of Psychiatry (2010), https://doi.org/10.1016/j.ajp.2018.04.005
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2. 1
SHAME AS A CULTURAL INDEX OF ILLNESS AND RECOVERY FROM
PSYCHOTIC ILLNESS IN JAVA
M.A. Subandia*
Byron J. Goodb
a
Faculty of Psychology, Gadjah Mada University, Indonesia
b
Department Global Health and Social Medicine, Harvard Medical School, USA
HIGHLIGHTS
 This is an exploratory study on complex Javanese meanings of shame in relation to
psychotic illness
 Shame is used as a cultural index of illness and recovery, as an indication of relapse,
and as a barrier toward recovery.
 Further study with a larger group of sample is needed to explore shame as a ‘socio-
cultural marker’ for psychotic illness in Java.
ABSTRACT
Objective: Most studies of shame have focused on stigma as a form of social response and a
socio-psychological consequence of mental illness. This study aims at exploring more
complex Javanese meanings of shame in relation to psychotic illness.
Method: Six psychotic patients and their family members participated in this research.
Ethnographic fieldwork was conducted in Yogyakarta, Indonesia.
Result: Thematic analysis of the data showed that participants used shame in three different
ways. First, as a cultural index of illness and recovery. Family members identified their
member as being ill when they had lost their sense of shame. If a patient exhibited behavior
that indicated the reemergence of shame, the family saw this as an indication of recovery.
Second, as an indication of relapse. Third, as a barrier toward recovery.
Conclusions: Shame is used as a cultural index of illness and recovery because it associated
with the moral-behavioral control. Shame may also be regarded as a form of consciousness
associated with the emergence of insight. Further study with a larger group of sample is
needed to explore shame as a ‘socio-cultural marker’ for psychotic illness in Java.
Keywords: shame, psychotic illness, recovery, Javanese
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1. Introduction
Shame is a universal emotion of human race, but its expression and manifestation
vary across cultures. For example, Japanese have a strong shame culture. They often commit
suicide because of shame (Pierre, 2015). For Javanese and Indonesians in general, shame is
highly significant in social relations (Heider, 1991). Many anthropologists such as Hildred
Geertz (1961), Keeler (1987) and Mulders (1994a) have demonstrated the importance of
shame among Javanese. Geertz (1961) discussed three critical emotions associated with
social relations in Java: isin (shame), wedi (afraid) and sungkan (respect). Isin (shame) refers
to a range of experiences and feelings that encompass shyness, shame, embarrassment, and
guilt. In her classic book on the Javanese family, Hildred Geertz (1961:105) described
childhood socialization – from earliest childhood to the age of four to six – as a process of
“learning shame,” as going from durung Jawa (not yet Javanese, not knowing shame) to wis
Jawa (Javanese, aware, knowing shame) (cf. Keeler, 1987:66-67; Mulder, 1994a:26). This
feeling is typically internalized in many different social situations, particularly in the
presence of authority figures and strangers. As part of the progression toward maturity, a
child has to develop his or her internal control by learning to recognize the feelings
associated with shame and experience these feelings when engaging in improper behaviors.
This learning process is called ngerti isin (to know shame). Collins and Bahar (2000) argued
that ‘to know shame’ is not specific to Javanese, but it is also evident in other Malay society.
Shame (malu in Malay or Indonesian) is considered as an essential cultural value, which is
also associated with Islamic teaching. In one of the Islamic traditions (Hadist), the Prophet
Muhammad has said that shame is one of the indicators of a believer.
In Java, shame has both negative and positive dimensions. The positive aspect of
shame is associated with cultural norms and traditions. It serves as a behavioral control. It
may “contribute to the development of respect for others and the desire to avoid conflict and
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confrontation” (Mulder, 1994a:26). Showing proper respect to others and being polite are
highly valued in the culture to maintain a harmonious social life (Mulder, 1992). Failure to
maintain cooperative relationships often lead to feelings of shame that indicates a violation of
a social rule. In other situation, the violation of religious and moral values could also result in
feelings of shame.
Geertz (1961) described the negative aspect of shame as a complex anxiety reaction,
involving fear and lowered self-esteem, seen as a hindrance to social interaction. Collins &
Bahar (2000) compared shyness in Western societies with malu (shame) in Malay societies.
They stated that Western societies considered timidity as an individual character viewed in a
pathological perspective. Meanwhile Malay designates shame as an appropriate shyness or
feeling of deference to show respect to others. More recently, Vriend et al. (2013) examined
shame that is close to social anxiety. They conducted a cross-cultural study on the emotion of
shame in Indonesia and investigated its clinical relevance to social anxiety. The authors
compared this emotion with the cultural bond syndrome in Japan, Taijin Kyofusho (James,
2006).
The study of shame in the context of mental illness has mostly focused on its negative
aspects, particularly related to stigma (Faith et al., 2002; Rüsch et al., 2005). Families often
go out of their way to avoid their member being publicly identified as mentally ill. Subandi
(2007) investigated family dimensions of psychotic illness. He argued that the most common
focus of stigma in Java related to problems regarding marriage. This can be understood in the
light of its connection with the Javanese cultural idea of bibit, bebet, bobot for choosing a
partner in marriage. Bibit literally means ‘seed.’ It refers to inherited factors and thus
biological worth (which includes the hereditary diseases). Bebet refers to social status or
wealth, while bobot refers to the moral character. It is widely accepted that psychosis is at
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least partially a genetic illness. Thus, having a mentally ill member of the family can imply
that the family does not have a good bibit, leading to social embarrassment (shame) and loss
of respect.
This research focuses on exploring the emotion of shame and its relation to illness and
recovery processes among persons suffering a psychotic illness and their families.
2. Method
As part of a more extensive program of research on recovery from first episode
psychosis, this study employed an ethnographic methodology (Subandi, 2006). However, it
does not fully follow a classical ethnographic approach. In the study of small-scale societies,
it is common practice for the ethnographer to ‘live’ among the participants, enabling him or
her to carry out routine participant observation. Despite living in the same general region as
the participants, in this research the investigator did not live in the neighborhoods nor villages
where the families being studied lived. During the fieldwork, the researcher visited
participants at their homes, approximately 10 to 30 kilometers from his house. Consequently,
there was a limit to the extent to which the researcher could follow their day-to-day lives.
Lucas (1999), however, argued that ethnography can make an essential contribution to
understanding people living in a dispersed distribution (i.e., people with mental illness
residing in a sub-urban situation). The critical issue is whether the data are gathered within
the context of people’s social engagement.
Nine people with first-episode of psychotic illness and their family members
participated in this research (Subandi, 2006). They were recruited from the department of
psychiatry of a local General Hospital and a private mental hospital in Yogyakarta. The
inclusion criteria were: First episode of psychosis and first contact with a psychiatrist; aged
15 – 50; length of illness no longer than 12 months; Javanese; and living with their family.
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All the interviews and participant observation were conducted in natural settings. The
interview data were transcribed verbatim and integrated with observational data. Several
processes were involved in the analysis. Firstly, reading the full transcripts of interviews
provided the opportunity to become familiar with the data and obtain a sense of the whole.
Secondly, themes and critical excerpts, essential to support the analysis and arguments to be
made, were identified. Finally, the interpretations of the data were put in a broader theoretical
perspective. In this paper, only six participants’ narratives were analyzed, examining where
the theme related to shame emerged. Three participants did not mention shame when telling
about their experience of illness and recovery, partly because two had a short single episode
of psychosis, while the other expressed guilt instead of shame in response to his illness.
3. Results
The six psychotic patients who participated in this research are identified as P1, P2,
P3, P4, P5, and P6. All participants were diagnosed with psychosis for the first time. The
result of this research is categorized into three different themes: (1) shame as an indication of
illness and recovery, (2) shame as sign of relapse, and (3) shame as an inhibitor of recovery.
Results of the analysis of shame and mental illness in this cultural setting are described
according to these themes.
3.1. Shame as an indication of illness and recovery
For these Javanese families, loss of shame by the person who was ill was an
indication of illness, while recovery was shown by the presence of shame. This theme was
evident in the narrative of P1, a 16-year-old boy suffering his first episode of psychosis. He
was the elder of two siblings. P1 was a ‘slow learner’ and could be categorized as having
borderline intellectual functioning (IQ around 90). His father thought that it was caused by
frequent falling from the bed when he was a baby. At his age, he would have ordinarily
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progressed to the third year of secondary school, but he was still in the last year of primary
school. Despite this borderline intellectual impairment, his interpersonal and social
functioning indicated proper adjustment. He was also deeply committed to religion and
involved in local mosque activities. His friends encouraged him to join an Islamic militant
group. According to his father, two problems led to the development of P1’s illness. First, his
father suspected that the Islamic militant group used a magic formula to influence his son.
Second, his father had experienced conflict with another man, a former friend, and believed
that this man had used black magic (sorcery) on P1 as a form of revenge. The father of P1
narrated that before his son fell ill, he was a regular Javanese boy who complied with social
norms and showed appropriate manners toward other people. His father said that he usually
felt shame if he was asked to eat in his relatives’ house. When he fell ill, however, P1 began
to be shameless in eating the food offered by their neighbors. He ‘lost his shame.’ It is
culturally prescribed to feel some degree of shame when eating outside the family’s home,
say, with a neighbor, and especially with strangers.
A similar story was narrated by the mother of P2, a 26-year-old female university
student when she fell ill. She was the second daughter of four siblings. Before she was ill, she
was a typical university student and behaved appropriately according to Javanese social
norms. The cause of her illness was the conflict between P2 and her family around marriage,
lasting from when she was 18 years of age to the time of the study. It was still an issue of
great importance to P2 when she became ill. Her mother narrated that P2 seemed shameless
when she was ill. She ate food in her uncle’s house without showing any form of politeness
or attention to proper Javanese manners. This was regarded by her mother as an early
indication that she lost her shame feeling.
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The loss of shame was also shown in P3’s narrative. P3 is a single woman who was
18 years of age when the study began. She was the youngest daughter of four siblings. After
she left high school, she took sewing lessons and worked for a furniture company. She said
that her workmates often teased her, and she took what they said to heart, causing her to leave
this job. Her illness slowly developed after she stayed at home and had nothing to do. The
father of P3 described his daughter as not being able to conform to, or even understand,
etiquette when she was ill. She often shouted, talked rudely, stared insolently at her father, or
lectured people in the village. This was in stark contrast to her previous pattern of behavior,
which her father described as polite and highly respectful.
While illness is associated with loss of shame, recovery is linked to the re-emergence
of shame. This re-emergence of shame was evident in P4’s narrative. P4 is a 16-year-old
female; the elder of two siblings who was described as having been a quiet girl. Her mother
often became angry with her but, according to her mother, she just tended to keep quiet. She
had recently finished secondary school when she fell ill. Her mother recalled that the illness
was triggered after she wore the wrong uniform to her new high school. She felt that all her
daughter's teachers and fellow students were teasing her. After returning home, P4 exhibited
odd behavior and later developed delusion of persecution and experienced visual
hallucinations. After several months of medication, P4 did not show any psychotic
symptoms. This was an indication of a functional clinical recovery. However, P4’s mother
believed that her daughter has not fully recovered. She said, “My daughter has recovered
ninety percent, but she still has no shame.”
A similar story was also indicated by P1. During one of the interview visits, the
researcher asked his father whether P1 has recovered. He replied, “No, he has not recovered
yet… because he still feels no sense of shame.” On a later visit, P1’s father described the
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emergence of shame in P1 and associated it with his recovery. He said, “Now, my son feels
shame to eat food at a neighbor’s house. This means that he has returned to his previous
condition.”
P3’s recovery process was also indicated by the re-emergence of shame. While she
was ill, P3 wandered around the village, shouted, scribbled on walls, and assaulted people. In
contrast, once she recovered, she stayed at home. She said that she felt ashamed of what she
did. She now considered these as shameful deeds.
3.2. Shame as a sign of relapse
The data of this research also indicate that shame, or loss of it, was used as a sign of
relapse. It is evident in the narrative of P5; a 35-year-old married man. He worked in an
aluminum company that manufactured household items. He described himself as being
interested in the mystical world. He often performed spiritual and mystical practices derived
from Islamic and Javanese asceticism. Although he had a history of drug and alcohol abuse,
his mental illness was not related to substance abuse, both according to the medical records
and to the researcher's observation. P5 himself attributed his illness to excessive ascetic
practices. His mother and wife suspected that he became ill after wanting to build his own
house quickly without having sufficient money to accomplish it. Following a week’s
hospitalization and a week on medication at home, P5 made a progressive recovery. Despite
the occasional emergence of paranoid ideas, he could return to his typical family life, build
his own house, and return to his previous job. His wife stated that her husband, after a period
of recovery, suddenly began to display suspicious behavior. She claimed that he felt someone
was going to harm him. That night he secreted a sword in his bedroom and told his wife not
to go out. The next morning, P5’s wife asked her brother to take her husband to the hospital
again. She said, “I gave my husband a bottle of tea in a plastic bag when my brother asked
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my husband to ride the motorcycle with him, but he immediately drank it in front of others
with no shame, so I concluded that he must have become ill again.” This inappropriate
behavior convinced P5’s wife that he had relapsed and needed medication again.
3.3. Shame as an inhibitor of recovery
For P6 shame had negative implications. Not only did it serve as an index of failure to
recover, but also appeared to play a role in preventing recovery. P6 was a 42-year-old
married man with three children. After graduating from a state university in Yogyakarta, he
became a teacher in a public junior high school. He had subsequently been working as a
principal at a private secondary school for eight years when he became ill. His wife reported
that he had caused a financial scandal at the school by using school project funds for personal
purposes. His behavior began to change several weeks before the illness. He had difficulty
getting sleep and became irritable. He showed recovery after several months of medication;
however, he felt shame after taking his first duty as a regular teacher. This feeling prevented
him from fully engaging in his work and relating to his colleagues. Fortunately, with the
support of his wife, he was able to overcome this inhibition and successfully integrated into
his workplace
For P3, she remained somewhat socially isolated, even at the time of the two-year
follow-up. In seeking to account for this, P3 stated that her weakness was that she closed
herself off to the outer world because she was ashamed of her behavior when she was ill.
P3’s brother also felt that her feeling of shame inhibited her ability to reintegrate with the
community or return to work, notwithstanding her strong motivation to accomplish these
goals.
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4. Discussion
Whereas “shame” is generally considered in the literature on stigma to be a form of
self-stigmatizing feelings, a response to societal meanings of mental illness and social
responses to those who are mentally ill, in Java, and in Indonesia more broadly, shame has a
much more complex set of meanings. “Knowing shame” – both in the sense of showing
proper deference in social settings and in relationship to social hierarchy, and in the sense of
feeling appropriate shame or embarrassment about inappropriate behaviors – is an essential
part of being normal, healthy, and morally mature person (Geertz, 1961; Mulder, 1994a).
These complex meanings of shame are reflected in the experience and response to psychotic
illness among the participants in the research reported here.
In previous writing on this research, Subandi (2015) discussed the local cultural
processes of recovery from first episode psychosis as including awareness as an essential
component to the emergence of insight. This included not only the awareness about
themselves by those with recovering from psychosis but also towards their social
environment. Subandi (2006) also discussed the traditional Javanese drama entitled Suminten
Edan (Crazy Suminten) as an important cultural representation of madness. This drama
emphasized the theme of rapid and complete recovery. Further, in this play, the recovery of
shame is dramatically represented as symbolizing recovery itself. When Suminten, the main
character of this play, regained consciousness from her madness the first sentence she uttered
was, “I am ashamed.”
There are two reasons why shame is used as a cultural index of illness and recovery in
this sample. Firstly, shame is associated with moral-behavioral control. According to Hildred
Geertz (1961, p. 114), “… to know shame is simply to know the basic social properties of
self-control and avoidance of disapproval.” Subandi (2006) also emphasized that psychotic
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illness can be understood as a process of escaping control. The role of shame is to control
behavior; in other words, losing control can also mean losing shame. Thus, the emergence of
shame means the re-establishment of self-control, which in turn indicates recovery.
Interestingly, our findings show that most of the participants’ experience with shame
occurred in the context of eating behavior and other manifestation of manners. This implies
the importance of eating behavior among Javanese. In his ethnographic account of Javanese
in Solo, Siegel (1993) observed that eating was considered shameful because it
acknowledged personal desire which should be controlled. “… Eating itself, however,
indicates the inadequate suppression of desire” (Siegel, 1993, p. 193). Siegel described this
further by saying that Javanese people with high social status know how to act appropriately,
namely that they are expected to restrain their appetite by eating lightly while with others.
They should pass the dishes on to someone else first, instead of having it for themselves.
While Siegel (1993) relates eating behavior with social status among Javanese, this study
suggests that proper eating behavior was used to differentiate between normal and mentally
ill patients. A normal Javanese would consider the proper way of eating in front of others,
while mentally ill patients follow their desire to eat food however they want. Aside from
feeling shame (isin), a typical Javanese would feel sungkan (respect, a more refined synonym
of isin) to eat a lot of food in the presence of others or in an improper way. For example, a
participant in this study had no feeling of sungkan to eat in his neighbors' house, while other
participants ate or drank while riding a motorbike.
As mentioned previously, a Javanese child has to learn to feel isin and sungkan as part
of the progression to maturity. When someone has no isin and sungkan, he/she is ‘not yet
Javanese’. Geertz (1974) observed that the criteria of ‘not yet Javanese’ not only applies to
small children, but also to boors, simpleton, the insane, the flagrantly immoral. This is in line
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with the finding of this present study that to know isin not only indicates maturity, but also
indicates sanity/normality – and being a full Javanese person.
Secondly, shame may be regarded as a form of consciousness (Mulder, 1994a). It is in
this context that, on a personal level, shame becomes associated with the emergence of
insight. It is in this sense that the finding of this research relates to many studies on recovery
from psychotic illness, which discuss the process of recovery as beginning with the
emergence of insight (Young & Ensing, 1999; Spaniol et al. 2002; Mintz, 2003). From a
meta-analysis study on the role of insight, Mintz (2003) concluded that insight was inversely
related to psychopathology. The more severe the illness, the less insight the patients have.
Subandi (2015) analyzed the term bangkit (to revive) that was used by the participants to
describe the process of recovery in Java. The term bangkit is associated both with ‘gaining
insight’ and with the reemergence of self-awareness. It is in this sense that shame is closely
linked to awareness. On a social level, gaining consciousness was associated with the
participants’ recovery of awareness of themselves as social beings living in a community,
where they gave proper consideration to social rules, norms, and the presence of others.
This research suggests that a sense of shame in the context of mental illness is not
only related to stigma as previously studied (Faith, et al. 2002; Rusch, 2005), but also in more
complex situations, an index of illness and recovery, particularly concerning the illness itself.
It means that shame not only has negative connotations as previous research found. For
example, in their study on the use of shame in Malay societies, Collin and Bahar (2001)
argued that shame be pivotal to the bound cultural syndromes of Amok and Latah. Both
syndromes appeared because of shameful experiences. In Amok, a man would respond to an
ultimately shameful experience with dissociation and aggressive behavior, randomly
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attacking whomever he met. In the latah syndrome, a person, usually a woman, would
express feelings in a kind of ritual of shame.
The emergence of shame in psychotic illness and recovery can be explained from the
perspective of self-construal theory (Markus & Kitayama, 1991). These authors differentiate
between independent and interdependent self-construal. While independent self-construal
focuses on the autonomy of an individual separate from the community, interdependent self-
construal emphasizes relatedness of an individual to the community. The independent self-
construal is mostly found among people from an individualistic cultural background.
Meanwhile, interdependent self-construal is frequently found in people with a more
collectivist cultural background. This is evident in Vriend et al. (2013) study, where the
Indonesian sample scored higher on interdependent and lower in independent self-construal
compared to Swiss (Western) sample. They also found that the Indonesian sample reported
more social anxiety and willingness to seek professional help. Although the shame in this
research is not as severe as social anxiety, the psychological mechanism underlying these two
phenomena is somewhat similar. In Indonesia, particularly in Java, individuals must consider
others' perception regularly. When someone can meet the community expectation, he/she
would be considered as a mature and normal community member.
To conclude, family members understood psychotic illness as losing shame while
recovery was understood as gaining shame. The reason shame served as such a critical index
of illness and recovery was its association with control and social awareness. When
participants were ill, their awareness was closed off, preventing them from feeling ashamed.
Once their awareness returned, shame emerged again. This analysis of the role of shame in its
positive sense as an indicator of illness, relapse, and recovery, represents a significant
contribution to the literature in this area. Most literature on social recovery focuses on social
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functioning, such as self-care and gaining domestic and social skills and responsibility. This
research suggests that social recovery should include the emergence of shame. Because the
experience of shame – isin (Javanese), malu (Indonesian, Malay) – is a deeply moral
experience, rooted in “local moral worlds” of Java, this work also strongly supports the
argument of Yang et al (2007) that stigma theory needs to take account of “moral experience”
in a more complex way than is true of most theorization of stigma associated with mental
illness. Indeed, this paper can be read as a contribution to such reworking of theories of
stigma.
Although this work is linked to a larger program of research (see, e.g., Good and
Subandi, 2004; Good et al., 2010), the main limitation of this study is the small sample of
participants. The subjective experiences of the participants can only be understood in their
own context and cannot be generalized to the general populations of Java. Future research
needs to examine the concept of shame in the context of mental illness with a more
substantial number of participants and in specific local cultural milieus within Indonesia.
Finally, the idea that shame serves as a social marker of psychotic illness and recovery in
Java needs also to be explored in clinical settings of psychiatrists and psychologists to
explore further the validity of this concept and its relevance to clinical practice.
Acknowledgement:
The first author wishes to thank the late Professor Robert J. Barrett, Professor Helen
Winefied, Dr. Rodney Lucas (University of Adelaide), and Professor Byron J. Good
(Department of Social Medicine and Global Health, Harvard University) for the supervision
of his dissertation from which this article draws.
Conflict of interest:
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We wish to confirm that there are no known conflicts of interest associated with this
publication and there has been no significant financial support for this work that could have
influenced its outcome
Declaration of interest
Declarations of interest : None
We wish to confirm that there are no known conflicts of interest associated with this
publication and there has been no significant financial support for this work that could have
influenced its outcome
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