Pacific Scoop

‘Chains free’ mental health campaign in Indonesia may end pasung

Bali psychiatrict patient

A patient is released from chains in North Bali by Professor Luh Ketut Suryani, founder of the Suryani Institute for Mental Health. Photo: Suryani Institute for Mental Health

For an estimated 20 million Indonesians who suffer a mental health illness, the chained or shackled conditions seen in this photo are an everyday threat. This practice, known as pasung, has been banned in Indonesia since 1977 but Holly Ryan reports for Asia-Pacific Journalism that it is still a problem.

Pacific Scoop:
Report – By Holly Ryan

The practice of “treating” mental health patients through electro-convulsive therapy or lobotomies and locking them up or shackling them to the floor, is widely regarded as a primitive treatment of the past.

However, for many of the 20 million people in Indonesia who suffer a mental illness, these practices – known as pasung – are still a reality.

But a new national programme is now trying to eliminate pasung once and for all, with the Indonesian government saying that it plans to make the training of mental health professionals a priority, and increase the accessibility of mental health services.

APJlogo72_iconAnthony Stratford, senior training and development officer of Mind Australia, an organisation working closely with Indonesia to find solutions to mental health issues, says the continued practice of pasung is a human rights tragedy.

“There is very little funding for this and we need strong leadership from people who really want to make a difference,” he says, adding it is an issue that should have been dealt with years ago.

For those in Indonesia who suffer from mental health issues, their illness often results in family members or community locking them up or shackling them to the ground if they cannot afford the health care needed, or want to avoid the stigma still associated with mental illness in many countries.

According to Indonesia’s Health Ministry an estimated 18,000 people are reported to be living in isolated, chained or caged conditions associated with pasung.

Naked, malnourished
For many, these living conditions also include being naked, malnourished and often forced to live in their own excrement.

The practice of pasung was officially banned in Indonesia in 1977.

However, this has not been enforced and has not resulted in any change in the poorly-funded and minimal mental health care in Indonesia – one of the main reasons for the continued practice of pasung.

Indonesia’s government announced the new national programme to try and eliminate pasung in February.

Director of Mental Health Diah Setia Utami said that “the practice of shackling mentally ill people still exists and eliminating it is one of our priorities for 2013″.

Utami also stated that a shortage of mental health professionals had been one of the biggest obstacles in tackling this issue.

Currently there are only 33 specialist mental health hospitals and 600 psychiatrists, numbers which, according to Utami, are far too low to deal with the 20 million mental health patients.

Spiritual leaders
Stratford says the underlying issues of mental health funding for psychiatric consulting and medicine has pushed many Indonesians to resort to spiritual leaders or dukuns, to treat their mental health issues.

Dr Pandu Setiawan, former Mental Health Minister, says that there is still a huge undercurrent of magic that runs through society, and that as many as 50 percent of mental health patients first see dukuns before seeking medical treatment.

However, many Indonesians see this as dark magic, and view these patients being treated as possessed by evil spirits.

Because of this, these patients are usually treated with suspicion and often the families of mental health patients are isolated or ostracised by the local community or forced to shackle their sick.

Stratford says families and communities need to be educated, and that they cannot be blamed for shackling mentally ill family members.

He says education and changing people’s attitudes towards mental illness is essential if Indonesia wants to be rid of this practice altogether.

Widespread practice
Pasung has for years been a widespread practice in middle to low income families, especially in rural Indonesia.

This cruel practice is not limited to Indonesia either; it is also common in some other developing countries and until very recently has been universally ignored.

A programme launched in 2011 by the Health Ministry, “Menuju Indonesia Bebas Pasung” (towards a shackle-free Indonesia), was hoped to address the issue.

However, since its implementation, officials have said the programme has been stalled by a lack of health professionals and inadequate funding.

The February announcement by the government to boost Indonesia’s mental health system has many people hopeful the practice will finally end.

The plan outlined by the government is to provide 30 percent of the 9000 community health clinics and 1700 general hospitals with staff trained to provide basic mental health care by 2014, according to Utami.

The Indonesian government also plans to implement nationwide health coverage in 2014 which will cover the majority of mental health costs.

Medication costs
Currently a psychiatric consultation costs around US$25 with medication costs adding to this. The majority of people who cannot afford these costs resort to pasung as a way to deal with the situation.

One aid organisation, which works in collaboration with Mind Australia in Indonesia, is Asia Australia Mental Health (AAMH).

AAMH manager David Paroissien says he is extremely hopeful that these new measures will succeed where previous schemes have failed.

According to Paroissien, the government “very much recognises the issue of pasung and have been taking steps to address this”.

Despite the bleak picture painted by so many in Indonesia about the country’s mental health issues, several organisations working closely with Indonesia believe things are slowly getting better.

A World Health Organisation (WHO) global mental health action plan to be implemented from 2013 to 2020, expects 80 percent of member countries to have updated their mental health policies by 2016 and to have allocated at least five percent of public health money to mental health expenses by 2020.

While this may seem a long way off, psychiatrists working at mental hospitals have already noted improvements in psychiatric health facilities.

Significant improvements
One worker from a psychiatric health institute in Jakarta stated that things had improved significantly in the last 10 years, and that while the institute used to be described as a prison, it was now “more like a hostel or at least a one star hotel”.

At the Suryani Institute for Mental Health, a non-profit institute set up in 2005 by psychiatry professor (and former head of the department of psychiatry at Udayana University) Luh Ketut Suryani, the focus is on dealing with mental issues through a combination of Western and holistic treatments.

Suryani regularly walks through neglected areas of Bali to find abandoned and hidden people with chronic mental illnesses.

Suryani says the work, while sometimes slow, is extremely rewarding, despite the lack of support from the government.

“I help my people because nobody helps them. Not the government not the hospital, no one helps the communities so I visit them and try to help,” she says.

Stratford also praised the work of the Suryani Institute, saying it had done “amazing things” for the communities in Bali already.

According to Suryani, of the patients she works with, 31 percent have drastically improved without medicine, 3 percent have not responded and the remaining 66 percent still require medicine, but also showed significant improvements with a combination of medicine, meditation and therapy.

Facebook campaign
Bagus Utomo, winner of the Doctor Guislain “breaking the chains of stigma” award in 2012, is the founder of several Facebook groups helping families with schitzophrenic patients to understand and better deal with the situation.

Utomo, whose brother was afflicted with schizophrenia, first began to research mental health help after feeling hopeless and lost dealing with his brothers’ issues.

Following this, he set up the Facebook page, Komunitas Peduli Skizofrenia Indonesia (Indonesian community for schizophrenics), a page which now comprises 7588 members who can discuss and share their experiences and help to support each other.

WHO representative Dr Limpakarnjanarat Khanchit says the issue of pasung has become much more prominent in recent years.

“There is a lot more attention to this problem now, a few years ago it was not mentioned but now things are being done.”

While it remains to be seen whether the government will reach its target of being free from pasung by 2014, it is clear that the issue of pasung has finally become a focus health issue for Indonesia, and good news for the thousands of people still locked up.

Holly Ryan is a Postgraduate Diploma in Communication Studies (Journalism) student on the Asia-Pacific Journalism course at AUT University.