Lack of mental health care and community support leaves nearly 19,000 Indonesians vulnerable to outlawed practice, finds Human Rights Watch.

Almost 40 years after Indonesia banned the practice of shackling people with mental health conditions, nearly 19,000 are still living in chains, or are locked up in institutions where they are vulnerable to abuse, according to a new report from Human Rights Watch (HRW).

The study says that although pasung – shackling or confining people with psychosocial disabilities – was banned in 1977, enduring stigma and a chronic lack of mental health care and community support services mean its use remains widespread.

People subjected to pasung can have their ankles bound with chains or wooden stocks for hours, days, months or even years. They are often kept outside, naked and unable to wash.

Recent figures from the Indonesian government suggest that more than 57,000 people in Indonesia have endured pasung at least once, while an estimated 18,800 are currently chained or locked up.

In 2014, 1,274 cases of pasung were reported across 21 provinces and people were rescued in 93% of cases. There is, however, no data on how many of those were successfully rehabilitated and how many were later returned to their shackles.

HRW researchers spoke to one man who kept his daughter shackled for 15 years because he feared she had been bewitched and didn’t have the money to take her to a doctor.

“She became destructive, dug up other people’s crops and ate raw corn from the plant. I was ashamed and scared she’d do it again,” he said.

“First I tied her wrist and ankles together with cables but she managed to untie herself so I decided to lock her up because the neighbours were scared.”

Although he released his daughter two months after the visit from HRW, he told the group that, for a decade and a half, she had been left to defecate in her room, which was never cleaned. She was not bathed in all that time, and was neither clothed nor visited. Her only contact with the outside world, beyond the meals pushed twice daily through a hole in the wall, came when local children pelted her with stones.

“Shackling people with mental health conditions is illegal in Indonesia, yet it remains a widespread and brutal practice,” said Kriti Sharma, disability rights researcher at Human Rights Watch and the author of the report.

“People spend years locked up in chains, wooden stocks, or goat sheds because families don’t know what else to do and the government doesn’t do a good job of offering humane alternatives.”

The report recognises that the government has taken action to address the practice through initiatives such as the “Indonesia free from pasung” programme, which aims to eradicate the practice by 2019. But it says progress is being stymied by the decentralised nature of the governmental system and by inadequate resources and infrastructure.

The study says that Indonesia, a sprawling archipelago country of 250 million people, has only about 800 psychiatrists and 48 mental hospitals, more than half of which are in just four of its 34 provinces.

Noting that the ministry of health’s budget is 1.5% of Indonesia’s central government expenditure for 2015, the report describes mental health spending as negligible, adding that the latest data shows nearly 90% of those who may need to access mental health services are unable to do so.

Those locked up in institutions, meanwhile, can fall prey to physical and sexual violence, or find themselves subjected to involuntary treatments such as electroshock therapy, seclusion, restraint and forced contraception.

HRW found some of the facilities were overcrowded, while personal hygiene levels in many were “atrocious”, with people “routinely forced to sleep, eat, urinate and defecate in the same place”.

The organisation also documented the use of “magical” herbs, Qur’anic recitation and electroconvulsive therapy without anaesthesia and without consent. Cases of physical and sexual violence were noted by researchers: in seven of the institutions visited, male staff were either responsible for the women’s section or were able to come and go as they pleased, raising the risk of sexual violence.

The report calls on the Indonesian government to make mental health a priority by putting an end to pasung, ordering immediate inspections of state and private institutions, and instigating regular monitoring.

Other recommendations include amending the 2014 Mental Health Act to give people with psychosocial disabilities the same rights enjoyed by their fellow citizens, training mental health workers, and developing community-based services.

Equally important, however, is listening to the voices of those affected by mental illnesses, consulting them over their treatment, and seeking their informed consent.

“The thought that someone has been living in their own excrement and urine for 15 years in a locked room, isolated and not given any care whatsoever, is just horrifying,” said Sharma. “So many people told me, ‘This is like living in hell’. It really is.”

This article is a trip through the current mental health field of Asia in 51 recent articles about 16 Asian countries.
Mental health services, legislation and capacity building on the Asian continent are developing step by step, although great challenges remain as you can read.
Not all countries and topics are included; it’s just an attempt to give you an impression about what’s going on and how it is reported.

Countries: China, Russia, Nepal, Malaysia, Indonesia, Burma, Sri Lanka, Afghanistan, Pakistan, Fiji, Japan, Bhutan, Laos PDR, Vietnam, Cambodia, India

NGOs can play a decisive role in ensuring that those with mental health problems aren't misdiagnosed, and receive treatment that takes cultural and educational barriers into account.

patient indonesia
A mentally ill patient, takes a bath at a small mental rehabilitation centre in Bekasi, West Java, Indonesia. Photograph: Mast Irham/EPA

The United Nations regularly declares that "there is no health without mental health." It's a statement that holds much truth, yet little meaning in relation to mental health's standing in the development sector and governmental policies.

About 13% of all global illnesses are said to be related to mental health, and in low and middle-income countries it's reported that up to four in five people fail to receive proper treatment or care. This, combined with the fact that a majority of the developing countries dedicate less than 2% of their health budget to mental health care (pdf), is a reflection of how inadequate awareness of the issue is.

NGOs can play a decisive role in ensuring that those with mental health problems aren't neglected; they can help rebuild community resilience, develop relationships between patients and carers, or those administering treatment, and create greater awareness of mental health issues. Understanding mental health as a disability is beneficial. Yet, even organisations who work with the world's 1 billion disabled population can often fail to deal with disability at a macro-level – for example, lack of awareness of the issue in their literature – so mental health as part of field work, at a micro-level, is vulnerable to being mismanaged too. This mismanagement is partly the result of a lack of comprehensive data and the way data collation is implemented.


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.

JAKARTA, 14 February 2013 (IRIN) - Indonesia is seeking to boost its community mental health services in an effort to end the lockdown and shackling of thousands of mental health patients.

“The practice of shackling mentally-ill people still exists and eliminating it is one of our priorities for 2013,” Diah Setia Utami, director of mental health at the Health Ministry, told IRIN, noting that the country’s “serious” shortage of mental health professionals has been one of the biggest obstacles.

The government aims to provide 30 percent of the country’s 9,000 community health clinics and 1,700 general hospitals with staff to provide basic mental health care by 2014, Utami said.

The Health Ministry estimates 19 million people nationwide have various mental health disorders, including anxiety and depression, and another one million have severe psychoses.

Currently, 33 specialized mental health hospitals and 600 psychiatrists offer public mental health care. “These hospitals are adequately equipped to treat mental patients, but in the future, patients will be encouraged to have treatment outside [the] hospital under the care of families and community caregivers,” Utami added.