Across the islands of Indonesia, people commonly use iron shackles, wooden stocks and rope to restrain individuals with mental illnesses. This is known as pasung, and includes physical restraints and confinement.
Many nurses and mental health workers chain patients or place patients in seclusion rooms to establish a sense of order in hospitals. Fearing a family member with a mental illness, families use similar practices at home, often in emulation of the professionals in the hospitals.
Such treatment compromises the health of the mentally ill, argues Dr. Soumitra Pathare, a psychiatrist in Pune, India, and expert in human rights law and mental health. He has assisted several countries, including Indonesia, develop mental health policy and law.
“Seclusion rooms do not get seen or talked about because the practice is not as obvious as chaining, but they create a sensory deprived world, which is more common, and equally harmful. Imagine spending twenty years in a room or a ward where there is no sensory stimulation, nothing to do, no activities. You’d go mad.”
The media typically blames health professionals and families in these situations, overlooking the lack of affordable care in resource-poor countries like Indonesia.
“Pasung is the result of a complex situation, like the availability of services, especially mental health services. By availability, I mean not only the services but also whether they are affordable and reachable,” said Dr. Albert Maramis, a psychiatrist based in Jakarta.
“Many people in developed countries, including most reporters, see pasung as a violation of human rights, torture, or cruelty. However, the problem with chaining mentally ill people is not as simple as a violation of human rights. In fact, accusing those who are using pasung, mainly the family, is not helping much at all.”
Providing widespread access to health care is difficult in a country as large as Indonesia, with its population of over 254 million people. The health budget is 2.4% of the GDP, according to the World Health Organization. (By comparison, it is 10% in Canada; the world average is 8.5%).
The country spends 1% of its health budget on mental health. Even then, most mental hospitals in Indonesia are located at the capitals of provinces. For those living in poor, remote areas, reaching these hospitals becomes difficult. Travel costs often exceed a family’s financial capabilities. It can take several difficult days for mental health patients to reach a mental health services.
The limited services that do exist lack the financial and human resources to function adequately. Mental hospitals are in poor condition, lacking staff, medications and equipment.
Panti Bina Laras Cipayung, for example, is a mental health centre in East Jakarta. With more than 300 inmates, the center is beyond its capacity. Authors of a report on the hospital found patients living in poor conditions, most naked. Some were chained to window bars, others emaciated and lying on the ground in their own excrement. A doctor visits once a week for two to three hours.
“So many of these hospitals that exist don’t help people get better at all,” Pathare told me. “Pasung becomes a response to the fear.
It reflects society’s unspoken fears as opposed to the reality. This fear leads to diagnosis and treatment that is more harmful than helpful for the individual. If the community has the presumption that you look dangerous, you may get chained. Often, any violence that starts is provoked by something – harassment, ridicule, treatment as inferior people – and the anger is seen as threatening and scary, and used as a justification to chain people.”
At the same time, he says, families are seen as the villains. “Yet in reality, in most countries, it is the families that carry the burden of mentally ill people, with very little support from services.”
In response to these challenges, the WHO launched the “Chain-Free Initiative” in Somalia and Afghanistan in 2006. Its objectives were chain-free hospitals and minimal use of restraints, chain-free homes and families with psycho-education, and eventually the removal of the social stigma of mental illness.
“These phases work towards removing stigma and realizing the dignity and rights of those with mental illness at the community level,” said the WHO’s regional advisor for the Eastern Mediterranean, Mohammad Taghi Yasamy. But the initiative’s progress is slow, because of budget constraints and staff shortages.
Maramis said, “The best way to bring about change is not by preaching, or by lecturing. It is not by distributing leaflets or brochures, but by proving that this condition is treatable. It is important to show the family the condition before the treatment and then the condition after the treatment. So they can see the improvement. So they understand that this is an illness then.”