Mental Health Care Unshackled

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In June, a report on the appalling conditions in which mental health patients are held in some parts of Indonesia appeared in the Australian media. The Age drew attention to a particular institution called Yayasan Galuh, in the city of Bekasi. Here, young and old were kept in unsanitary, degrading confinement and bizarre treatments were administered.

The situation is by no means confined to one institution — but the campaign to free mentally ill people from physical constraints is gaining momentum. The transition to democracy in Indonesia and sustained economic growth have created space for reformers to improve the lives of mentally ill people in Indonesia’s far-flung communities.

In many villages, it is still common to blame abnormal behaviour caused by mental illness on possession by malign spirits. At other times, people acting strangely are simply labeled troublemakers. These people are often locked in rooms or outbuildings. Others have their legs set in wooden stocks. Some are kept in confinement — a practice known as pasung — for months, years and even decades.

Most people detained in these ways aren’t deprived of their liberty out of malice. In fact, people are often locked up by their own families. Sometimes this is to prevent community reprisals for troublesome behaviour. And even when symptoms aren’t blamed on possession or mischief, where professional care is unavailable the families of mentally ill people have few options. Restraint at home is one option. Sending the patient to a place like Yayasan Galuh is another.

After reading the report in The Age, Dr Eka Viora, from the Grogol Psychiatric Hospital in nearby Jakarta, began a dialogue with Yayasan Galuh’s manager, Suhartono. Viora’s request to visit the institution with hospital workers was accepted. But as Dr Viora told New Matilda, Suhartono maintained that his centre had "special treatments" with which he did not want the hospital to interfere.

Because Viora determined that it would be counter-productive to confront the institution head on, her team instead obtained permission to clean the institution, wash inmates and to examine their physical health. Malnutrition and other problems were found. The team was granted permission to treat the patients’ physical conditions and to prescribe medication. Copies of medical records were obtained for the local primary care service. Dealing with institutions like Yayasan Galuh is an ongoing process with improvement of the patients’ situation the only measure of success.

Dr Irmansyah, the Indonesian Ministry of Health’s director of community development and services for mental health, is frank about the scale of the challenge. Releasing people from restraints is "the easy part", he told New Matilda. More difficult is stopping them from landing in the stocks in the first place.

Ending pasung has long been a totemic issue for Indonesia’s mental health leaders. Irmansyah says that by freeing restrained patients, "the whole system should be improved". This is because it would mean freeing families from the stigma and superstitions which are attached to mental illness — and because it would make genuine psychiatric health care available in small communities.

The pasung push is part of a wider effort to overhaul psychiatric treatment by creating a network of carers in Indonesia’s villages.

As recently as five years ago, regional health services focused overwhelmingly on hospital-based care. (Institutions like Yayasan Galuh aren’t hospitals.  They they do not offer medical treatment and fall outside Indonesia’s health system.) This, Irmansyah says, was "not a good strategy for mental health in Indonesia". People with conditions best treated in the community were needlessly confined. Others in remote areas had no access to treatment at all. Centralised institutions monopolised scarce resources.

The new model reserves hospitalisation for cases of demonstrated need. Nurses trained to deal with serious disorders are made responsible for as many as twenty families in a given area. According to Dr Viora, the goal is to "empower the primary health care worker" to treat people in their own communities. Judged a success in Aceh province, the model is now being rolled in other parts of Indonesia.

Professor Achir Yani, Head of the Provincial Health Office in Aceh, is managing a provincial government programme that aims to eradicate forced restraint and confinement by the start of 2011. Yani told New Matilda that as well as being less costly, community care reduces relapse problems.

Deinstitutionalisation has been a global trend in mental healthcare. Australian health services have been going through the process for more than thirty years. Decades ago, Indonesia was the acknowledged leader in healthcare among the nations of South East Asia. Over the past decade this vast nation has been working hard to catch up. As a question of human rights as well as of quality and accessibility of care, the campaign to end confinement is a fitting yardstick of progress.

Hundreds of people have been released. The issue has been placed on the national agenda, with the Indonesian government’s recent commitment to ending forced restraint nationwide by 2014. Dr Pandu Setiawan is a leading architect of mental health reform and heads the Indonesian Mental Health Network. He describes this commitment as the culmination of a decades-long campaign to improve mental health policy. And Dr Setiawan is confident that the committed group of young mental health professionals at the heart of the anti-pasung push will be successful.

Earlier this month, a sign proclaiming "Toward an Indonesia free of pasung" was posted at the entrance of the Ministry of Health (see image above). The words are superimposed over a shattered chain. If the efforts of the professionals and activists leading the charge are matched by sustained political will, Indonesia will meet its commitment to those still in shackles.

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