Indonesia's most severely mentally ill patients can be so aggressive that their families and communities – desperate in the absence of basic mental healthcare – bind their ankles with chains or keep them in wooden stocks for months or years.

Trapped in restraints or in isolation rooms, many wallow in their own filth and suffer such acute muscular atrophy that they are unable to walk or sit.

Indonesia has an extensive healthcare infrastructure, but mental healthcare remains scarce, especially in rural, remote areas, so families and communities keep the mentally ill under control with physical restraints and confinement – known locally as pasung – to prevent the individuals from hurting themselves or others.

"This is a human rights violation problem, but it is because of the scarcity of mental health services," said Hervita Diatri, a psychiatrist at the University of Indonesia's medical school, who has extensively researched the phenomenon.

 

Kept in restraints for such a long time, a mental patient's muscles atrophy. Mental health remains a key challenge in Indonesia (Photo: Alisa Tang/IRIN)

Diatri said pasung points to the families' hopelessness. "Hopeless because they don't have the money to bring their family to the mental health services... hopeless because of scarcity of the services."

Experts and the government are now trying to eliminate this practice, and with a mental health training programme in the easternmost province of Aceh – funded in part by international donors after the December 2004 tsunami – nurses and doctors have successfully treated and unchained 120 of 289 known pasung patients.

Diatri estimates 15,000 people are being kept in pasung across Indonesia, though she believes the actual figure is even higher.

Aceh, home to 4.5 million people, has a higher incidence of mental illness than the rest of the country owing to three decades of conflict and the tsunami that claimed more than 167,000 lives and left half a million people needing assistance.

Indonesia's National Basic Health Research in 2007 indicates that 14.1% of Aceh's population suffers depression and anxiety, compared with 11.6% nationally, while 1.9% is afflicted by severe mental disorders, more than three times the national rate of 0.5%.

Since the tsunami, 534 nurses and 203 doctors have received mental health training, and an additional 5,961 village volunteers have been taught to detect and report people in need of help.

 

Home care

The training programme has focused on nurses, as most are from Aceh and less likely than doctors to transfer out of the area, and has taught them to give patients medicine and counselling, while also caring for family members who have never understood a patient's condition.

It is better to treat these mental health patients in their communities, not in the mental health hospital.

"It is better to treat these mental health patients in their communities, not in the mental health hospital," said Syarifah Yessi Hediyati, coordinator of trauma counselling in the Aceh provincial health office. "This helps to decrease stigma, gives support to the family and to the community."

From 2005 to 2009, the newly trained mental healthcare providers assisted more than 14,000 patients – including 8,355 in home visits. Nurses reached out to the 289 pasung patients, providing home treatment or admitting them to the Banda Aceh Mental Hospital.

"The community and the family can see that three days ago, he was violent, and after this community mental health nurse came and gave medicine, now he is not aggressive anymore and can talk like a normal person," said Albert Maramis, a World Health Organization psychiatrist, who helped coordinate the training programme.

If a person is hospitalised for months far from home, the family and community cannot follow their progress or treatment. "They have the image of this person who is violent and dangerous, so when this person comes back, they are afraid," Maramis said. "When they can see the process, they won't be so frightened."

 

In the mental hospital

Nonetheless, the most severe pasung patients are admitted to the Banda Aceh Mental Hospital for intensive care.

Four men in turquoise hospital uniforms sat sedated in wheelchairs, listless in the sun, in the hospital garden. Their legs were scarred – some swollen, others atrophied.

This year so far, 42 pasung patients have been admitted here, including a 22-year-old man who had been chained up since he was 12.

"Every day the patients get better and better. I can see their progress," said Wahyu Kadri, a nurse, as he kept watch over the men. "When the patients first come here, they cannot walk, they cannot sit. They only sleep. Now we see some of them start to sit and walk."

Kadri made one request: "We need more wheelchairs, and we need more crutches."

 

Some Indonesian families and communities chain up severely mentally ill people (Photo courtesy of Aceh Provincial Health Office)

 

 

This post was first published in IRIN in June 2010.