How can Indonesia free the mentally ill from shackles once and for all?

Human Rights Watch reported last month that thousands of people with mental illness in Indonesia are shackled or locked up by families and religious healing centres.

The report, “Living in Hell”, shows human rights violations against people with mental illness continue in Indonesia despite a ban on shackling since 1977.

I am part of the National Task Force on Mental Health System Development in Indonesia, a collaboration between the Health Ministry and Faculty of Medicine, University of Indonesia, supported by the University of Melbourne’s Center for International Mental Health.

Why does the practice of shackling persist and how can we eliminate it once and for all?

More work needs to be done

In 2010, Indonesia launched a campaign aiming to eliminate shackling, locally known as pasung, by 2014. The Human Rights Watch report and the Indonesian government’s own monitoring and evaluation of the campaign show that we are far from achieving our goal.

Through the “Free from Pasung” campaign, the Health Ministry has found more than 8,000 people with mental illness in shackles and has given them care. But, in practice, eliminating pasung is not simply releasing the victims from shackles and closing down shelters that violate human rights.

This effort should include prevention and protection from new shackling practices or repeat shackling. To achieve this, people with mental illness must receive proper mental health care in time to help them recover.

Challenges for patients and families

People with mental health disorders and their families face various challenges in treating mental illness.

Many Indonesians lack knowledge about mental illness and proper mental health care.

For its 250 million population, Indonesia has only 48 mental health institutions. More than half of them are concentrated in four of the country’s 34 provinces. Eight provinces have no mental hospitals. Travel distances and the cost of transportation hinder people seeking proper treatment.

People with mental illness often do not have access to health insurance. They depend on funds from their families. Many could not afford to pay for treatment in general or mental health hospitals. Families then opt to send their family members who have mental illness to questionable traditional or religious mental health centres that are more affordable.

Even when families send patients to hospital, there is no mechanism for families to learn about how to care for their sick family members. When the patient returns home, families do not know how to help. Sometimes they reject the patient if, due to the latter’s illness, they had been violent.

Medication often brings side effects. Lack of access and poor insight from people with mental illness during relapse phases create the risk of discontinuity in their treatment. Families and patients often feel helpless in these situations too.

Multi-sector affair

The Health Ministry and the Social Affairs Ministry have carried out the five-year campaign. But we need to make mental health everyone’s priority to eliminate the practice of pasung.

They plan to sign agreements with the Co-ordinating Ministry of People’s Welfare, the Ministry of Home Affairs, the Ministry of Law, Justice and Human Rights, the Education Ministry, the Housing Ministry and the Ministry of Human Resources to work together on this issue.

This multi-ministry collaboration aligns with the president’s national plan of action to protect human rights, launched in 2015, and with the new Law on Protection of People with Disabilities, launched last month.

The National Task Force on Mental Health System Development is developing a number of measures to tackle the problem of mental health care in Indonesia.

We are working on an integrated information and data system, which can be accessed by all stakeholders, to spur collaboration. This system will store various research into treatment gaps, shackling and other mistreatment. The database will also be used to accurately record patients' identity and identify people with mental illness who should be assisted in accessing free health care and social assistance.

We are encouraging hospitals and centres to increase their standards of care and safety through accreditation.

We are working to improve the quality of mental health care by increasing the capacity of mental health practitioners and ensuring a good medication management system is in place.

We are campaigning for increased access to mental health treatment by encouraging general hospitals to provide more acute psychiatric care units. The ministry is urging the government to build mental health hospitals in provinces that do not yet have such services.

We are also planning to develop halfway houses. These will help prevent re-hospitalisation of patients and also prepare them for re-integration in the community after being treated in a mental health institution.

We are conducting a study on how to harmonise the Convention on the Rights of People with Disabilities, the Mental Health Law and the Law on Protection for People with Disabilities. The aim is to translate these into a more operational government regulation to protect the rights of people with mental disabilities.

Collaborating with consumer organisations, families and the media, we work to educate the public on mental illness and mental health care.

We are also working to provide guarantees of basic housing and jobs for people who suffer from mental illness to ensure they can live independent and productive lives.

This is a long and difficult task. Indonesia has few qualified mental health practitioners. And we are working within a culture that mixes medical, cultural and religious approaches in dealing with mental illness.

Indonesia should make mental health a development priority. Every sector should be involved in the planning, implementation and evaluation processes to free people with mental illness from shackles once and for all.