MENTAL illness is rarely discussed openly in any society. In Indonesia, however, the stigma seems particularly acute. In November last year, when the BBC’s Indonesia service highlighted the case of Mr Sukidi, a young man in his late 20s shackled for years at his home in East Java, the local media hardly regarded the matter worth reporting.
Although widely condemned, shackling is common in villages and slums across Indonesia. Parents usually justify the practice on the grounds that they have no other way of coping with the mental problems of the sufferer. Mr Sukidi was taken to hospital only after neighbours and village officials intervened.
Shackling is designed to prevent the victim of mental illness from wandering off or getting into trouble outside the home. Victims often lose the ability to walk after their muscles atrophy. According to the Ministry of Health, there are believed to be about 20,000 such cases across the country.
In September, when the Health Ministry’s director of mental health Irmansyah declared that the nation faced a mental health crisis, nobody took much notice. Attempts last month by lone Democratic Party lawmaker Nova Riyanti Yusuf to get Parliament to list a long-delayed mental health Bill as one of 64 Bills prioritised for deliberation this year were similarly unsuccessful. The proposed legislation provides for the creation of suicide hotlines and consultation centres. Therapy would also be made available for the victims of disasters.
According to Mr Irmansyah, more than 90 per cent of Indonesia’s estimated 19 million mentally ill people have no access to medical treatment. And the situation has become worse in recent years as regional autonomy has permitted local governments to convert mental hospitals into general hospitals.
The Jakarta Health Agency recorded 306,600 patients with symptoms of mild mental health problems in the first six months of last year, up from 159,000 over the same period in 2010. But only two hospitals in Jakarta are capable of treating patients with mental illness. Indonesia also has one of the lowest ratios of psychiatrists per capita in the world.
This leaves community health centres, known as Puskesmas, at the front line of the battle to treat the mentally ill. Yet less than 1 per cent of Puskesmas nationwide report such cases. Mr Irmansyah believes this may be because they either fail to detect such illnesses or because general practitioners simply do not know how to deal with them.
Dr Firman Lubis, of the Department of Community Medicine at the University of Indonesia, agrees. Speaking to me in Jakarta late last year, he pointed out that Indonesian medical schools no longer spend much time educating doctors on mental health issues. It was different in the 1970s and 1980s, he says, when teaching staff at the University of Indonesia’s Department of Psychiatry worked with the World Health Organisation to encourage awareness among the local medical community. A wide range of specialists, including foreign anthropologists, were also invited to Indonesia to share their experiences.
Certain cultural norms and practices are sometimes cited as predisposing Indonesians to particular types of mental illness. The Javanese idea that strong emotions should be suppressed is one example. Balinese music also tends to have manic qualities, a characteristic also displayed in dances which involve rapid changes in emotional states.
Dr Lubis cites the emotional problems generated within lower middle class families when strict religious upbringing clashes with the aspirations produced by consumerism. Incidents involving mass hysteria in schools, he argues, can be linked to the suppression of frustrations regarding excessive discipline. They also reflect longstanding family problems in situations where issues such as sex cannot be openly discussed.
Sadly, most Indonesians tend to accept alternative explanations that focus on demon possession and the use of charms. This seems particularly true of schizophrenia and autism. Parents of victims sometimes respond by changing their child’s name in the hope of confusing a demon or invoking divine protection. Village dukuns (shamans) use a variety of techniques, including chants and painfully aggressive massages. “Their screams are regarded as coming from the demon,” explains Dr Lubis.
Some observers have called on the government to respond by redressing the current acute shortage of psychiatrists. General practitioners also need to be made more aware of the issues involved and be better trained in early detection and treatment.
The real problem, however, lies with the social stigma associated with mental illness, an attitude that even pervades sections of the medical community. One solution is to run education programmes in schools and organise campaigns at community health centres. Dr Lubis also suggests that the government’s early child development programmes be expanded to include advice on mental health.
Mr Sukidi’s mental illness is now being treated. After weeks of rigorous work with physiotherapists, he is also able to walk. Many others are not so fortunate.
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