Overview Taiwanese Journal of Psychiatry (Taipei) Vol. 31 No. 3 2017 • 183 •

Challenges and Opportunity of Psychiatric Care in Indonesia

Andi J. Tanra, M.D., Ph.D.*, Ireine S. C. Roosdy, M.D., M.M.Sc.

Indonesia holds an important position among nations, geographically and so- cial-politically. As an archipelago of over 17,000 islands that lies between two large continents and two great oceans, Indonesia is an ethnically and linguistically diverse country, with around 300 distinct native ethnic groups, and 742 different languages and dialects. Government expenditure on healthcare in Indonesia is about 3.1% of its total gross domestic product. Many psychiatric problems were to be expected could raise from such a diverse cultural population, but as a nation, Indonesia has struggled to thrive to a mentally healthy nation by striving to de- velop its own personalized psychiatric care. Psychiatry arrived in Southeast Asia in the late nineteenth century. Dutch colonialism brought psychiatry and psychol- ogy to the Dutch East Indies (Indonesia’s name during Dutch colonialism). Mental health care policy of the colonial Dutch government in the Dutch East Indies was centered on the mental hospital, for custodial function. In the early 1950s, the new government of Indonesia took over full responsibility for mental health and mental health institutions, part of a larger policy of nationalization and centralization, with the director of mental health of the Ministry of Health in Jakarta functioning as the central agency for planning mental health services. In 2000s, there were new grow- ing interest in modern psychiatry. This emerging interest has come to uprise since the growing cases of narcotics and psychotropic abuse among Indonesian young- sters. A renewed Mental Health Act was published in 2012. President Joko Widodo in 2017 declares a national alert and fi ght over drug problems, taking mental prob- lem as a serious matter for the nation. In national strategic plan of Health Planning Guidelines for 2015-2019, there are seven aspects of Healthcare Development Program, including the Development of Mental Health Services. The target of this services is to increase the quality and access of mental health service and drug problems. We gave an example of Dr. Soeharto Heerdjan Mental Hospital, to de- scribe rehabilitation programs for its psychiatric patients and drug abusers.

Key words: Indonesia, mental health services, psychiatry, mental rehabilitation (Taiwanese Journal of Psychiatry [Taipei] 2017; 31: 183-94)

* Department of Psychiatry, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia Received: August 18, 2017; accepted August 22, 2017 *Corresponding author. RSP UNHAS Building, 5th Floor Perintis Kemerdekaan Road, Tamalanrea, Km 11, Makassar 90245, Indonesia E-mail: Andi J. Tanra • 184 • Psychiatric Care in Indonesia

many potential confl icts and problems in its social Introduction interactions. The vast area including fi ve main is- lands and thousands of minor islands adds more Indonesia as one of the nations in Asian re- complexity to the scheme. In spite of so many dif- gion, since even before its independence in August ferences in so many ways, Indonesian people hold 1945 holds an important position among nations, their national awareness of its own motto: geographically and social-politically. As an archi- “Bhineka Tunggal Ika,” which literally is “many, pelago of over 17,000 islands that lies between yet one,” meaning “unity in diversity,” all thanks two large continents and two great oceans, even to the spirit of this country’s founding fathers. since before this pack of islands inhabited by vari- Situated between the Indian and Pacifi c ous tribes exclaimed themselves one as oceans, Indonesia is the world’s largest island “Indonesia” in 1928, this nation has been long fa- country, with total area of 1,919,440 square kilo- vored by explorers. This area once called East meters, which consists of land 1,826,440 square Indies by the fi rst European nations came to be an kilometers and water 93.000 square kilometers important region in trading since around the sev- (Asian Center for the Progress of Peoples, 2007), enth century, when Srivijaya Kingdom and then and the population is 237,556,363 according to later Majapahit Kingdom traded with China and the 2010 Census (Statistics Indonesia, 2011). The India. Local rulers gradually absorbed foreign cul- average population density is 124 per square kilo- tural, religious and political models from explor- meters, but it is ranged from the density of West ers of the early centuries, Hindu and Buddhist Papua Province eight per square kilometers to the kingdoms fl ourished. Muslim traders and Sufi density of Daerah Khusus Ibukota, (DKI, Special scholars brought the now-dominant Islam, while Capital Authority) Jakarta as the capital city of European powers brought Christianity drawn into Indonesia 14,440 per square kilometers. Indonesia its natural resources of people and cultures. is the world’s fourteenth largest country in terms Following three and a half centuries of Dutch co- of land area and world’s seventh largest country in lonialism, at times interrupted by Portuguese, terms of combined sea and land area. British, and then Japanese rules, Indonesia se- Government expenditure on healthcare in cured its independence after World War II. Indonesia is about 3.1 percent of its total gross do- Indonesia is an ethnically and linguistically mestic product. Every citizen is protected under diverse country, with around 300 distinct native Jaminan Kesehatan Nasional (JKN), a scheme to ethnic groups, and 742 different languages and implement universal health care in the country dialects. The offi cial language is Indonesian (also which launched by Ministry of Health of known as Bahasa Indonesia), a variant of Malay Indonesia. It is expected that spending on health- and borrows heavily from local languages such as care will increase by twelve percent a year and Javanese, Sundanese, Minangkabau, etc. It has reach USD 46 billion a year by 2019. Under JKN, been some kind of a miracle that this multicultural all Indonesians receive coverage for a range of dan mutiethnic country can survive over multiple treatments through health services from public periods of colonialism, and still united and rising providers as well as those private organisations up until now. In psychiatric point of view, that have opted to join the scheme. The 2010 ma- Indonesia in its sociocultural complexity holds ternal mortality rate per 100,000 births for Andi J.Tanra, Ireine S. C. Roosdy • 185 •

Indonesia is 240. The main health problems are air two large mental hospitals be built. The fi rst men- quality, disease, child malnutrition, alcohol and tal hospital was located near Buitenzorg (Bogor) smoking. Health outcomes have signifi cantly im- and began receiving patients in 1882 (Bauer be- proved in Indonesia since the 1960s. Life expec- came the fi rst medical superintendent). A second tancy at birth is 70.8 years. The child mortality mental hospital opened near Lawang in 1902. Two rate has declined from 220 per 1,000 live births in additional mental hospitals were established near 1960 to 45 per 1,000 live births in 2007. It has Magelang and near Sabang, on an island just north been suggested that over a third of the children of Aceh. Both were opened in 1923. These large under 5 years old have stunted growth. More than mental hospitals treated patients of both European 28 million live below the poverty line of USD 17 and indigenous backgrounds, for European pa- a month and about half the population have in- tient treatments included continuous baths, bed comes not much above it. The malnutrition status treatment, and open air treatment, and for indige- has shown steady progress from 38 percent in nous patients there was agricultural work for the 1990 to 25 percent in 2000. The rate of smoking is male patients. Physical restraint, chemical re- high and about 400,000 die each year from smok- straint, and isolation were rarely used [3]. ing related illnesses. Two other types of institutions were estab- lished by the Dutch colonial government: acute- Past to Recent Years of care clinics and agricultural colonies. In the 1920s, Psychiatry in Indonesia several clinics (doorgangshuizen) for the treatment of acute cases for up to six months were established Psychiatry developed as a modern branch of in a number of metropolitan centres. If treatment in medical knowledge in Western societies and ar- these facilities was proved unsuccessful, patients rived in Southeast Asia in the late nineteenth cen- were transferred to the larger mental hospitals. tury. Dutch colonialism brought psychiatry and Because the existing mental hospitals were severe- psychology to the Dutch East Indies as part of the ly overcrowded, most of these institutions for short- development of European therapeutics in that part term care functioned as additional mental hospitals of the empire. Mental health care policy of the co- rather than as clinics. These establishments were lonial Dutch government in the Dutch East Indies opened in Surakarta, Batavia (Jakarta), Palembang, was centered on the mental hospitals for custodial Padang, Medan, Banjarmasin, Bangli (Bali), function. Indonesian individuals were confi ned to Makassar, and Manado. Mental hospital facilities mental hospitals only if they disturbed the social in the Dutch East Indies were always inadequate, order and a physician declared them insane [1, 2]. which led to overcrowding, poor care, neglect, and Bauer and Smit in 1868 as physicians in the placement of individuals with mental illness in charge of small hospitals in the Indies, conducted prisons (Engelhard, in Pols, 2006). Most indige- a survey on Java [3]. According to them, there nous individuals with mental illness were tolerated were around 550 individuals in need of institu- in their communities; a few were placed in wooden tionalization in the whole archipelago. They found blocks called “pasung” [2]. that about 300 of these individuals in pitiful con- Independent Indonesia inherited four large ditions in military hospitals, prisons, or aban- mental hospitals (each housing over 5,000 pa- doned in the community. They recommended that tients), about 10 acute-care clinics in the major • 186 • Psychiatric Care in Indonesia

cities, and an agricultural colony for chronic pa- tem, patients could be admitted only through court tients. During the years following independence, order or through certifi cation by a physician, after the Dutch psychiatrists were discharged, causing a which the patient’s name would be placed at the reduction of 18 professional doctors for Indonesian bottom of a waiting list. The Mental Health Act of psychiatry. By the 1950s, there were fewer than 1966 allowed patients to be admitted voluntarily 30 practising psychiatrists in Indonesia. The na- through non-legal procedures [2]. tional independence of psychiatry did mean that Initially, mental hospital care remained Indonesian psychiatrists could now distinguish largely custodial, with electroconvulsive therapy themselves on their professional merits, rather (ECT) and insulin coma therapy (ICT) available than be recognized by their colonizers through a on a modest scale. In 1966, the Directorate of European/native distinction. The independence of Mental Health propounded principles of preven- psychiatry also allowed for new input and direc- tion, treatment, and rehabilitation as the founda- tions from other international sources. Indonesian tion of a system of comprehensive mental health psychiatry was now freed from its colonial entan- care. During the 1970s and 1980s, the number of glements and seemed to come under the infl uence mental hospitals in Indonesia more than doubled, of American psychiatry. In 1956, the medical de- new forms of mental health care were developed, partment of the University of Indonesia became and a number of original research projects were affi liated with the medical center at the University undertaken. During this period, Indonesian psy- of California through a fi ve-year teaching project chiatry was presented as a model for other South funded by the American government. This result- East Asian nations. Unfortunately, during the ed in a new psychiatric clinic in Jakarta and the 1990s, Indonesia’s mental health care was de- introduction of somatic therapy and insulin shock clined because of reductions in government spend- therapy [1]. ing [1, 2]. In the early 1950s, the new government of In the years of 2000, there are new growing Indonesia took over full responsibility for mental interest in psychiatry in such a modern term. This health and mental health institutions, part of a emerging interest has come to uprise since the larger policy of nationalization and centralization, growing cases of narcotics and psychotropic with the director of mental health of the Ministry abuse among Indonesian youngsters. A renewed of Health in Jakarta functioning as the central Mental Health Act was published on 2012. agency for planning mental health services. As an President Joko Widodo in 2017 declared a nation- expression of their loyalty to the nation, psychia- al alert and fi ght over drug problems, taking men- trists were legally obliged to work until 2 p.m. tal problem as a serious matter for the nation. each day for the government health care service, which were paid very little. Only after this could Psychiatric Epidemiology over they work in their own private clinics [2]. Social and Cultural History During the 1960s and 1970s, medicine in and Background general and psychiatry in particular took new di- rections, especially when it came to outreach, A general outline of the history of psychiatry with legislation laying the foundation for new, in Indonesia show that psychiatry’s culture has open-style hospitals. In the old, Dutch-style sys- been infl uenced by local social and cultural back- Andi J.Tanra, Ireine S. C. Roosdy • 187 •

grounds. During the twentieth century, two main cultural and spiritual aspect was the background articulations governed the relation between psy- of the treatment. Another indication is the popu- chiatry and indigenous psychologies. Colonial larity of traditional or faith-based healing shelters and local psychiatrists had to develop a language for people with mental disorders. In a study by the for their new medical discipline, which meant not Department of Psychiatry, Faculty of Medicine, only incorporating foreign words into their native University of Indonesia, in Garut District, West language but also drawing on the language of in- Java, after the earthquake of 2009, people associ- digenous psychologies to construct a professional ated symptoms of mental disoders mostly with lexicon. Borrowing indigenous psychological ter- severe mental illness, i.e. schizophrenia: only a minology, they transformed the local discourse to few understood that depression and anxiety are fi t their disciplinary concepts [1]. also mental disorders [8]. According to the people Dutch psychiatrists in the Indies elaborated of Garut, causes of mental illness are life prob- on a number of mental affl ictions specifi c to South lems, illicit substances, birth-related defects, acci- East Asia that currently are designated as culture- dents, and also inbreeding. Other causes are super- bound syndromes. These are amok, latah, and natural forces, witchcraft, lack of education [8]. koro (see van Loon, 1927 [4]; van Wulfften Palthe, In 2007, Indonesia for the fi rst time carried 1935 [5]). Amok is the designation given to sud- out a national survey on mental health. It was a den violent outbursts in men that generally occur part of the fi rst Basic Health Research that was after extreme embarrassment, in which the indi- implemented by the National Institute for Health vidual attacks everyone and everything in sight, Research and Development. The Basic Health often with a lethal outcome. An attack can last Research 2007 had two sets of questions on men- several hours, after which amnesia occurs. Very tal health. The fi rst set was on severe mental dis- few cases of amok were admitted to the mental order and it showed that the national prevalence of hospitals because individuals with this disorder severe mental disorder (psychosis/schizophrenia) were often killed to prevent further bloodshed (for was 4.6 per thousand, with the provinces of DKI a critical view on amok see (Carr and Tan, 1976 Jakarta (20.3 per thousand), Nangroe Aceh [6]). Latah occurs mostly in older women, who, Darussalam (18.5 per thousand), Sumatra Barat after being startled, imitate the movements of the (16.7 per thousand), Nusa Tenggara Barat (9.9 per individuals around them. They often express vul- thousand), and Sumatra Selatan (9.2 per thou- gar language as well. Generally, it was said that an sand) being the fi ve highest, and Maluku (0.9 per attack of latah occurs after dreams with explicit thousand) as the lowest. The second set of ques- sexual content (see also Winzeler, 1995 [7]). Koro tions used the Self Reporting Questionnaire to is the fear that the penis will retract inside the pel- cover mental emotional disorders (depression and vis and disappear [2]. anxiety). National prevalence for mental emotion- There is little research on traditional, cultur- al disorders in the age group > 15 years old was al, and spiritual views on the cause of mental ill- 11.6 per cent. The “pasung” rate in people with ness in Indonesia, but there are a number of stud- severe mental disorder is 14.3 percent or about ies on mental disorders in disaster-affected 57,000 cases [8]. communities or on restrained or confi ned people Mental disorders and drug abuse also relate with mental illnes which indirectly show us that a to self-harmful behaviors, such as suicide. • 188 • Psychiatric Care in Indonesia

According to a report from Indonesian Police demonstrations, patients had to be brought from Main Headquarters in 2012, the suicide rate is Grogol, which was about 20 kilometers away. The around 0.5 percent of the 100,000 population, hospital next door to the medical school refused to meaning that there are about 1,170 reported sui- open a psychiatric ward, on the conviction that the cides have been reported within a year. The prior- sick and the insane ought not to be treated in the ity for mental health promotion is to develop same premises. In 1927, STOVIA was trans- Community-based Mental Health Efforts whose formed into a medical faculty which admitted spearhead is the community health center both Europeans and Indonesians; the degree it of- (Puskesmas) and works with the community, pre- fered was equivalent to those awarded in the venting the increasing number of mental disorders Netherlands. A chair in psychiatry and neurology [9]. was established and was occupied until 1942 by Data obtained from the National Narcotics van Wulfften Palthe [2]. Agency (BNN) survey and the University of During the Japanese occupation (1942- Indonesia’s Center for Health Research in 2008 1945), the medical school was run by the occupa- revealed that the prevalence rate of drug users is tion forces. For the fi rst time, Indonesian physi- around 1.9 percent of the total population of cians participated in teaching. During the struggle Indonesia, with an age range of 10 to 60 years. In for independence (1945-1949), a number of just three years, the prevalence has been increased Indonesian physicians ran an underground medi- to 2.2 percent. This number means that about 4 cal school parallel to the re-established Dutch million Indonesians are listed as drug abusers in medical faculty. After the transfer of sovereignty recent years [11]. to Indonesia December 27, 1949, most of the teaching staff at the Universityof Indonesia and 18 Training and Education of Dutch psychiatrists left Indonesia. In 1950, Psychiatric Medical Personnel Fakultas Kedokteran (Faculty of Medicine) was founded as part of the University of Indonesia; During the twentieth century, psychiatry was medicine was taught according to the model es- naturalized in Indonesia (and other Southeast tablished by the Dutch. Slamet Imam Santoso be- Asian countries) and integrated into the national came the fi rst professor of neurology and psychia- health care system. In the post-independence pe- try (for a biography see Oemarjati, 1992 [12]). riod, most Indonesian psychiatrists received train- Santoso was later involved with the establishment ing at Western universities and brought the knowl- of the Department of Psychology to make more edge back with them to their home country. In psychotherapists available in Indonesia (see 1851, (School ter Opleiding van Indische Arsten Santoso, 1959) [13]. [STOVIA, School for the Education of Indies In 1961, neurology and psychiatry became Physicians]) was established in Batavia (Jakarta). established in two different departments at the In 1920, with the part-time appointment of F. H. University of Indonesia medical school and R. van Loon, who taught psychiatry and neurology, Kusumanto Setyonegoro became the chairman of psychiatry offi cially became part of the medical the department of psychiatry (a position he had curriculum. Teaching was adversely affected by held until 1972). In 1961, there were about 32 the absence of a psychiatric clinic. For in-class psychiatrists in Indonesia (Kelman, 1968 [14]). Andi J.Tanra, Ireine S. C. Roosdy • 189 •

After visiting the USA as part of the association of of the East Indian archipelago was J. H. F. the University of Indonesia medical school with Kohlbrugge, a physician who spent 13 years on University of California at San Francisco (UCSF), Java around the turn of the twentieth century. Kusumanto came to advocate a holistic-eclectic Kohlbrugge worked as a physician on Java 1892- approach, which emphasized biological, psycho- 1899 and 1901-1906. According to Kohlbrugge logical, and social factors in the etiology of men- (1907) [20], the lack of mental development of the tal illness (Setyonegoro, 1965 [15]), which be- Javanese (and other ethnic groups in the colonies) came the basis of psychiatric thinking in Indonesia. was due to the pervasive presence of animism and In 1967, Kusumanto introduced a structured three- superstition, which held it in a tight grip. In addi- year residency training program in psychiatry tion, the oppressively hot climate deterred hard (which was extended to four years in 2000). [2]. work and impeded intellectual development. Postgraduate education in psychiatry has Kohlbrugge argued that the Javanese were highly been available to Indonesian psychiatrists on a suggestible, emotional, erratic, and child-like. The limited scale in the USA, Canada, the UK, and the complete lack of individualism, an intrinsic lazi- Netherlands. One initiative deserves special men- ness, the inability to plan ahead, the lack of devel- tion. From 1972 to 1973, the University of Hawaii opment of rational abilities, and the strongly pres- medical school organized a training program in ent emotions, meaning that Javanese society community child psychiatry in collaboration with would only develop slowly. Kohlbrugge warned the University of Indonesia medical school that Western education would erode indigenous (McDermott and Maretzki, 1975 [16]; McDermott culture, causing social problems, anomie, and the et al., 1974 [17]). Five psychiatrists spent a year formation of a discontented urban class which had on Hawaii for advanced training; after returning lost its cultural roots. He recommended that the they established child psychiatry as a sub-disci- colonial government limit itself to maintaining pline. Currently, there are 35 child psychiatrists in law and order, and that the psychology of the Indonesia. This project was followed by an an- Javanese be studied to aid the formulation of an thropologist as well, who made a number of ob- appropriate colonial policy, suitable to the nature servations about the specifi c requirements of the of the psyche of the indigenous population [2]. mental health care system in Indonesia (Maretzki, The idea of such uncivilized version of 1981 [18], 1981 [19]). In 1972, the Society for Indonesian people evoked strong protests from Indonesian Neurology, Psychiatry, and Indonesian physicians, who expressed their opin- Neurosurgery was established; in 1983 this soci- ion through the Society for Indigenous Physicians ety was dissolved and the Indonesian Psychiatric and the Indonesian Society (a group of Indonesian Association (Ikatan Dokter Ahli Jiwa Indonesia) students in the Netherlands). Its journals pub- was founded [8]. lished a coherent and well-argued critiques. They argued that the investigation of Indonesian indi- Research and Neuroscientifi c viduals with mental illness should be conducted Approach in Psychiatric Care by physicians who speak their language and who are aware of their cultural conventions. They also One of the fi rst physicians to write extensive- protested against the generalization of fi ndings ly on the psychology of the indigenous population based on a small group of patients in mental hos- • 190 • Psychiatric Care in Indonesia

pitals to the whole population of the Dutch East midwives, no attempts have been made to educate Indies. They questioned that generalizations could traditional healers about the nature of mental ill- be made about the over 300 different ethnic groups ness or to make them part of the mental health of the archipelago. And, lastly, they questioned care system. Nevertheless, it is now understood whether comparisons between a generalized that both groups are not operating in competition “East” and “West” would be meaningful [2]. [8]. From 1975 to 1982, the Directorate of Mental In Indonesia, research in general has not Health was appointed as a collaborative center of been a priority for some time. Even in academic the World Health Organization‒South East Asia institutions only small numbers of research activi- Regional Offi ce. During this time, many innova- ties have been done. Some factors that contribute tive research projects were undertaken. The fi rst to this situation are limited grant resources, inad- community-based mental health survey to ascer- equate facilities, weak coordination between de- tain the prevalence of mental illness in the popula- partments and un-stimulating reward for research- tion, based on a sample of 100,000 individuals, ers. In psychiatry, especially in schizophrenia the was undertaken in 1983. It was concluded that the situation is even worse. Only small numbers of prevalence of the major psychoses was 1.44 per researches have been conducted and mostly done thousand population. A comparison with groups by individual researchers. Some research got sup- of individuals suffering from schizophrenia in port from international grants and collaborative London demonstrated that Indonesian patients partners. Some areas of research are (A) the biol- suffered more from over-activity and less from ogy of schizophrenia, genetics and drug clinical delusions of persecution, visual hallucinations, trials; (B) clinical aspect, duration of untreated and depression, illustrating the signifi cance of cul- psychosis and neuro-cognitive aspect; and (C) so- tural factors in determining the symptoms of the cial aspect, pathway of health-seeking behavior, major mental illnesses [2]. burden of family of schizophrenia, stigma and A second research project was focused on mistreated of patient with schizophrenia [3]. traditional healing with respect to mental health Some political changes, especially in decen- problems in Indonesia. Because there are only a tralization policy, currently happen. Academic in- limited number of physicians and an even smaller stitutions get more autonomic status. Most of the number of psychiatrists in Indonesia, most people academic institutions at present try to put research consult traditional healers (dukun) rather than as one of their main priorities. Facilities, such as physicians when they are confronted with mental access to internet library, are improved. In addi- health problems. In some areas up to 80 percent tion to regular grant resources, some local govern- will visit traditional healers or religious represen- ments can also support research activities. tatives before consulting physicians. Surveys Hopefully this could be a better environment for were conducted in several provinces (Salan, research activities. In addition to some research Mustar, Bahar, Sosrokoesoemo, and Thong, 1982 activities that have been done, research on the ba- [21]; Setyonegoro and Roan, 1983 [22]). As a re- sic epidemiology data and on innovation clinical sult, a policy of co-existence between traditional and social approaches for schizophrenia are con- healers and regular physicians was proposed. sidered the foci of our research on schizophrenia Unlike public health initiatives with traditional in the future [10]. Andi J.Tanra, Ireine S. C. Roosdy • 191 •

and forensic psychiatric examination. In 2014, the Community and Government new mental health law was published and stated Supports in Mental Healthcare that a comprehensive and integrated mental health program is highly important [9]. As in the past, and still today, the indigenous The practice of pasung towards people with response to people suffering from madness has mental illness can be found all over Indonesia. depended on how disturbing their behavior has Pasung in Indonesian language refers to the phys- been to others, and this is no less true today in ical restraint or confi nement for criminals, crazy various Indonesian communities. Villagers care and dangerously aggressive people. In its devel- for those who are silently mad, although teasing, opment, the term pasung was narrrowed down to especially by children, is common. Aggressive those with mental disorders in the community. and violent individuals who lash out at people (but Furthermore, pasung is not only about physical do not run amok) might be locked up and held in freedom but also something to do with rights to stocks (pasung) until they calm down. The family access health services that will improve the func- might also turn to local healers called “dukun” or tion of people with mental disorder. Some studies “orang pintar.” If the patient does not recover, the in lndonesia have shown that the act of pasung family will collect money and send the affl icted to was initiated by families to protect the patient, a hospital, invariably far away, for treatment. family, and community from the violent behavior Similar attitudes prevailed from colonial era of of people with severe mental disorder (schizo- Indonesia. Since madness is generally an affair of phrenia); most of them are 20-30 years old, male, the family and the village, the increase in the num- with the duration of being in pasung between a ber of patients brought to the mental hospitals in few days to more than 20 years. More than 76 per- Indonesia refl ected local society’s greater involve- cent of them had once been in contact with the ment with and dependence over government’s health service but could not continue their treat- mental healthcare service [2]. ment for various reasons, one of which was low Twenty years after its independence, quality of the health service. Acknowledging the Indonesia developed its own mental health law, impact of pasung on physical, occupational, so- Law Number 3/1966 on Mental Health. This men- cial and humanitarian aspect of care, the govern- tal health law contained only 14 articles within ment of Indonesia announced the Pasung-free seven chapters, and mostly deals with treatment Indonesia Program on World Mental Health Day, and hospitalization of people with mental illness. October 10, 2010. This program was meant to free Indonesian Law Number 36/2009 amending Law people with mental disorder from the act pasung, Number 23/1992 about Health, reserved one and to prevent pasung and re-pasung [8] chapter containing eight articles on mental health Until 2013, people’s awareness of the impor- (Articles 144-151) that covers the objectives and tance of having health insurance has been low, as scope of mental health program, whose is the re- shown by the percentage of out-of-pocket health sponsibility and what are the responsibilities for expenditure which was 75.1 per cent in 2012 (The public information and education on mental World Bank, 2014). The risk of catastrophic ex- health, treatment of mental illness, rights of peo- penditure in this situation is high, especially for ple with mental illness including homeless people, people with severe mental illness who tend to • 192 • Psychiatric Care in Indonesia

move downwards in their socioeconomic status. patient but also to all health practitioners. In addi- Therefore, a good health fi nance system needs to tion, in providing services and care to the patient, be developed to share the risks and to protect peo- a psychiatrist should always uphold the nature of ple. At fi rst the government of Indonesia orga- humanism, professionalism, morally responsible, nized obligatory health insurance schemes for uphold medical ethics, social ethics and national civil servants, retirees, veterans, and private sector ethics. National Guideline for Mental Health employees with health and labor insurance ran by Service published by Ministry of Health in the de- Perseroan Terbatas Askes Persero and Perseroan cree of the Minister of Health of the Republic of Terbatas Jamsostek Persero, while securing the Indonesia number HK.02.02/MENKES/73/2015 premium of the poor and nearly poor with two in- about National Guidelines of Mental Health surance product: the Jamkesmas (National Social Service as a guidance on standard operating pro- Health Insurance) and Jamkesda (Provincial cedures in patient care that a psychiatrist must Social Health Insurance) [8]. know and operate in conducting optimal, profes- In national strategic plan of Health Planning sional and accountable health service activities Guidelines for 2015-2019, there are seven aspects [9]. of Healthcare Development Program one of which In 2014, the Indonesian government has is- is the Development of Mental Health Services. sued a Joint Regulation on Narcotics Addiction The target of this services is to increase quality and Narcotics Abuse Treatment to the and access of mental health service and drug. Rehabilitation Institution. Referring to Law No. Indicators of achieving these goals are: (A) 35 of 2009 on Narcotics and Government Percentage of Health Service Facilities Regulation No. 25 of 2011 on the Implementation (Fasyankes) Recipient Benefi ciary Institution of Reporting Netters Narcotics Report, this is the (IPWL) active drug addicts by 50 percent; (B) legal basis for efforts and measures to save drug Number of districts/municipalities with users. The drug users are no longer placed as Puskesmas that provide mental health efforts of criminals or criminals by reporting themselves to 280 districts/municipalities; and (C) Percentage of the Reporting Recipient Institution (IPWL) which Regional General Hospital Referral that organizes was inaugurated since 2011. Currently, there are mental health services/psychiatry by 60 percent 274 IPWLs in all over Indonesia from various in- [9]. stitutions including Puskesmas, Hospitals and Along with the progress and development of Medical Rehabilitation Institutions, either govern- science and technology in the fi eld of medicine, mental or private [11]. especially psychiatric or psychiatric science, nec- essary guidelines or reference work of quality and Mental Rehabilitation Service should be accounted morally and materially. The of Post Hospitalized Patients government has made aframework that may serve as a guide in providing services and care to pa- Mental disorder leads to disruption of the tients with mental disorders in government and ability of the people with psychiatric problems to private hospitals and other health facilities in play a meaningful rôle in the family and commu- Indonesia.Work guidelines are useful to avoid er- nity environment, therefore necessary handling/ rors in acting so as to cause harm not only to the service. Psychosocial rehabilitation is a service in Andi J.Tanra, Ireine S. C. Roosdy • 193 •

the form of strategies that facilitate the opportuni- lic transport, social interaction, self-employment ties that exist in individuals with mental health • Helping patients to get a job or self-employed problems so that it can function optimally in the • Inviting patients to visit banks, markets and environment by developing its capabilities and other public places can adapt to changes in the environment (WHO, There are many kinds of activities available 1995) [10]. for rehabilitation therapy program, such as: The main objective of the rehabilitation pro- • Opening activities, morning meetings, after- gram is to improve the quality of life and indepen- noon meetings dence of the patients in their social environment. • Educational therapy: English class, administra- In Dr. Soeharto Heerdjan Mental Hospital, the tion, computers, remedial, etc. psychiatric rehabilitation program cope of servic- • Occupational therapy: cooking, hairdressing, es includes [10]: sewing, handicraft, plantation, mug making, screening, etc. Symptom management • Music therapy: single organ, band, music, • Training patients to recognize signs and symp- choir, karaoke, etc. toms to prevent the possibility of relapse • Self-employment training: RH mobile, RH gar- • Training patients to recognize and overcome den, RH corner, RH cleaning service sequelae • Relaxation therapy (Biodanza, Reki Ling Chi, • Helping empower patients to overcome illness etc.) and can re-control their life • Sports (gymnastics, gym, etc.) The rehabilitation program for drug abusers Medication management by BNN guidelines includes three stages that must • Teaching patients to understand the treatment be undertaken. First, the stage of medical rehabili- • Teaching patients to understand and assess tation (detoxifi cation) is the process of addicts to drug effects and side effects stop drug abuse under the supervision of a doctor • Teaching them how to seek information and to reduce withdrawal symptoms (sakau). The sec- consult with health professionals related to the ond stage, the non-medical rehabilitation stage drugs they use with various programs at the rehabilitation, such as therapeutic communities program, 12-step pro- Basic conversational skills gram and others. Then the last stage is the ad- • Teaching patients how to speak systematically vanced stage of development which will provide • Exercising effective communication (verbal activities according to interests and talents. In ad- and non verbal communication, daily conver- dition, addicts who have successfully passed this sation, etc.) stage may return to society, either to go to school or to return to work [11]. Community re-integration • Teaching the patients how to reintegrate in the Acknowledgement society after returning home • Training patients with skills for self care, The authors declare no potential confl icts of housework, fi nancial management, using pub- interest in writing this overview. • 194 • Psychiatric Care in Indonesia

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