Patients with mental disabilities, unable to take care of themselves, should ideally receive special care and attention. Unfortunately, in Indonesia, a large number of those with special needs are living in unacceptable environments and are tied and locked up instead of being properly cared for by their families or primary caregivers.

Human Rights Watch (HRW) reports that about 57,000 patients in Indonesia with psychosocial disabilities had been shackled and locked up in small spaces at least once in their lives.

In 1977, the Indonesian government banned the practice of "pasung" or putting patients with mental health problems in shackles, but many family members, healers, and institutional staff still bind and lock up these patients inhumanely. The organization's report notes that according to government data, about 18,800 patients with mental health problems are still shackled and locked up by their families and health care providers.

"Shackling people with mental health conditions is illegal in Indonesia and yet it remains a widespread and brutal practice," says Kriti Sharma, a disability rights researcher at HRW and report author.

"People spend years locked up in chains, wooden stocks, or goat sheds because families don't know what else to do and the government doesn't do a good job of offering humane alternatives," she adds.

What Patients Go Through

The HRW interviewed 72 people, both adult and children, all of whom have psychosocial disabilities. Interviews with caregivers, mental health professionals, family members, government officials, institutional heads and disability rights advocates were also conducted to give a holistic understanding of the present condition of the patients.

In addition to the interviews, the HRW team also visited 16 institutions, including faith healing centers, social health care institutions and mental hospitals. During these visits in the five provinces of Java and Sumatra, the team documented 175 cases of patients who are locked up, shackled or recently freed.

"I used to be tied up at home with a plastic rope. My heart broke when they chained me ... I was chained when I first came [to Galuh]. I get chained often - at least 10 times since I have come because I fought with the others. It can last for one day to a week," said Rafi, a 29-year-old patient at the Yayasan Galuh Rehabilitation Center in Bekasi.

For a toilet, Rafi had to use the drain in the same room he was kept in. He also experienced physical abuse from the center's staff.

"Tell the government, I want to go home," he said.

In another interview, a father confided that he locked his daughter up after bringing her to a faith healer because she was destroying their neighbors' crops. He also said that they tied her up because she tried to dig her way out of the room. The patient endured 15 years of being shackled and locked up in the room where she slept, ate, urinated and defecated before she was finally released.

Government Efforts

In an attempt to curb the practice, the Indonesian government offered some campaigns like the anti-shackling campaign and a new mental health law that integrates mental health care along with primary health care.

The government also formed teams of medical practitioners, government institution staff and government officials that are responsible for releasing shackled and locked-up patients. Unfortunately, the local implementation moves slowly due to a decentralized Indonesian government.

Dr. Irmansyah, Indonesia's former director of mental health, spearheaded a campaign in 2010 that purports to eradicate the practice of shackling by 2014. The ambitious program's deadline is now pushed to 2019.

In an interview with Fairfax Media, Irmansyah shared that in 2015, about 8,000 patients were relieved from shackles. He equally acknowledges that much needs to be done.

"What is lacking is the unity of action. Ideally there should be standardized procedure in the treatment of mental health patients from when they are admitted to hospital to the day they return to their families," he says.

Another problem that the former health minister wishes to address is the lack of consultation from the families of the patients. He believes that only 70 to 80 percent of people afflicted with schizophrenia are brought to hospitals for consultation due to social stigma.

"They will go to traditional healers instead who will spit on the patient's face or ask them to bathe using flowers but in the end they remain mentally ill," says Irmansyah.

The current head of disabilities issues, Nahar, states that shackling persists because of the uncertainty in the part of the family members.

"The main problem is fear, fear of what could happen if a shackled person is released," he says.

An In-Depth Look At Indonesia's Mental Health Situation

This report sheds light on the current mental health situation of Indonesia. At present, Indonesia only has 600 to 800 psychiatrists to cater to the needs of 250 million Indonesians. This means that there is only one psychiatrist for every 300,000 to 400,000 persons. Additionally, significant data from the government show that in 2015, the health budget is only about 1.5 percent of the total.

The HRW report also raises concern on the length of stay of patients in a mental institution. There was one documented patient who stayed in an institution for seven years, while another was locked up in a mental institution for 30 long years.

Overcrowding and hygiene issues are also alarming as some rooms are infested with pests like lice. Some of the patients also have scabies that are left untreated. In a center in Java, 90 women are confined a room that is fit for only 30 persons.

Living in murky and crowded rooms is just one of the problems of these patients as they can also become victims of physical and sexual advantages of their caretakers and other people. Some of the patients also undergo restraint, seclusion, electroshock therapy without anesthesia and forced contraception without consent.

Recommendations

The Human Rights Watch recommends that the Indonesian government strengthen the implementation of the ban on shackling and by making amendments to the 2014 Mental Health Act to allow patients with psychosocial disabilities to experience the rights that fellow Indonesian citizens enjoy.

Furthermore, the report also encourages the government to undergo routine inspection of state and private mental health institutions. Sharma also recommends that the government and caregivers talk to those who are plagued with mental disabilities to know their stand on the treatment process.

Sharma expresses concern on the future of these patients needing special care.

"The thought that someone has been living in their own excrement and urine for 15 years in a locked room, isolated and not given any care whatsoever, is just horrifying. So many people told me, 'This like living in hell.' It really is," she says.