Understanding the use of Pasung for people with mental illness: Experience of families and communities, reasons for its use, and potential solutions

Author: Muhamad Taufik Hidayat

Hidayat, Muhamad Taufik, 2023 Understanding the use of Pasung for people with mental illness: Experience of families and communities, reasons for its use, and potential solutions, Flinders University, College of Medicine and Public Health

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Background. In Indonesia, the term Pasung entails the physical restraint through stocks and/or shackles and confinement of the person in the community, beyond the walls of institutions, and often inside their home. Usually, Pasung is applied to people who are considered to be severely mentally unwell, who are perceived to be dangerously aggressive towards others. While Indonesia has established the goal of being free from Pasung since 2010, the incidence of Pasung and its re-occurrence after hospital-based treatment remains high. The continued practice indicates that there are likely complex issues present within Indonesian society, and that a more comprehensive understanding and solution are needed.

Aims. This study aimed to explore the use of Pasung, the experiences of those involved, the perceived reasons for its use, current interventions, and potential solutions, drawing on a range of perspectives to inform improved understanding and proposed approaches to addressing Pasung in the Indonesian community.

Methods. An interpretive ethnographic approach was undertaken in a naturalistic setting in which people live, and in which Pasung is practised. The data included 30 in-depth interviews with Persons in Pasung (PIP), their families, the community, health professionals, non-health professionals, policy-makers, and managers, as well as 135 photographs, 3 videos, and reflexive notes concerning Pasung. Participants in the study were PIP who were part of the Free Pasung Programme in 11 districts in West Java from various geographic locations between 2016 and 2019. The Socio-Ecological Model (SEM) underpinned the study to examine the individual, interpersonal, community, and policy factors associated with Pasung.

Findings. The overarching theme of this research found that Pasung gave the PIP and the systems of support around them, particularly their family, “No room for escape” from its use. The findings inform us how this practice is multidimensional, socially and culturally accepted within the community, and how there are dynamic inter-relationships that exist across contexts associated with the four layers of the SEM that reinforce its use. ‘No room for escape’ is a term used by the author to indicate that Pasung occurs over time for PIP, sometimes for the remainder of their life, which creates barriers to receiving mental health services. This key finding also identifies a lack of accessible alternatives to Pasung, showing that the family and community believe there are no effective, accessible alternatives to these practices. This situation leads to ineffective implementation of the Free Pasung Programme (FPP). The overarching theme of “No room for escape” encapsulates that Pasung, although regarded as a ‘last option’ treatment, is perceived as the only effective, accessible means participants had to manage persons who were deemed as having aberrant behaviour when mental health treatment was not accessible and there were barriers to accessing mental health services. “No room for escape" implied a major imbalance in power relationships across the four layers of the SEM.

Discussion. The findings show that Pasung is not solely a result of individual symptoms or the refusal of family to accept psychiatric treatment. It can more accurately be attributed to a range of factors across the SEM, including government failure to provide basic mental health services for people with severe mental illness, the ever-present stresses of stigma, the fragmentation of hospital and community services, and the inadequacy of policy. Pasung is a problem that is unlikely to be fully addressed by simply offering mental health treatment in a hospital. Even in Indonesia, where Free Pasung Programmes are being implemented, the emphasis is on providing psychiatric medicine and basic psychoeducation rather than ongoing outreach and/or rehabilitation. Instead, a comprehensive model is required which includes caregiver support, a community development approach to enhance economic independence, a coordinated effort to increase health care adherence, and community education to reduce stigma.

Keywords: Pasung, ethnography, Socio Ecological Model, Person in Pasung, No room for escape, comprehensive model

Subject: Public Health thesis

Thesis type: Doctor of Philosophy
Completed: 2023
School: College of Medicine and Public Health
Supervisor: Professor Sharon Lawn