While the use of physical restraints in dealing with mentally patients remains controversial worldwide, treatment professionals in most countries are encouraged to consider their use only as a last resort for patients who might harm themselves otherwise.
Given the lack of viable treatment options in many developing countries, family members of people with serious mental illness often resort to extreme methods to restrain them. Keeping mentally ill family members chained to beds or enclosed rooms in the family home is often motivated by a sense of shame given the deep stigma surrounding mental illness in many societies. Affected family members are typically surrounded by a conspiracy of silence which prevents them from receiving any true treatment.
In Indonesia, the use of physical restraint is known as pasung and remains extremely common in dealing with mental illness, especially in low-income families. Although the full extent of pasung use remains unknown given family reluctance to admit the existence of mentally ill relatives, enough cases have come to light for local governments in Indonesia to develop programs for assisting patients who have been freed from pasung. Stories of mentally ill people being tied to beds or trees, locked in cages or boxes, or otherwise immobilized for years have done little to attract attention by international human rights groups or health organizations outside Indonesia.
As part of an initiative by the Indonesian government, the Health Ministry's director, Dr. Irmansyah, has called on local governments to require authorities to detect pasung across the country. The Health Ministry is also encouraging more education for health workers at local community centres about treatment options for helping formerly restrained mentally ill patients. Although national statistics on pasung use remain limited, Dr. Irmansyah has estimated that there could be as many as 26,000 mental patients being restrained. Given that the prevalence of mental illness in the nation of 229 million people remains high (11 per cent for the entire country with 1.8 per cent suffering from severe mental illness in Aceh), the use of pasung seems unlikely to subside without intensive education campaigns and government initiatives to combat the practice.
The local government in Aceh, Indonesia has led the fight with the launch of the Aceh Free Pasung program in 2010. The main goal of the program is to end the practice of pasung and to provide appropriate medical treatment and care. As the closest point of land to the epicenter of the 2004 tsunami, Aceh was particularly hard hit with over 130, 000 killed and more than 500,000 left homeless (estimates vary). While the long-running civil conflict between the Indonesian government and the Free Aceh movement has technically ended with a peace agreement in 2005, tensions still remain high.
With a badly damanged health care infrastructure, resources for treating mental illness in Aceh are scarce and many communities have turned a blind eye to pasung as a result. In one study examining 59 former pasung patients in the Banda Aceh Mental Hospital (the only psychiatric hospital in the region), 88 per cent of the released patients were male with length of pasung ranging from only a few months to as long as 20 years (average length was four years). At least 21 of the admitted pasung patients had significant muscle atrophy from their imprisonment and many were unable to walk at all by the time they came to hospital. Only one of the pasung cases had been referred by police, the rest had either been sent to hospital by family members or referred by a community health nurse. The majority of the 59 patients had a diagnosis of schizophrenia (90 per cent ) and reasons for use of pasung ranged from concerns about dangerousness to economic hardship.
The restraint methods used for the pasung patients varied depending on the circumstances of each individual family. In one extreme case, a patient was restrained in a garden two kilometres from the nearest village with both of his leg being bound in wooden stocks. For other patients, they were often restrained in a single room of the family home, in a small shelter behind the main house, or tied to a tree in the garden. While their immediate needs were tended to by family members, their lack of freedom left them completely dependent.
With the new program and the development of a community mental health system, free hospital care for the severely mentally ill has meant an end to pasung for many although access to care remains sporadic in many parts of Aceh. Aceh Governor Irwandi Yusef promised that the Aceh government would remove the chains from the mentally ill. While the Indonesian government remains publicly committed to abolishing pasung by 2014, whether that promise will be kept remains to be seen.