Discrimination of persons with mental illness: testing the principles for the protection of persons with mental illness and the improvement of mental health care in Indonesia

Introduction

Populations in most countries, including Indonesia, are facing mental illness struggles (Roberts, 2018). Nearly one billion people worldwide suffer from mental illnesses, and more than 75% of them do not receive adequate treatment (Kovacevic, 2021). According to Tang et al. (2022), suicide is the leading cause of death among people with mental illnesses because they do not receive timely and appropriate treatment. According to Hartini et al. (2018), 1.7% of Indonesia’s total population suffers from mental illness, which is often stigmatized by society. The proportion of people suffering from mental illness in 2022 was 3.7%, or 9.162,886 people, making Indonesia one of the countries with the highest number of people suffering from mental illness in the world (World Population Review, 2022), and it is expected to rise by 3.24 million before 2024 (Wolf, 2022). According to the Ministry of Health of the Republic of Indonesia’s Basic Health Research (Ministry of Health of the Republic of Indonesia, 2018), more than 19 and 12 million people over the age of 15 experience mental and emotional disorders, and depression, respectively. Furthermore, data on suicides show that 1,800 people per year, five per day, commit suicide, and 47.7% of suicide victims are aged 10-39 years, a group comprising teenagers and adults of productive age. The presented percentage of the suicide rate may be correct if no early efforts are made to slow the growth rate.

Globally, Ukraine has the highest number of depressed people according to their population at 6.30% followed by the United States of America and Australia at 5.90% each, and Brazil at 5.80%; whereas Laos and Nepal have the lowest proportion at 3.20% each (World Population Review, 2022). Further, Sweden, Germany, and Finland provide some of the best healthcare in the world because their governments promote psychological wellbeing including work-life balance and healthy work environments and allocate government spending to mental health care (CEO Magazine, 2022). Indonesia has the worst ratio of general medical practitioners to people worldwide, with only 0.22 medical practitioners for every 1,000 people (Clarkson, 2022). To overcome this problem, the Indonesian government imposed the National Mental Health Act (MHA). The aim of this act is to offer services regarding mental health for everyone and specify the rights of people with mental health problems (ODMK) are people who have physical, mental, social, growth and development problems and/or quality of life so they are at risk of experiencing mental disorders and people with mental health disorders (ODGJ) are people with personality disorders, where sufferers tend to have deviant thought patterns and deviant behavior. Although, it cannot be acquired optimally. The rights of ODGJ and ODMK individuals are sometimes ignored both legally and socially. There is still some stigma in society about people who have a mental illness, so families try to hide the existence of the members who have this issue. This sustains ODGJ and ODMK individuals’ access to adequate health services. Regulations and laws that are legally existing cannot comprehensively assist the fulfilment of ODGJ and ODMK rights.

Although Indonesia has ratified the United Nations Convention on the Rights of Persons with Disabilities, and has rules that guarantee the rights of citizens with mental illness such as Act No. 18 of 2014 concerning Mental Disease, Act No. 19 of 2011 concerning the Ratification of Convention on the Rights of Persons with Disabilities, Act Number 18 of 2016 concerning Persons with Disabilities, and the Regulation of the Minister of Health of the Republic of Indonesia No. 54 of 2017 concerning the Completion of Increase in People with Mental Disorders (ODGJ), it often violates the rights of patients with mental illness (Edwards, 2014; Hartini et al., 2018; Widodo, 2019; Tampubolon, Silalahi, and Siagian, 2021; Wolf, 2022). Further, Indonesia must respect inherent dignity, individual autonomy including the freedom to make one’s own choices, and people’s independence (United Nations Office of Human Rights of the United Nations from the High Commissioner, 2006); further, there shall be no discrimination on the grounds of mental illness (United Nations of the Human Rights Office from the High Commissioner, 1991).

However, problems arise when mental disorders are considered taboo, as they are in Indonesia (Subu et al., 2021; Puspitasari et al., 2020). In India, Kate et al. (2012) mentioned that mental disorders reflect abstract metaphysical entities; supernatural agents; witchcraft; disrespect for gods, teachers, or others; and excessive fear or excitement that causes mental shock and wrong bodily activity. These disorders are treated using herbs, ointments, mantras, prayers, and moral or emotional persuasion. In such situations, discrimination continues, causing the mental condition of the patient to worsen. To avoid the community’s taboo perception, previous practice in Indonesia stipulates that sufferers of mental diseases must be shackled by their feet so they cannot roam freely (Hidayat et al., 2020; World Health Organization Southeast Asia, 2021; Dahniar et al., 2022). To avoid being seen and so as not to disturb others, pasung (shackling) is enforced for sufferers of mental illnesses. Because of this method and inadequate health facilities, people’s health worsens, and they experience feelings of isolation and loneliness (Wang et al., 2017; Banerjee and Rai, 2020; McKenzie et al., 2022; Majmudar et al., 2022).

In the context of guaranteeing the rights of people with mental illness, the Indonesian government seems to be more focused on avoiding the practice of pasung than on treating people with mental illness by issuing regulations to eliminate the shackles that are so often used (Saputri, 2021). This has resulted in priorities that are detrimental to the rights of mentally ill individuals. In addition, the government’s lack of attention to building mental hospitals and the lack of psychiatrists available to treat patients with mental illnesses (Kokom, 2021) result in increasing feelings of isolation among patients and high suicide rates. This policy, which is not pro-mental health, not only hinders the right to access health facilities for people with mental illness but also causes them to lose their right to live due to depression and suicide.

Based on these facts, this study focuses on a new problem with two driving questions: Is there a policy protecting the rights of persons with mental disabilities in accordance with the Convention on the Rights of Persons with Disabilities? What is the impact of discrimination on the rights of people with mental disabilities? The answer to the first question is no. Second, the protection of the rights of people with mental disabilities, misaligned with the Convention of the Rights of Persons with Disabilities (CRPD), is increasingly suffering and resulting in the harming of other rights. This specific study was presented at the EDI Conference, London 10–11 July 2023 as a Development Paper.

Methods

This study critically evaluates the discrimination against people with mental illnesses in Indonesia and the inconsistency between mental health laws and the principles in the CRPD. Secondary research has been considered. It conceptually approaches human rights and legal studies approaches to overcome these issues and considers the fulfilment of human rights related to mental illness in Indonesia.

For this qualitative research, the author employs relevant national legal, social scientific, and health literature in its entirety, including international legal norms set by regulations. Secondary data were collected from articles selected from Google Scholar. All the studies were from 2002 to date; no studies were selected for qualitative data collection prior to 2002. This study evaluates Indonesian laws, and the Indonesian constitution regarding the health rights, operations, and structures of the “National Human Rights Commission”.

Mahendra (2023) considers that the government of Indonesia has a significant role in the development of the country that offers guarantees for decent and safe for citizens. The individual with disabilities as a citizen of Indonesia also has the same rights, similar to other general people. From the study of Eka and Daulima (2019), it has been found that mental illness stigma guides the abuse of human right and discrimination. To analyse the problem, primary sources such as MHA and CRDP records, as well as secondary data sources such as legal instruments, national and international literature, and reports by international organisations were required. Such a mix of approaches is ideal since it gives a solid foundation for exploring existing problems and finding more creative and liberating solutions.

This study begins with the MHA and the difficulties in its implementation as it has not fulfilled all the principles for the protection of persons with mental illness and the improvement of mental health care stipulated in the CRPD. The thematic analysis, as described below, focuses on answering the research questions: Does the MHA, which regulates the treatment of people with mental illnesses, fulfill their fundamental freedom and rights, and the provisions of the principles for the protection of persons with mental illness and the improvement of mental health care? Second, what is the impact on the other rights of people with mental illnesses? Different sources have been collected from Google Scholar, and later after analyzing every journal and article according to the study matter, relevant studies have been kept aside. From the selected studies, different themes have been established based on the subject.

We have limited the scope of this study to two areas. First, this study only focuses on whether the MHA meets the standards set by the CDRP principles of non-discrimination; therefore, no information is provided if the MHA is similar to other studies based on the studies (Praharso et al., 2020; Subu et al., 2023). Second, we used qualitative research to address the research problems, meaning that research on the same topic using quantitative analysis is outside the scope of this study. These are limited scopes, as this study only focused on these two aspects rather than other areas. The qualitative studies have been selected based on the study subject, which talks about laws and regulations regarding people with mental illness in Indonesia. Studies with quantitative analysis have been eliminated from this study, as it followed the qualitative data analysis method.

Tanaka et al. (2018) stated that the eligibility criteria for people with a mental health problem (PMHP) were categorised as epilepsy or “Diagnostic and Statistical Manual of Mental Disorders 5” (DSM 5). The main reason behind selecting people suffering from epilepsy as they are known to suffer discrimination and stigma. This study has observed that geographical barriers and stigma sometimes prevent patients from attending treatment till they are extremely unwell.

The dependent variable of this study is people with mental illness in Indonesia, and the independent variables are discrimination, certain mental illness-related acts, and human rights. From the selected articles and journals, all the necessary data have been determined and taken to complete the study. In case any particular data regarding mental illness in Indonesia has been taken, credit to the author has been provided there.

Results

Indonesians are still not concerned about the handling and treatment of people with mental illness or mental retardation. According to a 2022 Human Rights Watch (HRW) report in Indonesia, 57,000 people with certain mental health conditions have been in pasung at least once in their lifetime, and about 15,000 of them are still living in pasung. This difference in the perception of mental illness between Indonesians and World Health Organisation is shown in Table 1.

Discussion

It is undeniable that the Mental Health Law does not provide protection for people with mental disorders. This is due to the high number of ODGJ who are homeless or neglected because they do not have a place to live. Kementerian Kesehatan Republik Indonesia (Indonesian Ministry of Health, 2021) noted that in big cities in Indonesia, the number of homeless people with psychosis has increased by approximately 70%. In addition, the condition of individuals who have nothing, no one, or no support ultimately results in them living neglected or abandoned on the streets.

Second, mental illness is still socially stigmatized, leading families to hide the existence of family members who suffer from mental disorders. Furthermore, mental disorders and mental health in Indonesia are considered cursed diseases, so it is not unusual for family members who experience these problems to be hidden and placed in shackles. As such, some families choose to remain silent or hide, isolate, or shackle people with mental disorders (ODGJ). Many ODGJs wander the streets because they were abandoned by their families. This phenomenon occurs because of the stigma and discrimination that exists in society (Yu et al., 2023). Not only are ODGJs abandoned, but their families are ostracized by the surrounding social environment. This kind of behavior occurs because of a lack of access and information provided to the public; therefore, mental disorders are considered terrible.

A lack of public awareness and knowledge about people with mental illness and mental retardation leads to the poor treatment of and attitudes towards them. This is due to culturally different perceptions of mental health (Choudhry et al., 2016). In most developed countries, people voluntarily seek help from professionals to treat mental health disorders. On the other hand, in other places such as Indonesia, mental disorders tend to be ignored; so, people are less enthusiastic about treating mental disorders.

Third, mental illness is seen as a shameful family disgrace. Indonesian people think that mental disorders cannot be cured; so, suffering people deserve to be ostracized. The lack of knowledge about mental health disorders means that Indonesians believe that people with mental health disorders are different from those with physical illnesses that are also difficult to cure. Thus, labeling people with mental illness or mental health disorders as “strange creatures” can threaten their safety (Aulia, 2019).

The Western health model views mental disorders as problems that need to be cured. Thus, mental health services tend to be oriented only toward mental disorders that afflict the person and often ignore aspects related to the lives and welfare of the mentally ill (Choudhry et al., 2016). Therefore, in the Western world, those who suffer from mental illness receive special treatment without isolating them or putting them in shackles, as is the case in many areas of Indonesia.

Fourth, sanctuaries and shamans are considered treatments for mental illnesses. Indonesian society has several types of traditional and alternative medical practices, such as ‘smart people’, including shamans, Islamic religious leaders, religious teachers (kiyai or clerics), psychics, priests, and traditional Chinese medicine. In practice, ‘smart people’ use herbs, incantations, spells, inanimate objects, communication or spiritual guidance, and prayers as forms of healing. In contrast, the Western health model often ignores aspects related to religion while overcoming the impact of mental health illnesses on one’s life (Lucchetti, Koenig & Lucchetti, 2021; Harris, Edlund, & Larson, 2006).

The Indonesian government’s minimal efforts to save the lives of people with mental illness have catastrophic consequences for young people. These consequences are heightened in rural areas because they do not have access to healthcare. People are also reluctant to take those with mental illnesses to hospital because of the shame, exacerbating the situation. Statista (2022) notes that 19 million children under the age of 15 years suffer from mental illnesses and most live in rural areas far from medical facilities. Consequently, many people with mental illnesses die by suicide because they do not receive adequate treatment. Therefore, villagers are those most affected by government inattention. Apart from having minimal mental health facilities, they cannot afford the high cost of medical treatment.

The counter-shackle policy, the Issuance of Regulation of the Minister of Health Number 54 of 2017 Concerning Handling Detachment for People with Mental Disorders, instead of saving the lives of people with mental illness, wreaks havoc on them because it is not supported by health facilities. A recent independent survey by Statista (2022) predicts the number of people suffering from mental illness and related deaths will increase from 2,99 million in 2020 to 3, 24 million in 2024.

Additionally, the public’s reaction to mental illness impacts those struggling with mental health issues because it brings attention to their rights as human beings, including their rights to access treatment, obtain information, live, and be free from shackles. After the enactment of the Mental Health Law, the Indonesian government was deemed unable to protect the rights of people with mental illnesses. Further, the rights of people with mental disabilities are regulated under Article 42 of the Human Rights Law, which states:

Thus, the confinement of people with mental illness, even if carried out by their families with the aim of keeping themselves and those around them safe, clearly violates human rights and can be categorized as the deprivation of the right to live properly.

Although they may not be locked or shackled, the family cannot let someone suffering from mental illness roam freely. They might be charged under Article 491, point 1 of the Indonesian Criminal Code:

Finally, Article 10 of the Regulation concerning the insane in the State Gazette 97/54, February 4, 1897, stipulates that the immediate family of a mentally ill person has the authority to request the head of the district court to treat them in a mental care institution for the sake of peace and public order or for the sake of healing of the mentally ill person themself. However, in practice, it is difficult to trust the government’s ability to treat mentally ill persons.

Conclusions

Discrimination against people with mental illness occurs in Indonesia and the treatment offered does not align with the principles for the protection of people with mental illness and the improvement of mental health care. This policy discriminates against people with mental illnesses; not only are they shackled but they do not have adequate treatment facilities, resulting in high mortality rates. This is because treatment methods contradict these principles. In Indonesia, the recovery model for people with mental illnesses is a discriminatory policy that does not meet their needs and, further, violates human rights, especially the rights to life and health.

Therefore, the government must provide adequate facilities for people with mental illnesses by referring to the principles of protecting them and improving their mental health services. To realize the effective and conducive recovery of people with mental disorders and the fulfillment of the rights of people with mental disorders, Law No. 18 of 2014 on Mental Health (Mental Health Law) must fulfill the principles and elements stipulated in the instrument for treatment of people with mental disorders and improvement of health services.