A couple of weeks ago, the first Dutch Global Health Film Festival took place (28 October 2017). I took the train to Utrecht and arrived at art house cinema ‘t Hoogt just on time (or rather, a bit too late). The one-day long festival consisted of documentary screenings on various topics within the field of global health, especially concerning low- and middle income countries. About half of the attendants were medical students or medical professionals, the other half were individuals with an interest in global health (of which I am one).
I could go on to give an overview of the various films that were screened during the festival. Instead, I would like to focus on one documentary specifically: “Breaking the Chains” (2015). I have multiple reasons for this.
Firstly, “Breaking the Chains” (64 min) captures a pressing issue: the confinement and maltreatment of the mentally ill in Indonesia. To be precise, the documentary was filmed in the West part of Java. Confinement of the mentally ill is an issue concerning global mental health and human rights – both personal fields of interest. During my bachelor’s degree I studied international law, anthropology and psychology. For my thesis, I looked at the connection between large-scale societal developments and mental health issues among today’s generation of young adults.
Also, this ethnographic documentary truly moved me. I sat in the cinema with a close friend of mine and we were left puzzled by the disturbing images but also awe inspired by the power the film had on us. I believe that when a documentary leaves such a mark, it is a good piece of work. I was glad my friend convinced me to go over and talk to the filmmaker after the screening.
“Breaking the Chains” is the work of Erminia Colucci, professor in the field of mental health & culture, and cultural psychiatry at Middlesex University, UK. Colucci is also a visual anthropologist and former clinical psychologist. The aim of this documentary is to raise awareness about the confinement of the mentally ill, as well as to gain an understanding of the set of beliefs and customs supporting the practice (Colucci 8, 2013).
Background on pasung
Confinement of the mentally ill has a long history. Almost all societies have restrained people with mental illness at some point in time (WHO, 2011). Today, the physical constraint of mentally ill individuals still takes place in many parts of a world and is an issue that is pretty much completely ignored (Colucci 7, 2013).
Indonesia is the first of low and middle income countries to take measures to eradicate the confinement of the mentally ill, a practice known as pasung in Indonesia (Colucci 11, 2013). In 2010, a local program was initiated in the Indonesian province Aceh to eradicate pasung. Shortly after, the Indonesian Ministry of Health followed with a nationwide program: Indonesia Bebas Pasung (Indonesia Free of Pasung). The main goal of the program was the eradication of pasung by 2014 (the deadline has been extended to 2020) as well as the provision of appropriate medical treatment and care to those in pasung (Puteh, et al, 2011).
According to estimates, in 2013 around 26.000 mentally ill individuals were in pasung in Indonesia (Colucci 7, 2013). Due to the national program, this had somewhat decreased, with an estimated 18.000 individuals in pasung in 2016 (Sharma, 2016).
These individuals live in isolation, locked away in a small space, in a room of the family home, a small shelter next to the home, or up to a few kilometers away from the home (Puteh et al., 2011). They do not see any daylight. Most of the time the confined individuals are naked, underfed and have to live in their own excrement (Colucci, Movie-ment). Methods of physical constraint include shackles, rope, and wooden stocks. Confinement can last for a few months but also years, sometimes up to 30 years (Suryani et al., 2011).
Causes of pasung
Despite the national ban of pasung in 1977 (Sharma 17, 2016), it was not until 2010 that the government set up a national program with the aim of making an end to pasung. It took so long because of the absence of a human rights framework and mental health legislation in Indonesia (Colucci 10, 2013). This largely has contributed to the prevalence of pasung.
The practice of pasung is also deeply connected to poverty. In the rural area of West-Java, as in most parts of Indonesia, there is a lack of mental health care resources. Impoverished farmer families live hours away from the only, overcrowded and underfunded psychiatric facility in the area (Colucci 510, 2016). Treatment is not only unaffordable but also difficult to access (Colucci 10, 2013).
Furthermore, the inadequacy of the Indonesian mental health system is held in place by uncoordinated, and at times even conflicting health care interventions: traditional (spiritual) versus a biomedical intervention.
Thus, in nearly all cases, confinement is the only available means of protecting severely mentally ill individuals from possibly doing harm. The caretakers fear the individual to be a danger to him/herself, and/or to the wider community (Puteh et al., 2011). Data is lacking – barely any research has been done on pasung. However, one of the few studies indicates that 87% of those in pasung are schizophrenic (Puteh et al., 2011), showing that the practice of confinement concerns those with severe mental illness.
Breaking the Chains
For “Breaking the Chains”, over the course of one and a half month, Colucci followed several volunteers of the community organization Komunitas Sehat Jiwa (KSJ, ‘Community for people with mental illness’). The organization, based in Cianjur, West-Java, is led by individuals who themselves previously suffered from mental illness. Efforts to eradicate this practice are taken on all levels (Colucci 8, 2013), from the top-down government approach to the bottom-up approach of volunteers.
The volunteers of KSJ work by continuously going on home visits. The film follows the leader of KSJ, Nurhamid, who had previously been diagnosed with bipolar disorder (Colucci 15, 2013). He and his team check up on those in pasung, mostly individuals affected by schizophrenia. They travel miles and miles to reach confined individuals, some so remotely located that they are inaccessible by car. Ultimately, the aim of the KSJ team is to convince the caretakers to provide the individual in pasung with a medical treatment and eventually for him/her to be released (Colucci 15, 2013).
“Breaking the Chains” tells several stories of pasung victims. One is that of Yayah, a woman who has been chained for 17 years. Another is that of Asep Abdul, a young boy who was confined after he went missing for years. The film also follows Nurhamid and his helpers when they go searching in the jungle for Hadad, who was buried in the ground up to his neck for 12 years (Colucci 509, 2016).
Spiritual vs. biomedical paradigm of health
During home visits, the KSJ volunteers educate the families and broader communities about mental illness, which they conceptualize as a ‘disease of the brain’. The volunteers’ biomedical understanding of mental ‘illness’ is clearly in contrast with lay people’s view of a ‘mental problem’ (Colucci 23, 2013). The concept of mental illness as a ‘disease of the brain’ is something many are unfamiliar with; especially those with a low level of education, often in rural areas. Their health beliefs do not fall within the biomedical paradigm.
For example, Asep, a very religious young Muslim was confined after he had set his house on fire, killing his father in the process. His local community and family believed his madness was caused by a possession by jinns (Colucci 23, 2013), “due to him overlearning the reading of Qu’ran and thereby living in his own world detached from the real world” (Tyas 39, 2008). Also in the other cases, the caretakers would attribute the conditions of the pasung victim to supernatural forces, such as possession by the devil or jinns, spells or black magic (Colucci 25, 2013).
Each of the individuals in pasung in the film had been taken to a religious center at one point in their lives. Usually they were treated more than once and at different centers, as the caretakers typically would try alternative options when one failed (Colucci 26, 2013). Spiritual healers, not just in Indonesia but in many low to middle income countries, remain, “highly popular despite the routine maltreatment of the mentally ill in their facilities” (Read, et al., 2009), such as back whipping and extremely poor hygiene (Colucci 25, 2013).
However, it would be too simplistic to entirely dismiss spiritual healing and to deny the important role spirituality can play in healing processes. The volunteers, not religious themselves, did not attempt to dismiss the religious beliefs and practices. Rather they tried to negotiate co-existence with the spiritual healing methods of the local communities by introducing an alternative method.
The volunteers never confronted or rejected peoples’ spiritual beliefs and healing methods. Instead, they would suggest alternatives: “Ok, you can continue with the spiritual healing methods but could you also try this or do this?” They often managed to gain the trust of the caretakers and eventually were able to convince them of freeing the pasung victim (Promise, 2015). Thus, they were able to bring about change by finding a way around spiritual beliefs and working within the existing system, rather than against it (Promise, 2015).
However, before the individual could be freed from confinement, he/she had to be on psychiatric medication, provided by KSJ, for a certain period. Medical treatment was required in order to “gain a functional enough state of mind to be released” (Suryani, et al., 2011:143). This is not to say that medication was the entire solution. Rather, medication was part of a list of to do’s that the volunteers provided the caretakers with, e.g. “talk to him, show your love, clean him, take him for a walk, be encouraging” (Colucci 27, 2013).
With “Breaking the Chains”, Colucci made an activist film aiming to raise awareness about pasung but also as a tool to make an end to the practice. She took a human rights stance but the same time is a filmmaker and cultural anthropologist, and tried to maintain a certain distance in order to observe the local beliefs and practices. As previously discussed, the practice of pasung has various (external) causes: an inadequate mental health care system and utter lack of resources, as well as conflicting health (and illness) beliefs.
While forced physical confinement is a human rights violation, overall, the intentions of the caretakers are good, namely to protect the confined individual (ABC News, 2013). The caretakers are not perpetrators but rather victims themselves of their living circumstances: structural poverty and a lack of mental health care resources. It is a tricky situation without a clear perpetrator and victim, and the lack of mental health resources leading to (unintended) inhumane conditions or ‘human rights violations’.
To conclude, I really admire Colucci’s work. She succeeded in making a touching but also alarming film that calls for action without being too explicit: the images speak for themselves. As Colucci says about her work:
This research-film is my contribution to understanding and giving a voice to those who have seen their basic rights as ‘humans’ (let alone their voice) be taken away because of their mental problems and my invitation to others for an applied, public and activist visual research (38, 2013).
And further research and activism is definitely necessary: while the amount of individuals in pasung has decreased from 26,000 in 2013 to 18,000 in 2016 (Sharma, 2016), there is still a long way to go.
For more information on the documentary and practise of pasung: https://movie-ment.org/breakingthechains/
Trailer of “Breaking the Chains” documentary: https://vimeo.com/146913142
ABC News. New documentary explores Indonesian practice ‘pasung’. Video (2013). Video expired on ABC website. Available here: https://www.dailymotion.com/video/x2sw9c8
Colucci, Erminia. “Breaking the Chains: ethnographic film-making in mental health.” The Lancet Psychiatry (2016).
Colucci, Erminia. “Breaking the Chains: Human rights violations against people with mental illness in Indonesia”, University of Manchester (2013).
Colucci, Erminia. “Movie-ment”. WordPress blog. www.movie-ment.org
Sharma, Kriti. “Living in Hell: Abuses against People with Psychosocial disabilities in Indonesia”, Human Rights Watch (March 2016).
Promise, “Erminia Colucci on Breaking the Chains”. Youtube video (2015). Retrieved from: https://www.youtube.com/watch?v=a0Z6i-JPMU8
Puteh, I et. al. “Aceh Free Pasung: Releasing the mentally ill from physical restraint”. IJMHS (2011).
Read, M. U. et. al. “Local suffering and the global discourse of mental health and human rights: An ethnographic study of responses to mental illness in rural Ghana”. Globalization and Health (2009).
Suryani, L. K., et al. “Treating the untreated: Applying a community-based, culturally sensitive psychiatric intervention to confined and physically restrained mentally ill individuals in Bali, Indonesia”. Eur Arch Psychiatry Clin Neurosci (2011).
Tyas, T. H.. “Pasung- Family experience of dealing with “the deviant” in Bireuen, Nanggroe Aceh Darussalam, Indonesia”. MA in Medical Anthropology, University of Amsterdam, Amsterdam (2008).
WHO. (2011). “Bugs, drugs & smoke. Stories from Public Health”. Retrieved from http://whqlibdoc.who.int/publications/2012/9789241564366_eng.pdf (June 2013)