Mount Merapi, Yogyakarta. Research conducted in Yogyakarta, Jakarta, Denpasar and Palu indicates that cultural beliefs, practices and stigma are major obstacles to seeking professional treatment for mental health issues. Photo by Andreas Fitri Atmoko for Antara.
“My family is religious. They do not have much knowledge of mental health problems. They asked me to pray more often, and even try fasting. When I first told them about my problem, they had difficulty accepting it. They asked me not to go to a psychologist.”
– Person living with anxiety disorder, Jakarta
“They held me down and burned my eyes with incense. Then they started yelling, ‘Get out! Why are you bothering him?’ They thought I was possessed by a demon. I am not. To this day, I still hate alternative therapy. They made me drink a concoction made of water, lime and a piece of tile… I threw up when I drank it. The rituals and concoctions cost me and my family millions of rupiah. Each exorcism ritual cost Rp 3 million [$290]. Imagine how much actual medicine I could have bought with that amount of money.”
– Person living with schizophrenia, Denpasar
Official statistics on mental health disorders in Indonesia are alarming, even accounting for massive underreporting of the problem. According to the results of the 2018 Basic Health Survey (Riskesdas), an estimated 19 million Indonesians over the age of 15 experience social-emotional mental issues, while almost 12 million experience depression. Seven in every 1,000 households have a member with schizophrenia. Yet in general, mental health does not attract the same level of concern as physical health in Indonesia, and strategic policy to address the issue is lacking.
To understand the full picture, mental health must be considered in its social and cultural context. In Indonesia, this context is a complicated picture indeed. Religious and spiritual beliefs, as well as cultural expectations, greatly affect the experience of mental health patients and the types of treatment they receive.
Research conducted this year by the HIV/AIDS Research Centre (PPH) at Atma Jaya University found that in the eyes of the general public, depression, schizophrenia and bipolar disorder are not seen as psychological disorders, but rather spiritual or paranormal problems.
The research was conducted in four cities – Jakarta, Yogyakarta, Denpasar and Palu – and involved 60 informants at various levels of leadership and service engagement, as well as patients and caregivers of people with mental disorders. The results of this small sample indicated that cultural beliefs, practices and stigma were the main obstacles to accessing mental health services for the majority of respondents.
There is significant social stigma attached to mental illness in Indonesia. For example, there is a common belief that it affects those who are not close to God, or are not praying often enough, and so are being punished for their sins.
Other viewpoints focus on the supposed influence of supernatural entities, such as beliefs that mentally ill people are possessed by demons that cause them to change their behaviour, hear voices, or experience hallucinations. Another folk explanation is black magic – perhaps the patient has been hexed by someone who bears a grudge against them, and the side effects of the hex include mental disturbance. These myths were common findings in our research.
These misconceptions are not only unscientific, but also result in people with mental health problems being mistreated, shunned by their communities, and unable to receive timely and effective medical treatment for their conditions.
Our research found that in some cases, people with mental health concerns were first referred by friends and family to “healers” and shamans, who claimed to be able to treat their illnesses. Treatments promoted by these healers include practices such as drinking traditional herbal remedies, bathing in water mixed with flowers, or being treated with incense or massage.
Others reported that they were subjected to treatments that involved inflicting physical pain, through ritual beatings or burnings. Some reported being sent to spiritual healers, who recommended reading religious texts, fasting, giving alms, or continuously praying throughout the day to ease symptoms.
Of course, most of these practices do nothing to address the root cause of patients’ mental health problems. Some of the patients interviewed reported spending vast amounts of time and money trying the approaches of various alternative healing practitioners, with no improvement in their condition. It some cases, it took them years to finally decide to seek help from healthcare services, when their condition had already become severe.
So why do people tend to seek out alternative approaches rather than immediately consulting a health professional?
Our research confirmed that for those who believed mental health issues to be a result of demonic or spiritual disturbance, western medicine approaches such as visiting a psychologist or psychiatrist were not considered to be suitable solutions.
In such cases, alternative approaches were often regarded as better ways to restore physical, spiritual and mental health. This is likely because they involved the patient’s family and community members in the treatment. Alternative healing practitioners also tend to be figures who are respected within their communities, avoiding the need to involve outsiders in treatment.
The influence of family is another major reason people chose alternative approaches. Family members, who should provide support and care for sufferers, are instead often informed by stigma in their responses – providing unnecessary advice, making hurtful comments, refusing to address the problem, or referring patients to alternative healing practitioners.
These kinds of responses are indicative of a low level of community understanding of mental health, and can be harmful for people with mental health issues.
Identifying and understanding all the perspectives on mental health – including cultural views and social stigma – is important to get a full picture and find solutions for Indonesia’s mental health problems.
Cultural constructs play a vital role in the identification and treatment of mental health problems, and must be considered in the creation of strategic mental health policy – people cannot be expected to come willingly to mental health providers if their cultural viewpoints are not adequately understood.
Providing space for discussion among alternative healers, healthcare professionals and other stakeholders is the first step towards developing culturally sensitive mental health services.
However, misconceptions must also be addressed when they delay or inhibit treatment of serious conditions. Promotion of reliable information on mental health must target people with mental illness and their families. Access to this type of information can be a deciding factor on whether families seek treatment from alternative approaches or mental health professionals.
Mainstreaming a better understanding of mental health issues and promoting mental health services must become a priority to support the health and wellbeing of millions of Indonesians.
