Wednesday, December 6, 2023

A Long Way to the Psychiatrist's Couch: Mental Illness Treatments in Indonesia

Dhania Sarahtika
June 1, 2018 | 10:15 am
One of the artworks at Bipolar Care Indonesia's 'Ekspresi Ragam Jiwa' ('Diverse Expressions of the Soul') exhibition at Taman Ismail Marzuki in Jakarta last March. (Antara Photo/Dodo Karundeng)
One of the artworks at Bipolar Care Indonesia's 'Ekspresi Ragam Jiwa' ('Diverse Expressions of the Soul') exhibition at Taman Ismail Marzuki in Jakarta last March. (Antara Photo/Dodo Karundeng)

Jakarta. Many people suffering from mental health problems in Indonesia are reluctant to seek help from professionals because they don't want to be seen as "crazy." This stigma on mental illness, caused by lack of awareness, often sends patients deeper into a downward spiral.

Livia Iskandar, a psychologist at Pulih@The Peak: Women & Family Empowerment Center in South Jakarta, a counseling service and part of non-profit organization Yayasan Pulih, said they receive many requests for assistance from people with mental health problems who have left it "a bit too late" to seek professional help.

Psychiatrist Endah Ronawulan, who practices at Central Pertamina Hospital in South Jakarta, said people with mental health problems usually need a combination of two types of treatment to get better: psychotherapy (counseling) and pharmacotherapy (medication).

"There are over 100 types of mental illness, from mild to serious ones. If the illness has interfered with our social and professional life, medication is unavoidable," she said.


Medication for mental illness ranges from mood stabilizers for bipolar disorder, anti-psychotic drugs for schizophrenia to antidepressants and sleeping pills for depression and anxiety.

Mental health professionals in Indonesia follow the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders (DSM-5)" to diagnose  what types of mental disorders patients are suffering from.

Endah said she sees 20 to 30 patients every day, leaving her little time for counseling. But she works together with psychologists to offer more talk therapy for patients.

What Happens on the Psychiatrist's Couch?

The couch is the first image that comes to people's mind when they think of psychiatry or any kind of psychological counseling. But what exactly happens on it?

Livia said as a counselor she uses cognitive behavioral therapy to reduce or stop destructive behaviors. In cases of depression and anxiety, she asks patients to identify their symptoms and do exercises to prevent negative thoughts from spiraling into something worse.

Most of Pulih@The Peak's patients are young adults between 13 and early 20s, and for this very reason Livia devises a "systemic" therapy that also observes the patients's family backgrounds, their parents’s personalities and their parenting style.

"The parents’s mental health affects the patient. If a parent is neurotic, the child will likely develop the same trait. What the child does is copying the parent’s internalized coping mechanism. In those cases, we need to change the way the parents deal with problems, so the the child won’t copy them," she said.

This "family therapy" also helps develop a stronger support system for the patients.

"We can’t just focus on the person [suffering from mental illness], we have to see what their daily life is like and if the people around them give them enough support," Livia said.

Another form of treatment for mental illness that's getting quite popular in Indonesia recently is hypnotherapy. Endah, who has been studying hypnotherapy for years, said unfortunately she's seen many therapists claiming to offer hypnotherapy after only a month of training.

"They say they're hypnotherapy experts, but they aren’t. In hypnotherapy you give suggestions to the subconscious. There are many words that you have to avoid. It can’t be done carelessly," she said.

She said people with severe schizophrenia, bipolar disorder or depression are not allowed to have hypnotherapy. The treatment is reserved for patients who are in a stable condition.

How Long Until One Gets Well?

How long you have to be treated for mental illness varies greatly according to the severity of the cases. Endah said for bipolar disorder and schizophrenia, the first stage of treatment takes 6 months to a year. If the patient suffers from a relapse, the next course of treatment can take 2 to 5 years.

When patients are medicated, they should never miss a dose. In cases of bipolar disorder, for example, the cause is an imbalance in the brain's neurotransmitters. Medication is needed to restore that balance.

"As time goes on, their dosage will be reduced. The patients can do various exercises to help them become more independent. If things go well, they can go on a 'drug holiday,'" Endah said.

Endah agrees that family plays a crucial role in helping mentally ill patients to recover. One thing that family can do to help their loved ones get better is giving them rewards and positive reinforcements. It can be as simple as rewarding them for completing a menial task, such as tidying up the bed every morning.

Art Therapy

Having a hobby or interests that patients are passionate about can also help them recover. Endah said getting passionately involved in a hobby keeps your brain active and can distract patients from their symptoms.

Visual artist and founder of Bipolar Care Indonesia (BCI) Vindy Ariella said, "Art is an effective and safe medium to complement medication and psychotherapy. It can be cathartic, you can use it to vent and express trauma, sadness, anxiety, as well as happy and calming feelings," she said.

BCI regularly hosts sessions of art therapy, which also involve theater work and creative writing. Last month, it held a two-week exhibition titled "Ekspresi Ragam Jiwa" ("Diverse Expressions of the Soul") at Taman Ismail Marzuki in Central Jakarta.

Ruqyah: Yes or No?

People who are having a nervous breakdown or a schizophrenic episode in Indonesia are often mistaken for having come under the spell of a demonic possession. Often their own families, not knowing what they're dealing with, would take them to a dukun (shaman), priests or clerics to be exorcised.

One of the most popular "alternative" healing rituals for the mentally ill is ruqyah. According to Adi Supriadi, an ustad (Islamic preacher) from Bekasi, West Java, who practices ruqyah, the name of the practice means "incantation," but not the kind used in sorcery.

To him, ruqyah means using prayers, including verses from the Koran, to heal one's batin (spirit or soul).

"Ruqyah for people who are depressed, stressed or mentally disturbed is more like counseling. I ask them what their problems are and encourage them to pray more. Just like that. It’s not like the ruqyah people perform for a demonic possession," Adi said.

Adi said many families come to him insisting that their mentally-ill family members are possessed by the devil because they prefer an instant cure than months of therapy.

Adi believes ruqyah can complement modern medical assistance because "doctors can’t help you all the time."

"A patient sees the doctor once a week, let's say. But what happens at home? I don’t know if what I’m about to say is scientific, but doctors should also recommend patients to surround themselves with people who are spiritually healthy or religious. It should help the patients overcome depression," Adi said.

According to Livia and Endah, ruqyah can only work if the patient is still in the very early stage of an illness.

Both Livia and Endah say they have been seeing more patients in recent years, which may indicate that more people are seeking professional help for mental illness.

Bagus Utomo, the head of Indonesian Community Care for Schizophrenia (KPSI), said ruqyah only gives reassurance to families, and that the recovery of the patient relies on medication.

Bagus pointed out there are asome ruqyah facilities, such as the Abu Albani Centre in East Jakarta, that refer mentally-ill patients to medical professionals.

How Much Does Treatment Cost?

Adi, like many people who provide alternative treatment for medical ailments, replied that people pay "seikhlasnya" ("as much as they're willing to") for his ruqyah treatment.

He himself does not refer his patients to medical professionals because most people coming to him for help are from poor families who "can’t afford to go to professionals."

Endah said some patients come to her after wasting a lot of money on alternative treatments that do not work. "Some of these alternative healers charge up to Rp 30 million ($2160) for a single session," she said.

Psychiatrists in Jakarta charge around Rp 400,000-Rp 500,000 per session. In Greater Jakarta areas, including Bekasi, the fee can be up to 50 percent cheaper.

Yayasan Pulih's Pasar Minggu branch charges Rp 100,000-Rp 150,000 for each consultation while the Pulih@The Peak in Kebayoran Baru charges Rp 350,000-Rp 500,000. Each session with a psychologist lasts 75-90 minutes.

Treatments for mental illness are covered by the state healthcare insurance provider, BPJS Kesehatan, but there’s a limitation: it will only pay for the generic versions of the drugs that patients are prescribed for.

According to Bagus, generic drugs aren’t always available, and schizophrenic patients are likely to suffer from a relapse when their medication is stopped.

BPJS also requires patients to be admitted to hospitals to receive treatment, which can be very difficult to do when the patient is at an aggressive state. Moreover, medical professionals aren’t always cooperative when it comes to providing services for people with mental illness.

"I once made an emergency call to 118 [ambulance line] but they refused to come. They'd helped us once but after that they don't want to pick up patients suffering from anxiety attacks anymore," he said.

Bagus said the government should stamp out discrimination against patients with mental health problems in the health services by providing full services – including full insurance coverage – for patients suffering from a mental illness, just as they do to people with other illnesses.

Additional reporting by Diella Yasmine

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