With all the hustle of being involved in the global mental health movement, it would be better for Indonesia to start at home, Nova Riyanti Yusuf argues. (Photo courtesy of Harvard Kennedy School)

Commentary: Growing Pains of the Mental Health Law


APRIL 14, 2015

With all the hustle  of being involved in the global mental health movement, it would be better for Indonesia to start at home, Nova Riyanti Yusuf argues. (Photo courtesy of Harvard Kennedy School)

As rookie and naive member of House of Representatives back in 2009, I initiated the Mental Health Bill and successfully delivered this bill to be enlisted in the National Legislation Program 2009-2014. At the time, I believed in standing up for the rights of 18,000 people with mental disorders being shackled, caged, locked, and/or physically restrained at their homes and shelters. Little did I know, initiating was only  5 percent of the entire process. It took me five years to keep maintaining the energy and belief to pass this Mental Health Bill into law.

With the increasing number of suicides, natural disasters — ranging from volcanic eruptions, floods, landslides, tsunamis, etc. — the fourth-largest population in the world with its multidimensional problems, how can Indonesia survive as a nation without a comprehensive Mental Health Law as the foundation to our new and reformed mental health care system?

The eruptions of Mount Merapi in central Java took place in 2010. More than 350,000 people were evacuated from the affected area. Three hundred and fifty-three people were killed during the eruptions. Obviously the Health Ministry is aware of regionalization in disaster-prone areas. As for me, any awareness contributes to no avail should those people facing natural disasters be gripped with helplessness.

At the very least, we shall make the best preparation that we possibly can. Thus after a through discussion I came up with a model project: Psychological first aid on-the-job training for 200 community mental health nurses from five mental health hospitals in Central Java. I flew to the affected area in the emergency phase and attended the national coordination meeting with the National Disaster Mitigation Agency (BNPB) in Magelang, Central Java, and the BNPB approved my proposal to fund the project.

I insisted that the check be delivered directly to the local health office. The purpose of the training was to provide them with standardized competence and qualification of the inter-agency standing committee guidelines on mental health and psychosocial support in emergency settings. I have a huge empathy toward the survivors of natural disasters but I resent the melodrama of learned helplessness. Mental health professionals must be standardized.

Didier Fassin, in his book “Humanitarian Reason: A Moral History of the Present,” wrote: “The tsunami that hit South Asia on December 26, 2004, causing the death of more than 285,000 people and sparking a campaign that resulted in donations estimated at more than 5 billion euros [$5.26 million], dramatically highlighted the historical fact that natural disasters, insofar as they represent both the most massive (in terms of numbers of victims) and the purest (being putatively beyond human control) of collective misfortune, belong to the modern moral universe.

“In short, natural disasters represent consensual parentheses in the flow of history, privileged moments in which solidarity is displayed, inequality is erased, and conflict suspended. For example, it was widely — although not quite convincingly — asserted that the tsunami seemed to obliterate the disparities of condition between Western tourists and local people in Phuket, Thailand, as well as the violence of the civil war in Banda Aceh, Indonesia. All that counted were the dead and the survivors — all, apparently, objects of the same solicitude. The fact that these are fleeting moments, and that the reality of inequality and conflict quickly reasserts itself, only underlines the moral and political exception that these events represent.”

In 2011, I formed a focus group discussion with 30 experts ranging from psychiatrists, psychologists, community mental health nurses, health experts, human rights commissioners, social workers and so on and so forth, who shared the same belief about the urgency of a mental health law. These knowledge, expertise, ideas and experiences were then formulated into an academic paper that was later used as the prerequisite to inquire the Mental Health Bill to be extracted from the National Legislation Program into a priority bill to be discussed in the relevant commission.

The FGD took four months and I asked a legal drafter to take part in the process. Unfortunately the cost of a legal drafter was very expensive. I asked for a 75 percent discount from the original fee they proposed. After three years in the House, in 2012 the Democratic Party assigned me as the deputy chairwoman for the health and manpower commission. This was a blessing to jump-start the Mental Health Bill’s push into law.

In 2013, the Health Ministry released its latest findings in the Basic Health Research that the number of people with mental disorders who were being restrained had increased from the previous 18,000 to 56,000. It was a devastating fact. I decided to launch another model project for outreach to society. I chose May 20 because it marked the commemoration of the National Awakening Day and the Indonesian Doctors Devotion Day. I launched a mobile mental health service program.

The model project in the early stages was tested in the Jakarta area, taking into account that the highest prevalence of severe mental disorders are in the region. Al Jazeera television made a feature report about my model project. Then in 2014 came the eruption of Mount Kelud. Two weeks before the eruption, I set out with Eka Viora, the Health Ministry’s director of mental health, to prepare another PFA training.

Unfortunately while it was in the process of preparation, the eruption occurred much earlier. The MMHS units also had not been dispatched to the location. My staff were on site while setting up posts for women and children. They could not get out and I certainly could not get in. Airports were closed. A day after the eruption, I set out to the region with the presidential entourage and we took the train following the closure of certain airports due to the eruptions. After the presidential visit, the units were dispatched to train the nurses and doctors while also visiting remote villages in Blitar district to meet with students.

My energy and belief was contagious. With the help of fellow legislators and expert staff, I managed to pass the Mental Health Bill into law on July 18, 2014. I plunged into the fountain in the parliamentary complex after the bill was passed into law. The legislation initiative has been approved and codified in law and is being monitored for implementation.

What is particular about the Indonesian Mental Health Law? The Mental Health Law, or Law No. 18/2014, is ambitious in playing its role as a new foundation for the Indonesian mental health system. It consists of 10 chapters: general provisions; mental health care; mental health care system; resources in mental health care delivery; rights and obligations; mental health examination; duties, responsibilities and authority; community participation; criminal provisions; and concluding provisions.

In the general provision chapter, we define a person with a mental problem, or PWMP, and a person with mental disorder, or PWMD, in relation to chapter 2, which regulates that mental health care consists of promotive, preventive, curative, and rehabilitative. With a limited number of mental health professionals (1.07 per 100,000 citizens, or a total of 773 psychiatrists, 451 clinical psychologists and 6,500 mental health nurses), and the mental health budget less than  1 percent of the total health budget, as the chair of the working committee on the drafting of the Mental Health Bill, I explored ideas on how to get more professionals to help this new mental health system to work for our population of approximately 250 million people. We agreed on the fact that the diagnosis process was key, and could not rely on psychiatrists alone, taking into account the limited number of psychiatrists.

Diagnosis is carried out based on the diagnostic criteria by a general medical practitioner, a psychologist or a psychiatrist. We invite psychologists to work in clinical settings, especially the primary health care setting. Treatment of the mental health of a PWMD is performed at a mental health care facility, in general hospital must be integrated to general health care, and through a referral system.

Another interesting fact is the need for medication to salvage the people with mental disorders from being treated with false interpretations by spiritual healers (in some cases, to them, people with mental disorders do not need psychiatrists and take patients into their own hands) and violations of human rights by shelters (shelters allowing malnutrition cases leading to death, or the use of physical restraints such as chains, scaring with snakes, etc.). It becomes problematic when there is exclusivity and rejecting complementary existence. But we should condemn the violations of human rights in shelters especially if the effort to educate the owner has been done. We still do not allow the use of methods other than medical science to be practiced within the medical setting. But outside the medical settings, it’s happening out there. We try to regulate this in the law.

Treatment of a PWMD using methods other than medical science may be performed only if such treatments are fostered and overseen by the government and regional government to ensure that their efficacy and safety can be accounted for. Further provisions regarding treatment for PWMD using methods other than medical science is set forth in a government regulation.

Another important aspect in this law is the role in decriminalization of the people who are victims by misusing/abusing narcotics, psychotropic drugs and addictive substances. To decriminalize is not to deny their rights to medical treatment and to prevent the overcrowding of penitentiaries or jails. We regulate this in a chapter overseeing the resources in mental health care that every mental hospital shall provide a ward for patients who suffer from narcotic or psychotropic drug or addictive substance abuse with at least 10 percent of the total number of beds available at such a facility. Beds must include facilities.

Our mental health law is comprehensive by also regulating the mental health examination for law enforcement purpose and for the purpose of employment. We want people with mental disorders to be protected in the hospital setting by clearly stating in the law that every government-operated mental hospital and provincial government-operated mental hospital must be equipped with at least one treatment ward having a safety level that satisfies the applicable standards.

As in psychiatric examination for the purpose of employment or assumption of particular position, this law regulates the need for examination before, during (periodically), and after being in particular position. The exam itself consists of intelligence profile, personality profile and psychopathology potential and/or other specific potentials. This exam is not to be overgeneralized because we do not want to further the stigma by discriminating the PWMD from being employed. However, the implementation should not be misguided. The implementing regulation should be very clear on what professions needing this examination. Emphasis on people’s safety is also necessary to prevent a tragedy similar to the Germanwings.

How about the practice of shackling/caging/locking? We cannot punish families and shelters with good intentions without having the government take full responsibility in implementing the mental health law itself. Thus in chapter IX regarding the criminal provision, despite our restlessness in witnessing the harrowing fact, we came up with this article for the current situation: Any person intentionally shackling, neglecting, committing violence against and/or causing others to shackle, neglect or commit violence against a PWMP and PWMD or any other action that violates the human rights of a PWMP and PWMD is subject to criminal punishment in accordance with the applicable laws and regulations.

In regards to the government’s roles in implementing the mental health law, we put them in the concluding provisions. This is key to be understood by the public that the implementing regulations of this law must be enacted by no later than one year following the enactment of this law, which is  three months from now. Will we arrive on time? I am skeptical. Although I am no longer a member of parliament, I still speak in public discussions to build the awareness and introduce the Mental Health Law.  Thus far, the director of mental health at the Health Ministry is still in contact with me. She informs me of the progress of the implementing regulations and also the active role of the Health Ministry of the Republic of Indonesia in the global mental health movement by supporting the post-2015 call to action to include mental health in the Sustainable Development Goals (SDGs).

The minister of health of the Republic of Indonesia has sent a letter to the minister of foreign affairs, who will discuss the final SDGs this month in New York. But then again, why do we need a global mental health target in the SDGs? Are the following reasons relevant to Indonesia’s case? 1) High prevalence: One in four people experiences mental illness; 2) Global emergency: Human rights violations, stigma and discrimination; and 3) Growing burden of disease: Reduced lifespan by up to 20 years. Indeed there is relevance in different scales, but with all the hustle and bustle of being overly involved in the global mental health movement, would not it be more appropriate if we do our homework first?

Nova Riyanti Yusuf is former Indonesian legislator and currently a visiting scientist at the Harvard Medical School. This article was previously presented at a seminar of the Indonesia Club at Harvard and Harvard Kennedy School Indonesia Program on April 1, as well as at the Society for Psychological Anthropology Biennial at OMNI Parker House, Boston, on April 10.