The Indonesian
government is challenged by an ever increasing population, a reluctance of
physicians to practice in remote areas, and a lack of funds to modernize existing
facilities or to build new medical facilities. As a result, the government
hospitals are overcrowded, terrifying places, where families are at the mercy
of the staff, and from which patients beg to come home. While the hospital is
not necessarily seen as a remnant of colonial domination, it is still an
institution foreign to Javanese culture, and every attempt is made on the part
of the families of the patients and (and sometimes staff) to allow for elements
that make care in the hospital more culturally acceptable. Lower-class families
cowed by the educated and imperious staff receive little information about the
prognosis of their patient, but can busy themselves with helping keep their
patient clean, calm and well fed, and with prayer: there are good-sized mosques
at every government hospital and Christian chapels at some.
Although family
members with the resources can request a private (non
intensive care) room with an extra bed for a family member, and can also
choose to receive hospital meals, people will bring cooked food and snacks from
home for the patient and their visitors. Outdoor open-air pavilions house the
families of patients who do not have private rooms, but with untold people
sleeping on mats one next to the other, using scant public bathrooms, and
visiting patients with communicable diseases freely and with no attempt to
control contagion, sanitation is suspect; conditions seem chaotic; and despair
is seen on many faces. Even in the birthing wards, the most cheerful area of
any hospital, in the "baby seasons" that follow like clockwork nine
months after the two months of the Javanese year deemed particularly auspicious
for weddings, beds are placed so closely together that they touch, and
sometimes women are two to a bed.
The perception exists
that while people do not die from treatment by a dukun or a kyai, people can be
killed by the treatment they receive from the doctors and nurses at the
hospital. The fact that the patients are brought in in extremis, as a last
resort, does nothing to dispel this perception.
The mental hospitals
inspire their own form of horror: a fundamental fear of human beings who have
lost the control of themselves that defines them as human in Javanese culture.
The government mental hospitals face even greater funding constraints than the
general hospitals, and despite very dedicated doctors, often staff are poorly
trained and spread too thinly. These institutions are for the violent, the
psychotic, those the families can no longer handle without tying them up or
locking them in a shed or a bamboo cage. The option for free treatment for the
impoverished inspires many families to bring in their patients; the shame that
a mentally ill family member brings to a fami1y also helps the institution
become a viable option. The private mental hospitals, like private
general or birthing hospitals, have a much more pleasant environment and cater
to patients who check themselves in by choice, to partake in a kind of rest
cure, but the truly economically and emotionally desperate usually end up
housed in the government mental hospitals, helpless and hopeless.
The
development of a formal health care system in
Indonesia
In 1621 the Verenigde Oost-Indische Compagnie
(imitating the British, the Dutch East Indies Company, commonly known as the
VOC, or just "the Company"), built a fortress in Batavia (in the area
of what is now Jakarta) as the local station for their lucrative trade between
the Netherlands and the islands of Indonesia then known as the East Indies.1 In
1626 they built the first hospital near the fort, to help heal the sick and
wounded sailors and traders, in order that they could more quickly return to
making money for the VOC (Sciortino 1996:24-25).
More hospitals
eventually followed: in 1648 a small hospital was founded on the island of
Ambon; in 1715 a small hospital was established on the island of Sulawesi at Makasar; another near the original fort in 1779; and a
military hospital at Weltevreden in 1800. Small
medical posts were set up over the same time period, scattered over the Dutch
trade areas in the Indonesian archipelago on the island of Sumatra, in the
Spice Islands and the Moluccas (Schoute 1937 quoted
in Sciortino 1996:25). The VOC went bankrupt and was
formally dissolved in 1800, and its territorial possessions-including
infrastructure and trade networks in Indonesia - became the property of the
Dutch government. Many of the small medical posts closed, and the hospitals
that were kept open "stagnated and deteriorated" (Schoute
1937 quoted in Sciortino 1996:27).
During the whole of
the 19th century, medical care in what was then the Dutch East Indies was run
by the military medical service, and was aimed at maintaining the health of
armies, the civil administration, traders and planters, with little concern for
the indigenous population (with the exception of the period of 1811-1816 when
the-English briefly ruled the area). There were very few medical officers for
such a large area: no more than 130-160 stationed there (mostly in Java) on the
average over the 19th century (van Heteren 1996: 8).
Although many of the medical officers only had honorary medical degrees, they
gained important medical knowledge in the areas of epidemiology, parasitology,
and bacteriology-especially with reference to tropical diseases such as
typhoid, dysentery, cholera, malaria, and hookworm. While working to keep the
troops healthy, they performed research into nutrition and vitamins, hygiene
and public health.3 In 1820 the military underwent a major reorganization, and
with the medical system under new management, a couple of new institutions were
set up to serve the non military European poor and
the' indigenous population, but they quickly became "neglected shelters
for all kinds of marginal people, such as prostitutes, prisoners, the mentally
ill, and mendicants" (Sciortino 1996:29).
The Dutch did however
relatively little in the field of public health in Indonesia prior to 1910,
with the exception of giving smallpox vaccinations. Public health policy was
non-existent under the colonial administration, except for a vaccination
campaign in the early 1900s (Connor 1982:50). However, the obvious need for
more medical aid led to the call for indigenous medical help, which led the
Dutch chief medical officer in 1851 to open the Dokter
Djawaschool for Javanese noble-class men who could
read and write Malay (cf. de Moulin 1989: 27), with the intention that they
would learn some medical skills, and return to their area of origin to practice
on their fellow Javanese, and 50 Javanese gentry were trained as doctors and
nurses to serve the urban and village sick. In the 1890s, the official
recognition of the natives as an important factor in economic development
caused a shift in the focus of the training of the indigenous doctors (Worboys 1989: 153-155). Soon the school was reorganized and
additional tutelage in the. natural sciences, including anatomy and physiology
(which required the dissection of corpses), physics, geology, and hygiene was
offered, and an extended clinical residency was required in which students
practiced pathology, surgery, and wound dressing. In 1899 the school was
renamed School Tot Opleiding van lndische
Artsen (known as STOVIA, Training School for Indian
Physicians).
In 1901 in Indonesia
there was one doctor per 560,000 inhabitants, while in Europe the average ratio
was one doctor for every 2000 people (Sciortino'
1996:35). Despite the fact that the Western system of medicine was not totally
accepted by the indigenous Indonesians (in fact they were suspicious of the
motives for the inoculations, and found the hospitals to be quite unpleasantly
foreign), political thinking in the Netherlands started to produce new colonial
policies that centered on the idea of the moral duty of the colonists to
improve the life of the colonized-the so-called "ethical policy"
-instituted in 1901.This policy led them to consider it no longer justifiable
to reserve medical treatment for the wealthy few, or treat people only during
epidemics. So a flurry of building ensued, with new hospitals built in major
urban centers, and old hospitals refurbished (Sciortino
1996:32-43).
In 1925 then Public
Health Service was formed; and the health system was decentralized, placing
responsibility for running the health centers with local, lower, administrations
in provinces, regencies and districts (Sciortino
1996:42). And a more elaborate public health care infrastructure developed by
1939, but this public health system collapsed after the Japanese invasion in
1942. The Japanese colonized Indonesia from March of 1942 to August of 1945.
All over the archipelago, large buildings like schools and hospitals were taken
over and used by the Japanese. During World War Two, mortality rose
dramatically and the general health situation of the country deteriorated
(Frederick and Worden 1993:131). In the postwar period, a network of community
health centers was established, but resources were still extremely limited. The
network of medical institutions in Indonesia followed the Dutch colonial
economic development: hospitals were set up in major urban areas only. In the
1950s and 1960s, birthing hospitals, anti-smallpox campaigns and other public
health programs were developed. In the 1970s, many community health centers
(Pusat Kesehatan Masyarakilt) were set up to help
provide the low-cost, basic primary health care that was required by World
Health Organization policy of that era (Connor: 1982:51). These puskesmas, as they are known, helped decentralize medical
care, but rarely were any of them staffed by a psychiatrist.
Despite the fact that
direct central government spending on health fell by 45 percent between 1982
and 1987 because of declining revenues from the oil industry (Frederick and
Worden 1993:132), and that the country has been hard hit in the economic sector
due to political upheaval, natural disasters, and the Asian monetary crisis of
the 1990s, health in Indonesia has shown improvement: life expectancies have
risen almost ten years since the 1970s, and infant mortality has declined
(Frederick and Worden 1993:129; WHO Country Health Profile-Indonesia 2003).
Health insurance is becoming increasingly common: a 1992 law required all
employers with more than ten employees to provide health insurance; free health
care for government employees has set the standard for corporate employers, who
now generally provide a health insurance benefit for their employees; and
factories have on site private clinics. But the actual infrastructure has not
been greatly enhanced; the Indonesian government has continued the Dutch
colonial pattern of low investment in health care, not spending even as much as
other Southeast Asian nations on supporting the health care system. The rural
poor, especially those on islands other than Java, have much less access to
cosmopolitan health care than their urban neighbors, and the ratio of hospital
beds of 0.06 per 1000 population hasn't changed since the late 1980s and
continues to be the lowest among Southeast Asian nations (Frederick and Worden
1993:129; WHO Country Health Profile-Indonesia 2003). In the following table we
can see some of the pertinent health statistics for Indonesia culled from the
most recent sources available: 1998 statistics from the Indonesian Ministry of
Health Center for Health Data, Indonesia HealtProfile
1999 Jakarta, February 2000, and from the World Health Organization Country
Health Profile-Indonesia. Although comparing statistics from a developing
nation with a developed nation may have little instructive value, it serves to
demonstrate the vast differences in resources that can be brought to bear in
the health sector, and the concomitant effects on the health. of a population.
It is very difficult
to get accurate statistics in Indonesia since there exists a universal practice
of fixing the statistics at a local level to conform to central government
policy and goals. My students who chose health care as a research topic in
Java, Bali, Sulawesi, and Madura regularly were offered or were shown when
asked two sets of books that local clinics or birthing centers kept - one that
listed the actual patients seen and medications dispensed, or the other that
indicated compliance with national goals. This common practice is what Sciortino describes as 1/ a socially accepted way of
handling a situation wherein the health workers are unable to deal with all the
tasks they are called upon to perform by a health policy defined according to
international and national ideals, a policy which does not take into account
the actual capacity of the health center and its staff" (Sciortino 1995:147). This makes it very difficult to
extract accurate information, but nonetheless the general situation is obvious.
Government and
private health care facilities, like many of the other resources in Indonesia,
are most readily available and most developed in Java. The outer islands still
continue to suffer a severe shortage of physicians and hospitals, despite the
fact that they are the places often most hard hit by natural disasters,
economic crises, political or ethnic conflict, and are all deeply impoverished.
In 1961 the first
private mental hospital opened in Jakarta, followed by others (three more in
Jakarta by 1971, and other private facilities in Yogjakarta
and Surabaya in Java, and in Medan in Sumatra). These facilities, and the developing
health department, began to focus on preventative measures, rehabilitation and
paramedic education, rather than simply control of aggressive, impulsive and
destructive" patients (Setyonegoro
1976a:83).They began work that included university researchers, mental health
workers, and communities surrounding the mental hospitals, which was intended
to help develop society's understanding and acceptance of mental illness. In
1966 then a major law was passed which legislated
funding for the Directorat Kesehatan Jiwa, and
established sub-directorates for promotion, prevention, service and curing,
rehabilitation, research and data collection, and a position of the head of
administration that would handle personnel, budgets, planning and supplies (Setyonegoro 1976a:84-85, 1976b:20-21). It explicitly
identified problems of industrialization, urbanization and modem technology to
be addressed by this directorate, along with other problems such as juvenile
delinquency, mental retardation, narcotic addiction, individual or group panic,
and mob violence (Setyonegoro 1976b:21; Maramis 1998:17-18).
In 1971 when Setyonegoro took over the directorship of the department of
mental health, other new laws were instituted, which stated that if a psychotic
individual was brought to or picked up by the police, the police were required
to bring the patient to the mental hospital, and the cost of their treatment
would be paid by the Dinas Social DK Jaya (a social welfare agency). The Badan Koordinasi Rehabilitasi Penderita Patien Jiwa
(Coordinating Agency for the Rehabilitation of Mental Patients) was formed to
come up with ways to speed up the return of mental patients to their homes, to
help find them jobs where they would be „ free or protected", and to
determine how the institutions could follow up on released mental patients.
This group included members from the departments of Social (Welfare), Labor,
Transmigration, Industry, and members of the faculty of psychiatry from the
University of Indonesia (Setyonegoro 1976b:10-11). By
1975 there were 40 psychiatrists and about 60 general doctors, some of whom
were continuing their education at medical schools in Jakarta and Surabaya for
psychiatry (Setyonegoro 1976a:87). The function of
the mental hospitals underwent a change, from the Dutch model of simply
custodial care to developing in the areas of mental health promotion,
vocational rehabilitation, and "psychopharmaceutical, psychosocial, and
psycho-cultural research" (Setyonegoro
1976a:89). In 1974 the directorate started work to integrate the puskesmas local health clinics into the mental health
services system, and published the first edition of the Buku
.Pedoman Kesehatan Jiwa Untuk
Puskesmas (Manual for Mental Health for the Puskesmas) a kind of basic manual for identifying and
treating the mentally ill for the doctors, nurses and social workers that
staffed these small local health centers. The puskesmas
staff were still, and continue to be, encouraged to consider themselves a
back-up or resource facility, and to send any emergency cases of / adolescent
crisis, family crises, psychotic episodes or suicide attempts, rapes, extreme
anxiety or any other condition that requires a psychiatrist" to the
nearest formal mental health facility, which had grown to include a mental
health section of the Army hospital(s), and the private mental hospitals and
clinics (Setyonegoro 1976a:92).
In an attempt to
ensure consistent and uniform diagnoses, the Directorat
held a Seminar Kesehatan Nasional (national health seminar) in 1973 to discuss
diagnostic categories and methods of diagnosis, and the results of this seminar
were sent to mental health facilities and educational institutions all over
Indonesia. This developed into a Buku Pedoman Gangguan Jiwa Indonesia
(Guide to Mental Illnesses in Indonesia) which was published in 1975 and
continues to be used today, in an attempt to systematize and unify diagnosis
and treatment country-wide (Setyonegoro 1976b:15).
Various projects have been instituted to collect statistics on the epidemiology
of mental illness, and to evaluate the efficacy of various facilities. Some of
the more interesting of these projects were research into the social background
of outpatients in Java and Bali, research into the marital conflicts that
result in divorce in Medan, and the effects of tourism on the mental health of
the Balinese (Setyonegoro 1976b:15-19). The
development of anti-anxiety medications, anti-depressants and anti psychotic medications that began in the 1950s
instigated a collaboration among psychiatrists, psychopharmacologists and
biochemists, in an effort to treat patients more effectively and more humanely.
However, the "Electro convulsion Apparatus" was still considered.
vital to treat some patients (Setyonegoro1976a:94-95). The goal became not just
to contain the patients someplace where they' would not present a danger to
themselves or otherbut to "send them home as
quickly as possible so that they could return to being an active part of
society's activities"; the statistics showed that approximately 40 percent
of mental patients in government hospitals were staying there more than a year
(Setyonegoro 1976b:13).
In the 1990s the
Indonesian government developed various programs and projects designed' to
expand coverage of the mental health services and develop and revitalize mental
health services and facilities. This undertaking can be seen from the example
of one educational program that delivered training for personnel from 661
health centers, 437 general hospitals, and almost 5000 various seminars or
activities designed to provide guidance to health workers on how best to deal
with the mentally ill (Setiawan 1999/2001:6-7). A 1992 law defining mental
health (Setiawan undated paper circa 1999:1) outlined the
decentralization of the administration of mental health services, causing
concern that the mental hospitals will be forced to provide more general health
services in an attempt to help generate revenue for the area government
services, according to psychiatrist Dr. Aminullah,
the head of the Union of Indonesian Mental Hospitals (quoted in Dahuri 2002:1).
By 2006 when we did
this research, there were 34 government mental hospitals (including one
hospital for drug dependence) in 24 provinces out of the 30 provinces of
Indonesia, and less than 30 small private mental hospitals. Huge provinces that
still do not have mental hospitals are Central Kalimantan (Borneo), East Nusa
Tenggara (the many islands east of Bali), and East Timor. Out of 806 general
hospitals, 50% or 403 have mental health professionals working there (Setiawan
1999/2001:4). Out of nearly 20,000 community health centers across the
archipelago, only about 10% or 1852 health centers have any kind of mental
health professional available to consult with them on a regular basis, or
associated with them (Setiawan 1999/2001:4). Community health centers (puskesmas), with a physician as titular head but in effect
run by nurses, will refer psychiatric patients to the nearest government
hospital, where they might find a bed. The bed occupancy rate averages 90% in
government hospitals and 50% in private hospitals. However the patients in the
state mental hospital have no privacy, no entertainment, just three concrete
walls and a wall of bars that closes them in and opens them up for scrutiny to
whoever chooses to stare at them. The well-groomed expansive grounds look
peaceful and welcoming to the Western eye (once one gets past the guard posts
and the gates), but visitors are few and far between, and maybe it is just that
openness that creates in the Javanese a sense of eerie aloneness or
abandonment. Tiny barred windows face the parking lots and the green expanses
which surround the buildings; pristinely painted buildings echo the Dutch
colonial influence, and in some cases actually are converted military or
government buildings built in colonial times. Mental hospitals have a
completely different feel from the hospitals that typically treat the
physically ill: there home is brought to the patient in the hospital. Entire
families camp out near the room of the patient or in the special family
pavilions while they gather on their rattan mats, cook their familiar food, and
keep their vigil.
Patients are fed and
bathed by their own family members, with food, clothing and bedding brought
from their own home, and concern about disease vectors and community opinion
seem to be non-existent. The patient with no family to visit her or him, no one
to sleep in the bed next to them, are very much pitied, but even here the
mental wards are fenced no-man's-lands that are carefully avoided. Families of
physically ill patients are anxious to bring their loved ones home as soon as
possible, but families of the mentally ill seem only, 'too glad to be rid of
them. They are the willfully forgotten ones. Over a number of years I collected
about fifty articles from local and national newspapers pleading for citizens
to bring out their mad, to take their confused, catatonic, or caterwauling
family members to the state mental hospitals for free treatment rather than
locking them up ,in stocks. The shame, the horror, the potential impact on mate
selection and job possibilities and any kind of acceptance in the community for
their (other) children make the families desperate to hide the stigma of
madness. If the "bobot, bibit,
bebet" of a potential mate for a son or a
daughter, includes the existence of mental illness or other inheritable
diseases in the family I a marriage is out of the question.
Madness in the family
effectively negates the social future of a Javanese. The state mental
institutions "work" for the community and the family of the patient,
in that they restore order to the community; they remove a blight from the
family's existence; they erase a blot of shame from the family rolls (in fact
the family no longer even has to list the institutionalized mentally ill on the
government census card that lists the members of their household); they
eradicate a painful nuisance from the family compound; and they negate the
possibility of exposure of a shameful family secret. But do they work for the
patient? I suppose being locked up with others like yourself and receiving some
medicine on a regular basis has something to be said for it, especially if the
alternative is being constantly alone and bound' hand or foot. The prognosis
for these patients is not good but it seems that the curing of these patients
is not the point - control of the patients and a return of calm to their
community seems to be the priority in most cases. In the large government
mental institutions in Java they struggle with trying to get people to bring
out their mad, and trying to house them in as clean and comfortable, as
orderly, and yes, as secretive surroundings as is possible with the resources
the central government has allotted them. It is a hard and thankless job that
the doctors and other staff do at these state mental hospitals, but it is a
harder and even more hopeless place for the patients.
A distinguished
psychiatrist and director of the very humane Rumah Sakit Wikarta Mandala mental
hospital in Pujon, just outside of Malang (Java),
described the function of paternalism within his relationships with patients
and their families, and within his institution: For the person who is sick, we
want to work on awareness, to make the patient aware of themselves and the
world around them, the microcosm and the macrocosm. We do various therapies to
help them get back in touch with reality. In order to develop this, to
socialize patients, we use drugs, learning therapy, behavior modification -now
those are all very typical. But we don't just use psychotherapeutic counseling,
or Freudian psychotherapy, because Indonesians are not satisfied if we come to
a counselor asking for help and we are just asked to talk... we don't want to
say anything. The strategy that we use is that we have to instruct them: ok,
this is what you have said, this is what your problem is, and this is what you
have to do. If we give them non-directive measures, they don't understand why
they are just ordered to tell a story, we have to give them instructions about
how to behave and solve their problems, and that satisfies the Indonesian
client. .. The nurses are also encouraged to develop their potential, so that
we can trust them and be certain of their ability to deal with patients on a one-to-one
basis in a way that is like family, like sisters and brothers, just as the
doctors are very much like parents. The patients are treated with respect, so
that they do not have to be restrained or tied up or isolated, which we do not
practice. We train our nurses so that they do not have to be afraid of the
patients, and can treat them with respect, and know that they can control them
without restraints, with just their own knowledge and ability. We are confident
enough to deal with the patients as family; we guard the hierarchical
relationship within the idea of the family. We-doctors, patients and
nurses-guard the feeling of family. This works well in Indonesia because the
power and ideology (of family), the pattern of paternalism is very strong here
in Indonesia.
In fact the
tone of the communication a physician or psychiatrist selects to address his or
her clients and their families depends on two things: the setting, and the
social class of the client., Limited time and an unending stream of patients emands rapid treatment and quick consultations with nurses
or doctors on duty. Thus even desperately depressed and anxious patient is
dismissed after about three minutes of questions, and the family was simply
told to take them elsewhere, as the puskesmas
facilities were,inadequate. Physicians speak the
egalitarian Bahasa Indonesia, with sprinklings of English and Eriglish medical terms, but some will speak Javanese with
their patients, especially the elderly ones, and principally when important
information is being expressed and the doctor wants to avoid misunderstanding.
It is nor surprising therefore that Indonesian psychiatrists
express frustration with the nearly overwhelming forces of globalization,
modernization, social pressures and changes that they bring to a rapidly
changing, and stressed, population. For a patient diagnosed with psychotic
behavior, Browne found that the consultation is relatively brief, usually five
to ten minutes. For patients suffering from anxiety and depression, on the
average the sessions are a bit longer, the patients are encouraged to talk
more, and "sometimes a little psychotherapy is provided'(Browne
1999:216).Sessions at the psychiatrists'- private practices are much longer,
but still focused on very practical questions, inquiries less about how the
patients were feeling than about how well they were -managing to control their
anti-social behaviors. - Physical examination of patients presenting emotional
distress is minimal, and the only medical instruments are occasional use of the
stethoscope or he blood pressure gauge.
As we have seen this
is distinctly different from curing sessions with the kyai or the dukun. Like Sciortino's descriptions of clinical encounters with nurses
at the puskesmas, the patient of the psychiatrist
asks no questions, requires no interpretation of symptoms, and is given very
little information - they simply place their trust in the modem medical
knowledge and medicine mastered by the psychiatrist. But under the unquestioned
authority of the psychiatrist, Western medical theories and medicine also,
become sacred, or at least sacrosanct; all the rest of their treatment is
unrelentingly secular, with the exception of the religious therapy offered at
Dr. Soeyono's hospital, designed to make Western
psychiatric treatment culturally acceptable to the Indonesian client and their
family. Thus at the exemplary Rumah Saklt Wikarta Mandala in Pujon (pointing to a direction for other Indonesian
institutions to devellop into), all patients are
expected to join in group therapy every day of the week. Occasionally
dispensation is granted by the doctor, when requested by the patient, to be
excused from therapy for one or more days. The therapy includes music therapy
(singing individually and reading patient poetry with a band of two electric
guitars and a drum set, and singing and dancing as a group), dance therapy
(classic Indonesian as well as Western disco), group discussion, sports
(including hikes, swimming, volleyball), crafts (such as sewing and sculpting)
and cleaning therapy. (where the patients are supervised and given lessons in
how and why to keep themselves, their personal areas, and the hospital grounds
clean and neat). In the drama therapy, small plays are memorized and performed
from scripts written by the staff social worker and therapists, scripts that
serve as moral and practical object lessons in social conduct for the patients.
The patients are engaged in role-play with the therapists to reinforce or
relearn social integration. Various kinds of therapy encourage appropriate
integration into social structure; performing in scripts featuring typical
situations, patients are taught or retaught how to respond in a socially
acceptable manner, that is how to have social intercourse in a way, the Javanese
way, that never challenges the status quo, that is designed to maintain rukun with their family and community. Opportunities to
observe and practice Javanese rules of etiquette -tata krama and sopan santun-are modeled and
patients were coached in appropriate response to Javanese cues about hierarchy
and social distance.But they are also given the
opportunity to practice religious meditation of any kind, and are coached, if
they have reached an appropriate state of awareness, in Javanese kebatinan practice.
As we have seen in
general people are admitted to the mental institution by families who could not
control their violent behavior, or felt they were victims of demonic
possession, or admitted themselves for help with uncontrollable. stress. While
they were given medication, as far as we could determine there was no
institutional labeling of an individual's condition, no focus on development or
expression of self, or resolution of internal conflict, obsession or grief. If
they were at an institution that actually performed regular, organized therapy
with their patients, most were treated to an exploration of problems of
assimilation. Patients were involved in integrative group therapy, focused on
resocialization,-and the provision of a space in which the individual can rest
away from the society that so stigmatizes their condition. The physician's
literature reflects this difference in the Indonesian style of treatment, with
several doctors writing on the necessity of putting the person back in balance,and returning him to a harmonious relationship with
the others around them. The problem of mental illness, as Indonesian
psychiatrists see it, is not disorder of the individual personality (although
they use the term), but disorder within the particular brain chemistry or
social situation or spiritual condition (ie spirit
possession) of that individual. The majority of psychiatrists in Java are
unwilling or unable to adress the socio economic
factors and that may hasten the onset of mental illness, and limit themselves
to providing for their patients perscriptions that
presumably will help balance their brain chemistry. They don't have the time or
training to give patients much more than medicine. As a couple of doctors
admitted, the rest is best left to psychologists. This is a subtle but very
telling difference in the way Western psychiatric principles are interpreted,
and the best example of the way culture influences the clinical practice of
most Indonesian psychiatrists.
Conclusion: What we
have seen in the first parst of this investigation is
that traditional medicine is still robust part of the health-seeking process in
Indonesia, but may not produce universal, permanent cures. The cost of seeing a
dukun or a kyai can vary but it is necessarily cheap although he kyai is the
cheapest of all options. For the social scientist however, it is difficult to
obtain statistical information on the rates of paths of resort today in Java,
other than to determine that traditional medicine is still a valid option. In
fact many people today are embarrassed to confess their resort to kyai or dukun.Yet the Javanese feel that the dukun and the kyai are
somehow more altruistic than the doctors. Undeniably, they see a visit to
a doctor will engender a quick fix for many kinds of purely physical simple
ailments, but for the more complicated symptoms of mental illness, the dukun or
the kyai are the curers of choice for many Javanese.
Sciortino came to the same conclusion: "In general it can
be said that when they desire quick results they use one of the many public and
private biomedical options... But when they desire a treatment that truly
eliminates the causes of disease and does not merely suppress its symptoms,
they prefer traditional remedies" (1995:237). The temporary state of shock
and the symptoms of mental illness as it is culturally constructed in"
Java are often relieved by a visit with a kyai or a dukun, who help the
sufferer return to a "stable state of self-control, reclaim their personal
and social equilibrium, regain acceptance of fate or 'God's will', as it
reaffirm their religious or philosophical perspective.
Cures as socio-cultural constructions of identity
People are
simultaneously affected by all kinds of influences because they are at once
subject to social, cosmic and material forces. Each kind of influence on a
person is partial. None is considered by villagers to account for all
illnesses. D1nesses must be explained so that an appropriate remedy can. be
found... Explanations of illness are linked, explicitly, to therapeutic
choices. But these explanations have implications that extend beyond healing as
well. The actions people take to understand and cure illriess
also assert visions of a social world. Explanations of illness refer not simply
to 'what happened' to an afflicted person but serve, as well, to delineate a
person's place in specific social relations.-Stacy Pigg, Disenchanting shamans:
Representations of modernity and the transformation of healing in Nepal,
1990:262-274.
Indeed we have seen
that the cultural values that the Javanese have learned as children, the values
expressed in their home and neighborhood, their ethnic and religious identity
and affiliation, all affect the interpretation of symptoms and the paths of
resort to a curer. Javanese feel responsible for one another; family ties and
social obligations are extremely important since there is no national welfare
system in place.Through primarily private religious'
institutions like mosques, orphanages, pesantren
religious boarding schools and public schools, Javanese support the destitute
and give generously, and directly, to those worse off than themselves. The
philosophy and. practice of gotong royong (mutual help) and musyawarah
(consensus decision~making), cause the network of
social relations and the ethics of civil society to be quite strong. As
Javanese are involved in the community, so is the community often involved in
the lives of each Javanese family. The poorer the. neighborhood, the more
likely it is to be ethnically, religiously and econonUcally
homogenous, and the more likely it becomes that family decision-making will be
strongly influenced by' community opinion. Thus for the Javanese,
socio-cultural status often defines what kind of curer they will go to first,
and the type and level of symptoms will determine if the patient ever sees the
inside of a psychiatric hospital. The community may insist that their local
elected leader, the RT or the RW may intervene and institute the instruments of
social control if the symptoms of mental illness are violent or disturbing
enough that community rukun is repeatedly violated.
At that point the decision is effectively made for the family, when the agent
of disorder is removed to an institution. This path of resort is in many cases,
a path of last resort, simply resorting to storage and containment of the
disturbed individual with little or no hope for a cure.
While illness clearly
has an important semantic component (symptoms are culturally constructed in
meaningful ways) and clinical interaction has an interpretive dimension (e.g.,
physicians fit self reported patient symptoms into a
clinically meaningful diagnosis) it is necessary to analyze these processes in
terms of the role of culture in sustaining power and privilege. -Merrill Singer
and Hans Baer, Critical Medical Anthropology, 1995:269
While individual
class and ethnic identity are unchanging markers, social status is context
dependent. It can vary according to the class, age, gender, kinship relation,
education or position of power of the individual with whom a Javanese relates.
The language that one uses, the body posture, the gestures-indeed whether or
not another might even be addressed-is dependent on the politics of identity,
whom the Javanese must become in each encounter to conform to the unwritten
laws of social relations. For the Javanese, their social identity is a major
determinant of the paths of resort for medical treatment that they will pursue.
This is not as simple as identifying as villager or urbanite, as a Muslim or
non-Muslim, as a member of a particular gender or ethnic group. They have
something to do with economics and education, but these are not the only
determinants of difference. Very real social differences lie in the quality of
their religious beliefs and practices, the nexus of custom and belief that is
praxis. Different kinds of curers are associated with these degrees of social
difference, and the varieties of the curers' beliefs and practices reflect the
varieties of power recognized by the Javanese - religious power, supranatural
power, and institutional/ governmental power or the power of position. Unlike
other studies which suggest that increased education, rise in income and/ or
ascending social status reduce the level of belief in mystical, magical or
supernatural stuff, everyone in Java would agree that there is a level of our
world, or a world that coexists. with the world of our perceptions that is
beyond normal comprehension or even apprehension. However, the cosmology of
their mystical world will differ depending on the level of their commitment to,
internalization of and interpretation of Islam. And the likelihood that they
will choose a particular kind of curer will be tied not to their educational or
economic situation, but instead be often tied to their network of social
relations. In Java, the modem has not yet edged out the traditional. For
example, in many countries, as Pigg found in Nepal, urbanites have problems
accepting ghosts and spirits (pigg 1990:452) but not
in Java. Traditional Javanese ritual and fundamental Islamic belief are a large
part of even the largest cities in Indonesia. In East Java Islam seems to have
taken the strongest hold on the population, and more people are actually pious,
practicing Muslims than elsewhere in Java, but the Islam with its Sufistic
mystical flavor, makes the kind of meditation, trance and ascetic exercises
practiced by the dukun perfectly understandable, and makes the existence of
kyai who have developed powers through participation in similar practices
virtually guaranteed.
The psychiatrist
possesses the power of the ' moderen', of science, of
the institution; is much more likely to be of a different social class and
ethnicity from his client; and is the only curer whom the government would not
question if he confined his patient. The kyai possesses the ability to channel
the power of God. And the dukun with their paranormal powers, like the shaman
described by Levi-Strauss, "provides language" (1967:198) and
promotes reintegration for the patient, allowing mind, body, individual self
and society the chance to express their shared symbolic system. The individual
East Javanese will not consider each of these types of power as equal, equally valid,
or equally strong. Geertz's characterization of the Javanese health-seeking
process as "flailing" is mistaken: even if they are desperate,
Javanese will not grab at any straw. For the lower socio-economic classes,
hospitals are still where you go to die; they do not believe in the power of
science to diagnose or cure the extremely ill, but they won't all go to just
any kind of a traditional healer. However, how people choose to treat mental
illness depends on how they define and diagnose the symptoms, and on the social
milieu in which they live. When determining the potential efficacy of any kind
of cure, all. will depend on if the curer cocoks-fits--with
the individual patient, and for now the continuity of Javanese culture is still
there.
Psychiatry and Beliefs in Indonesia P.1
Psychiatry and Beliefs in Indonesia P.2
Psychiatry and Beliefs in Indonesia P.3:
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