On call: RSJ has 165 nurses for its current 280 patients.A visit to Rumah Sakit Jiwa Bangli (Bali’s RSJ) is an eye opener. The imagined horror stories of a mental hospital in a developing nation were not in existence when The Jakarta Post dropped in on just two hours notice to the RSJ recently.
Following an interview with hospital director, Made Sugiharta Yasa, who took up the role in late 2010, the Post was welcomed to visit all areas of the hospital and ask questions without censorship; the hospital’s only request was that, out of respect, patients faces were not photographed.
There are no high fences at Bali’s hospital for the mentally ill, visitors are welcomed by patients and staff alike. Set amid gardens the hospital is surprisingly calming.
Twenty-three-year-old Edy from Gilimanuk met us near the front gate. Delusional but functioning, he said he was waiting to be picked up to go home.
“I came here a month ago because I could not sleep and I was kicking people. I have been here about five times now. Yes I can sleep really well again. I am getting better, but I want to go home,” says Edy, cadging a cigarette before putting aside his fantasy of going home just yet, heading off to the kitchen for lunch instead.
Mental health nurse of 26 years, Nyoman Arta, explains that when patients are well enough and responding to treatment, they are free to wander the gardens and visit the kitchens, the hospital reception area and run the hospital’s farm.
“It’s beautiful in the mornings to see the patients harvesting the fields or gathering grass for the cattle and then sit and rest by the lily pond after working, it’s like they are home,” says Nyoman, adding “patients can wander around like they are in their own village, they help themselves to food and work together,” says Nyoman.
Nyoman began his career in mental health because “we nurses choose to do this to be humane — these are people who need our care. When they come here they are so very sick in body and mind; in the end after a few weeks to a month they are getting well and have started to relax and make new friends. My heart feels full when I see patients getting well.”
The hospital has success stories even with cruelly ill patients, such as a current patient who had been placed in stocks (pasung) for more than a decade.
“When she was in the pasung she couldn’t eat, she couldn’t speak, she could not walk. When she first came to hospital she could not go to the toilet because in the pasung she urinated and evacuated her bowels where she sat. She did not know how to bathe or toilet herself. That was seven months ago.
Even though she is still very thin she has now put on weight, she can walk and use the bathroom and is talking with other patients. She can even sweep the floors as part of her therapy, but she is still terribly ill,” says Nurse Desak Putri Seriasa who has worked at the hospital for 20 years.
During 2010, RSJ released and treated 41 pasung victims.
“Of these 30 are now home and doing well. None have been returned to pasung,” says hospital director, Made Sugiharta Yasa.
Nurse Nyoman says he has never gotten over the horror of finding patients in pasung. “When I see people in pasung I feel broken hearted; I think what can I do to help this person — I don’t sleep. I started this job to help people.
“By the end of 2011 the governor [Made Mangku Pastika] has decreed every pasung victim must be released, treated properly and re-housed. That is regardless of family objections. We will try gentle persuasion first and if that does not work, we will use the law,” says nurse Nyoman of the hospital’s estimated 114 to 152 people still locked in pasung, chained or caged across Bali.
Nationwide Indonesia’s health department believes pasung victim numbers are between 10,000 and 26,000 across 5,263 districts according to the Post’s 2010 report “RI to abolish pasung practice by 2014”. The drive for their discovery and release comes from director of community development and services for mental health for the Health Ministry, Irmansyah.
Families of mentally disturbed people are sometimes deeply lacking in care says Nurse Nyoman who is tender with the patients under his care.
“Some families treat them [mentally ill] like garbage — they don’t want to ever take them home,” he says with emotion.
The hospital says it can demand the release of pasung victims and Bali’s Governor Made Mangku Pastika has decreed that the estimated 114 to 152 in pasung across Bali must be released this year, 2011. However the case Gede Budayasa proves this is not always the case. Budayasa has been held in wooden stocks for almost 10 years. His family refuses to release him into the care of the hospital.
Reports to Bali government staffers on the decade-long pasung victim from Buleleng have not yet met any response.
“We can force to take these people [from pasung] and treat them in the hospital, but we need to build relationships with the family for when they are retuned home. So with building safe houses for poor families with a mentally disturbed person, families can learn that if a patient becomes agitated they can be locked up safely in these homes. People like Gede would have a lockable home,” says Made of the plan to build more than 100 safe houses in villages across Bali for the mentally disturbed following hospital treatment.
Made stresses initial treatment should be given in hospital so patients can be properly monitored for drug reactions and evaluation. With 90 percent of presentations for mental illness diagnosed as schizophrenia, monitoring for side effects to extremely powerful antipsychotic drugs is vital. Side effects can include seizures, orbital rotation of the eyes, lack of breath and Parkinson’s disease-like shaking that can become permanent if not rapidly addressed.
The hospital has developed an outreach program for follow up of patients and discovery of new patients. Two doctors daily visit mentally ill in their regions and the hospital also works with local clinics, known as Puskesmas.
“Every month we visit Puskesmas across 30 towns. This year that will increase to 46 towns. We work with local staff there and have knowledge transfer so they understand patients with mental illness in their districts. The Puskesmas are ideal because they are so closely linked to local communities,” says Made.
He says the hospital has ample funding for its new programs and building work on a new hospital will begin this year.
“This is the only governor [Made Mangku Pastika] who has paid attention to the issue of mental illness and works directly with us. We have adequate funding and a new hospital costing more than Rp 100 billion is budgeted for,” says Made of the improvements being made in Bali’s mental health services.
The hospital is currently home to 280 patients and has a nursing staff of 165 along with 20 doctors.
This gives a round the clock ratio of just five patients to one nurse, “better that we have in Australia,” says a registered mental health nurse, Sister Jenny Hanley who has worked with mentally ill for the past 30 years.
Beds available: Rumah Sakit Jiwa Bangli (Bali’s RSJ) is spotlessly clean and patients report being well cared for.“I remember in Australia when we were seeing children who had been locked in a cupboard under the kitchen sink. They were crippled by the time they were brought to hospital, but that is gone now,” she says of the fear mental illness creates in people from all different backgrounds.
Made stresses all medical treatment for the mentally ill is completely free, including medicines and hospital stays.
He also points out every public hospital across Bali must under law dedicate 10 percent of its beds for people suffering acute psychosis and all medication and nursing must be given free of charge.
As part of its therapy regimen the hospital has sports, creative activities, a singing group and chores that give the patients a sense of responsibility, preparing them well for their return to their communities.
Despite these resources and government efforts, families of pasung victims continue to have the final say over the lives of the mentally ill. RSJ attempted last week to have Gede Budayasa released into its care; his family refused as they have done also with home and community psychiatric care NGO, the Suryani Institute and police. The family have not been arrested for its decade long torture and brutality of Budayasa.
— Photos by J.B. Djwan
