The experience of people with mental disorders in social function adaptation after suffering from pasung

Abstract

Objective

Pasung is a physical restraint or confinement of people with mental disorders performed by non-professional members of society. It can cause various effects on people with mental disorders. Pasung can affect the people adaptation to functioning socially in society following the release from pasung. The purpose of this study was to describe the experience of people with mental disorders, post-pasung, in adapting to society

Method

This was a qualitative study, using a descriptive phenomenological approach. Purposive sampling was used to select the participants. Data were obtained though in-depth interviews with seven participants, and the data were analyzed by using Colaizzi's method.

Results

Pasung has a physical and psychosocial impact on people with mental disorders in adapting to society. The results of the study can be summarized by four themes: a) withdrawal from others as an initial manifestation of release from pasung; b) biopsychosocial changes after pasung that act as an impediment to performing a social function; c) improved social function through the optimization of support systems, and d) satisfaction with life as a result of social adaptation.

Conclusions

Increased social support is needed to optimize the social function of people with mental disorders, post-pasung.

Introduction

Pasung is a form of physical restraint or confinement conducted by family or the community on people with mental disorders, such as schizophrenia, who have aggressive behavior¹. The practice of pasung is conducted by chaining or tying an individual to something such as wood, a stake made from wood or hard objects as a form of restriction of movement; chaining or binding ankles to a stationary object; or locking an individual in a room²,³. The phenomenon remains unresolved in cases in Indonesia. The national average of people with severe mental disorders has reached 1.7/1000 of the population, and the proportion of families whose family members have ever experienced pasung has reached 14.3% and most of the individuals with mental disorders live in the countryside (18.2%)⁴. The duration of pasung⁵ has been applied to the individual with mental health is varied between 2 and 21 years¹ and 2 weeks to 28 years⁶. In addition to the definition of pasung, the perspective of the families of mentally ill patients about pasung in Indonesia was that pasung is a coping mechanism against the stress of a mental illness that it addresses security needs in the face of a family's powerlessness.

People with mental disorders who have been isolated by pasung for a long period can experience atrophy of the parts of their body that have been pasung. This can make them unable to stand, experience muscle contractures, suffer damage their organs, face the risk of infectious disease or the risk of death, and have a slow healing process. It can also lead to psychological problems and affect social rela-tionships⁷. In addition, it can lead to trauma, revenge on the family, feelings of abandonment, low self-esteem, hopelessness, and feelings of alienation and embarrassment. These prove the need for eliminating pasung⁸. The step to release pasung can be initiated by providing training to health care workers, and in the rehabilitation phase by providing occupational therapy so that those who have experienced pa-sung are able to adapt to their social environments⁹.

The adaptation of social function is the adjustment that people perform in their social environment after being released from pasung. The process of adaptation to a social environment is a challenge after pasung. This kind of adaptation covers the skills and performance having a role in society. Their ability to adapt is influenced by a variety of conditions, such as coping skills, sociodemography, social and psychological condition, as well as management of negative symptoms of schizophrenia¹⁰. The duration of pasung can affect the severity of negative symptoms and will affect ability in adaptation. Deep understanding of the experience of adaptation is expected, in order to broaden nurses' insight and to further develop strategies in providing appropriate therapy.

Method

This study used the qualitative research method with a phe-nomenological approach. The aim of this study was to describe the experience of people with mental disorders after experience pasung. The participants in this study were selected using the purposive sampling technique, with criteria of having been in pasung for a minimum period of three months after hospitalization for the mental disorder and never having experienced a relapse of mental disorder; being able to express their experience; and being aged between 18 and 60 years.

The method of data collection was an in-depth interview. It was conducted in accordance with the ethical principles of beneficence, respect for human dignity, and fairness¹⁰. This research obtained ethical clearance from the ethics committee of the Faculty of Nursing UI. The analysis of the data was conducted according to Colaizzi's method¹¹. The trustworthiness of this study was achieved through member-checking to ensure the themes come from the participants' experience, as well as discussion with the supervisors of this research. All these measures were taken to achieve the credibility, dependability, confirmability, and transferability¹² of this study.

Results

There were seven participants in this study. They consisted of one female and six males. They were adults, with ages ranging from 26 to 53 years old. The length of pasung they experienced varied from one week to three years, and the length of time they had been diagnosed with schizophrenia ranged from nine months to four years. The four themes generated in this study were: withdrawal from others as an initial manifestation of release from pasung; biopsychoso-cial changes after pasung that act as a impediment to performing social function; improved social function through the optimization of support systems; and satisfaction with life as a result of social adaptation. Each theme will be described below. All participants' quotes were translated from Bahasa Indonesia.

Theme 1: withdrawal from others as an initial manifestation of release from pasung

Withdrawal from others after pasung was observed by the subjects' expressions about the first thing they did after receiving treatment in hospital after being released from pa-sung. This theme was comprised of three categories; namely, introversion, avoiding interaction, and loneliness. The subjects expressed their introverted behavior through staying at home, as described in the following statement:

“For the first three weeks, I only stayed at home; after that I went out. I was willing to come up again, find a job, whatever, working odd jobs to smoke and have coffee” (IB).

Another behavior of withdrawal was described as avoiding interaction during the initial period after pasung. This avoidance was shown in the subjects' statements; one example is as follows:

“I have experienced pasung and isolation. Now, I feel ashamed to go anywhere; I do not dare to go anywhere” (MI).

This withdrawal behavior was experienced for varying lengths of time, but none of the subjects experienced it for more than a month. This variation in the time needed to start socialization is affected by the length of pasung, and the situation after it.

Theme 2: biopsychosocial changes after pasung that act as an impediment to performing social function

The inhibiting factors to performing social function were physical changes, which could include disability as the result of the deprivation, which caused the participants to have difficulties in social function adaptation. This was revealed by one participant in the following statement:

“I could not walk; I was lame, and it was abnormal, painful. I don't dare to go anywhere. After medication, and having massages, then I could walk” (MI).

Changes in psychology could involve feelings of shame, inferiority, and stress after the deprivation, as described by one participant's statement:

“It does not matter when I am unaware, but when I am aware, I feel ashamed after remembering that I was in pasung” (DD).

The changes to social aspects after the experience of pa-sung include participants' experiences of losing jobs, and not having people nearby. This can be seen in one participant's statement, as follows:

“Since I have been like this, people do not want to give me a job” (YN).

The changes encountered after pasung have caused the participants to face obstacles in their social activities. The physical changes require most of the participants' social activities to involve assistance by caregivers. Feeling embarrassed and clumsy in greeting people around them makes the participants stay at home, without making an effort to socialize with neighbors. This can be compounded by the absence of meaningful people during the deprivation, because it could cause a sadness that could culminate in self-blame. To escape from this condition, existing support systems need to be optimized.

Theme 3: improved social function through the optimization of support systems

The theme of improved social function through optimization of support systems is constructed of three sub-themes; namely, social function, the source of support, and the form of support. From the participants' experience, social function is consisted of three categories: ability to carry out daily activities, involvement in social activities, and social function regarding work.

Almost all of the participants expressed that they could carry out their daily activities at least three weeks after they were discharged from the hospital post-pasung, as seen in the statement below:

“Yeah, I clean the house, mop, cook, wash, just like that... sweep the yard” (YN).

The ability to get involved in social activities was made possible through interaction with surroundings and activities in society, as expressed in the statement below:

“I get used to accompany the security in their work, chatting there with Mr. U, Mr. D” (IB).

According to participants, the ability to implement social function is possible due to support from themselves, their families, and communities. This encouragement and care was presented by one participant in the following statement:

“There is support from my older brother, giving motivation” (IB).

The types of support provided were emotional and financial support. The support was expressed by the participants as something that could build their capacity in the adaptation of social function. One participant explained it this way:

“Every day, my father goes to work, so he can give me money. I can use the money as an asset [to start a company]” (MI).

The optimization of social function occurred due to the ability of the participants in performing their social functions through the support of various stakeholders. Inner strength plays an important role in determining their ability to perform social functions. With the emotional and financial support of family and society, the participants' ability to achieve satisfaction in life is further increased.

Theme 4: satisfaction with life as the result of social function adaptation

The theme of satisfaction with life as the result of social function adaptation was observed in four categories: quiet, helpful, positive thinking and self-awareness. One participant expressed this in the following way:

“Yeah, just feeling happy. Now I can be autonomous again, not depending on siblings, and can rely on my current job” (DY).

The achievement of participants' life satisfaction was also attributed to the mindset of prioritizing positive thinking by eliminating suspicions. Their ability to perform social function made them rediscover the meaning of life, and helped them change from feeling unable to do anything, to being useful to themselves and the people around them. The enhancement of life function enabled them to achieve life satisfaction. Self-awareness and feelings of serenity also contributed to life satisfaction.

Discussion

Withdrawal is a response for avoiding interactions with others. The response of withdrawal is in the range between adaptive and maladaptive responses¹³. People with mental disorders tend to be silent for some time as a form of adaptation to a new environment, and as a part of self-reflection. Being silent occurs because of the desire to be alone and have privacy, as well as the desire to postpone closer relationships so a more stable life can be reached¹⁴.

Another example of isolation was seen in the case of a participant who had been in pasung for three years. Pasung led to the decline of interest in social relationships. Experiencing pasung long-term and not getting appropriate treatment led to an increase in dopamine, which can kill nerve cells⁷. The damage on the nerve cells can interfere with cognitive, emotional, and verbal function.

The behavior of avoiding interactions is seen by participants feeling discouraged, or ashamed to interact with other people, and avoiding social activities. Feelings of loneliness occurred even with their families around them. Loneliness is not about the condition of loneliness itself, but rather the subjective experience of isolation. Therefore, to avoid prolonged isolation, an intervention strategy is necessary to help patients with their social activities. One strategy for improving social relationships is to approach patients with the aim of increasing support for them, in order to establish new social contacts and provide emotional support for their adaptation process¹⁵.

The process of pasung had an impact on some of the participants, such as physical, psychological and social changes. Physical changes post-pasung included scars on their bodies or caused by being tied or chained¹⁶. The condition during pasung on the physical disability could continue to the early days after pasung. Some participants experienced paralysis after pasung, which was caused by the restriction of movement on both legs. Pasung also caused psychological impact on the participants in this current study, caused by a loss of job and separation of the loved ones, as well as various other limitations that caused these individuals to experience barriers in their social function upon release from pasung. After monitoring of the individual who experienced pasung for three years, it was found that there was no significant change to the post-pasung patients' ability to work⁶. Another study found that people with mental disorders with more severe or evident diagnoses have more supporters that are aware of and sympathetic to the condition, but they are also vulnerable to rejection and discrimination by acquaintances or strangers¹⁷. This mental disorder condition was perceived by all participants, who expressed that close family felt sorry and concerned, but some other people felt afraid to mingle with them. The existence of this paradox causes people with mental disorders to require increased support in their social environment.

Family or caregiver support is the main support system, so family plays an important role in supporting social function. In patients with severe mental disorders, social support is channeled through the provision of public support, in order to improve their welfare and reduce symptoms of the disease¹⁸. The stressor, especially related to jobs, financial difficulties, interpersonal relationships, and social companionship make a substantial contribution to mental health¹⁹. The need for personal fulfillment led people with mental disorders post-pasung to begin thinking about, and having the motivation for, work. The desire for life satisfaction and other desires were able to motivate them to continuously work harder. Work was regarded by the participants as a way of relieving the symptoms of the disease experienced. A flurry of work would be perceived well by the participants, as the mind would focus on the job and the symptoms of the disease would not be felt. Work related to financial stability, and improved their social lives, self-esteem, integration into society, and symptoms, as well as decreased boredom and isolation²⁰. Nonetheless, work can also cause an increase in stress and fatigue, and a decrease in stamina.

The need for support for people with mental disorders in facing post-pasung life is urgent. According to Thoits²¹, support is usually obtained from family. The support comes either in the form of emotional support, or through the form of active coping, and from meaningful people and have the same problem could reduce the physical and emotional effects of stress²¹. Support from the government is urgently needed to improve health services, starting from hospitals to the health center level, and cooperation is needed from related sectors such as social services, including psychosocial and social rehabilitative services. The existence of support could improve people's satisfaction in performing social function.

The life satisfaction of the participants could be seen in the achievement of the social function achievement. Freedom is felt through the ability to run social function, as well as from experiencing changes in psychiatric symptoms. The ability to achieve basic necessary functions will lead people with mental disorders to operate independently, and to perform activities that can give them the feeling of having meaning in their lives.

The lives of people with mental disorders are hampered by various changes to their physical, psychological, and social lives after pasung. The involvement of families and communities in providing support will give optimal results in helping people with mental disorders to adapt to a social environment gradually, starting from fulfilling their daily activities to having their own income through work. The capabilities of people with mental disorders to address the development of their lives can help them experience satisfaction in living with all their limitations.

It is necessary to conduct further studies to further examine describe people with mental disorders after experiencing pasung, in order to measure the effects of nursing treatment on their ability to conduct social function adaptation in society.

Acknowledgement

We acknowledge Directorate of Research and Community Engagement Universitas Indonesia, which has provided funding for this research publication.

Conflicts of interest

The authors declare no conflicts of interest.