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Lost in Paradise: The Chained-Up Mentally Ill of Bali

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Not far from the glistening beaches of Bali, mentally ill people are kept in chains or locked up in small shacks. Locals simply don't know what else to do with them. But psychiatrist Luh Ketut Suryani has made it her job to set them free.

Before Luh Ketut Suryani leaves paradise, she applies lipstick in the rearview mirror of her SUV. Suryani wants to look good when she encounters the horrors of the day. On this particular morning, she selects a deep red color.

Then she takes her iPad from the passenger seat and spends a few minutes in preparation. Calmly moving her fingers across the screen, she reviews the medical histories of her patients, including their names, how long they have been kept locked up, and their diagnoses. Some of the case histories are 30 pages long, an attempt at order in the face of madness.

Komang, in chains for the last eight years: "A mother, in a shack next to the cowshed. After her divorce, she wandered naked through the village for nights on end."

Ketut, in chains for 19 years: "A construction worker, a bamboo cot in the jungle. One day he tried to kill his brother. No one knows why."

Kadek, locked up for the last 24 years.
Her hand stiffens.
"A farmer, a windowless shack. When her mother died, she took a knife and went into the street. There are worms eating their way through her stomach. Diagnosis: schizophrenia. She is dying."

Suryani, 68, with six sons and 17 grandchildren, is a pleasant woman with a face as round as the moon. She is a psychiatrist on the island of Bali, a vacation paradise for some, hell on earth for others.

Her patients cower next to trees, lie in shacks, and are abused and sometimes forgotten. Because their relatives are overwhelmed by the care they require, because the healthcare system doesn't work and because insanity is seen as a punishment by the gods, people with mental illness live like chained dogs in Bali. There are 350 such cases in Bali and up to 40,000 in all of Indonesia. The Balinese refer to them as "pasung," or "in chains."

Suryani has already freed 52 people. Komang is not one of them.

A Shack Next to the Cowshed

On this morning, Suryani drives to the northern part of the island. The roads circle around like the patterns on a snail shell, with rice terraces in various shades of green to the left and right. The palm trees are shrouded in fog, and it smells of rotten fruit and soil. The sun is high in the sky when she arrives at her destination near the mountain village of Lovina Beach.

Six families live there, together with their pigs and chickens. And then there is Komang, whose right wrist has been attached to a one-and-a-half-meter (five-foot) chain for the last eight years. The other end is attached to a post, in a shack next to the cowshed.

Komang, 26, is naked, cowering inside the hut. She is singing a song in a high-pitched voice. She pounds her fists against the wall. Perhaps she is trying to drive out the voices in her head. She also tries to drive out Suryani, who is standing in front of her door, next to a box of drugs. Suryani, perspiring, remains motionless. Eventually she says: "Psst, my child, it's okay."

The windowless hut, all two square meters (about 22 square feet) of it, is made of concrete. There are several items on the floor: a pink mat, a pair of underwear, a wooden plow, a toothbrush, a comb, a tape measure, an oil can and a nail brush. A bee's nest hangs from the ceiling. There is a trail of ants next to the mat.

Komang hasn't bathed in two months. She is unable to express what she thinks or what she needs. But when Suryani looks at her face, Komang returns her gaze.

"Komang is always naked," says the brother, whose body is muscular from hard work. He and his sister used to play together by the river and hide in the fields, and when Komang was afraid at night, he would hold her hand. He was the one who chained his sister when she ran away naked.

'An Evil Spirit'

The brother grows rice and soybeans, supporting his elderly mother, his disabled sister, his mentally ill brother and Komang. The family owns two bamboo huts. A meal of rice and greens is cooking on the fire. They subsist on the equivalent of €1.30 a day.

"Komang was a normal girl," says the mother. "But when she turned 12, she was possessed by an evil spirit."
The sister-in-law says: "She was married at 18. Her husband brought her back. He kept her child. She has been screaming ever since."
"Komang is with the cows," says the disabled sister.

"Bring me a chair," says Suryani. She often spends hours talking with the families before beginning treatment. She asks about the patients' symptoms, their childhood and whether they have nightmares. But many don't know what is wrong with their mentally ill family member, or why he or she began to change. One day the family member simply becomes unhinged. When that happens, the families lack the time to cope with the problems, and they are often helpless. They try to protect themselves from the sick individual and protect him or her from the anger of the community, which explains the chains.

Asia isn't the only place where pasung exists. The practice is also known in Somalia, Nigeria and Sudan, countries plagued by civil war or terror and possessed of poor infrastructure --societies in which people believe in spirits. Where money and knowledge are in short supply, the mentally ill are often treated like the festering discharge of the system that produced them. Some literally rot away while still alive.

But there are few places where tourists and pasung are in such close proximity to one another as in Bali. Every year, three million tourists visit the island, where they go surfing and diving, get massages during the day and party in the clubs at night. Tourists come to Bali to unwind, oblivious to those locked up in chains because they are mentally ill, only a few hours' drive from the island's resorts.

Losing Hope in Recovery

Suryani's mission on behalf of the chained began when several bombs exploded in the village of Kuta in 2002 and 2005. She was director of the department of psychiatry at Udayana University in the capital Denpasar at the time. She had heard that suicides had been on the rise in villages after the bombing so she decided to travel into the hinterlands to investigate the causes. Although her effort was unsuccessful, she found a confused man attached to a chain next to a chicken coop.

She had never seen anything like it. "Why do you do this?" she asked. The relatives told her what it was like to lose a person, and then to lose hope in his recovery. They said that the chain was the only solution they could think of.

Suryani, witnessing the mentally ill in chains, in her island paradise, was so horrified that she founded the Suryani Institute, a private practice in Denpasar. Using the money she had earned treating affluent patients, including tourists, she hired seven employees. She sends them to two of the nine Balinese districts, one in the north and one in the east, which are most afflicted by poverty. Their mission is to track down the chained mentally ill. When they find one they call Suryani and she gets in her SUV. They found Komang in 2008.

On this particular day, Suryani is standing in front of Komang's hut for the 38th time. "What have you eaten?" she asks. Komang continues to sing. Suryani believes that Komang suffered a trauma, but she doesn't know what caused it. She has to assemble her diagnosis like a puzzle. Perhaps it was sexual violence, or a genetic defect. The family claims she ate poisoned food. "Komang didn't love her husband," says the mother. The gods, she explains, gave her this affliction as a punishment.

Suryani often diagnoses schizophrenia, both manic and bipolar. The word feels like a catchall for everything that can't be explained. But perhaps the diagnosis isn't really that important for the patients, especially given that therapy is hardly an option under these circumstances.

Suryani prescribes several drugs for Komang: 1.5 mg of fluphenazine, 2 mg of trihexyphenidyl, Sakaneuron, a neuroleptic agent against hallucinations, a drug to treat motor disorders and vitamin B.

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1. The homogenization of mental illness
Udom 05/10/2013
Those from more traditional cultures that see in mental illness the influence of spirits are more accepting of the patient and much less demanding. Sufferers in such conditions have far fewer relapses and less agitation. Also, patients tend to adopt symptoms based on popular cultural stereotypes about what is typical. The west is exporting self fullfilling prophesies to suggestible individuals, and replacing local concepts of mental illnesses and successful methods of managing them with much less efficient ones. This foray into standardizing mental health concepts mirrors previous efforts to standardize religious and political life... Another negative effect is that labelling someone as "mentally ill" has been shown to lead to their dehumanisation, leading to hatred and fear. That's where the chains come in.
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