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GSTF Journal of Nursing and Health Care (JNHC) Vol.3 No.2, June 2016.
Literature review of mental health recovery in
Indonesia
Mamnuaha, Intansari Nurjannahb, Yayi Suryo Prabandaric, Carla Raymondalexas Marchirad
a
b
PhD Candidate Faculty of Medicine Universitas Gadjah Mada, Indonesia.
Associate Profesor, School of Nursing Faculty of Medicine, Gadjah Mada University, Indonesia.
c
Associate Profesor, School of Public Health, Faculty of Medicine, Gadjah Mada University,
d
Indonesia.
Associate Profesor, Psychiatric Department, Faculty of Medicine, Gadjah Mada University,
Indonesia
Abstract— Background: The recovery process for mental health
patients in Indonesia is still not optimal. This is evident from the
high recurrence rate of patients with mental disorders. This
article describes how literature views the recovery process of
mental health patients in Indonesia. The purpose of this article is
to illustrate the recovery process of patients with mental
disorders through literature searches on publications on the
phenomenon of recovery in Indonesia. Review: Literature
searches were conducted through Google Scholar, BMC,
Springerlink, Science Direct, Scopus, Proquest and the Cochrane
library. A key word that was used in English was recovery, which
is “pemulihan” in Indonesian. The literature search was
undertaken up until August 2015 and retrieved 66 articles
consisting of 60 research articles and 6 non research articles. Out
of these 66 articles, two were in duplicate. 42 of the remaining 64
articles were excluded thus 22 articles in total were reviewed.
There were two articles from a patient’s perspective in the
research focused on the recovery process of patients with mental
disorders. Other research focused on information pertaining to
the recovery process. Results: Only one of the articles portrayed
the stages of the recovery process in Indonesia. There are three
stages to the recovery process for patients in Indonesia, which
consist of the first stage: Arising, gaining insight, the second
stage: Effort, struggling to archive recovery, and the third stage:
Harmony, harmonious integration with the community. The
other 21 articles were on part of the recovery phase, however the
majority of them supported research on the first and second
stages of the recovery process and the third stage, the
harmonious integration with the community has not had much
attention or focus in research. Conclusion: Research needs to
address the recovery of patients with mental disorders in
Indonesia, particularly pertaining to community integration.
mild mental disorders or emotional mental disorders, such as
anxiety and depression, are prevalent in those aged over 15
years with 6 percent of the population or 16 million people
suffering from these disorders. Severe disorders such as
psychosis affect 1.72/1000 or an estimated 400,000 people and
14.3 percent or 57 000 people with mental disorders are
physically restrained by their families [1]. The majority of
mental health problems are long lasting (chronic) and require
ongoing care and relapse preventive measures from the
community. Others, however, can be prevented through
promotive and preventive efforts.
The phenomenon of shackling people with mental illness in
Indonesia indicates that the recovery of patients is not optimal.
This may be due to the fact that families and communities are
not being prepared to participate in the recovery process of
patients. According to Stuart [2] recovery is defined as a
process in which people can live, work, study and participate
fully in society. In understanding the recovery of
schizophrenic patients according to Buckland, Schepp et al.
[3] there are four elements, namely: fulfilling and maintaining
hopes, developing a positive identity, discovering meaning in
life and taking responsibility for the lives of others. In looking
at some of these definitions it can be concluded that recovery
is a process that is experienced by a patient in attaining their
hopes and living responsibly in society.
Estimations on the utilization of both primary and secondary
level services indicates that the scope of mental health services
is still <10%, and the recurrence rate of patients is still quite
high, as is stigma, which still affects people with mental
disorders (PMI) [4]. The research of Fadli and Mitra [5],
shows that within two years patients with schizophrenia
relapse 1.48 times on average with a standard deviation of
1.18 times. The highest recurrence frequency of schizophrenic
sufferers in two years is four times. Families that exhibit high
Keywords-component; mental health, recovery, Indonesia
I.
INTRODUCTION
Community mental health problems in Indonesia are very
prevalent and pose to be a significant burden in health. The
2013 Riskesdas (National Basic Health Research) showed that
DOI: 10.5176/2345-718X_3.2.115
©The Author(s) 2016. This article is published with open access by the GSTF.
20
GSTF Journal of Nursing and Health Care (JNHC) Vol.3 No.2, June 2016.
Identification
expressed emotion, such as hostility and criticism makes
patients more likely to relapse compared to families that
exhibit low expressed emotion.
The Indonesian government has regulated the rehabilitation of
patients with mental disorders through the Health Law No. 18
of 2014 on Mental Health in Article 25 with mental health
rehabilitative efforts. These efforts are part of and/or a series
of activities in mental health services that are aimed at
preventing or controlling disability, restoring social functions,
restoring occupational functions and preparing or developing
the ability of people with mental disorders to be independent
in the community. Managing psychiatric problems involves
the intervention of various parties from professional
associations and the community through to the government via
the Ministry of Health. Some government policies have been
implemented to facilitate access to mental health services,
including the National Health Insurance Scheme (JKN) and
other approaches that are cross-sectoral in nature.
Record identified
through database
search (n=66)
Screening
Record after duplicates
removed (n=64)
Record
(n=64)
Record
excluded
(n=42)
Eligibility
Full-text
articles
assessed for eligibility
(n=22)
Studies included in
qualitative synthesis
(n=22)
Included
These cross-sectoral approaches are implemented through
Community Mental Health Advisory and Implementing
Teams (TP-KJM) whose membership consists of central,
provincial and district or municipal government levels. The
Mental Health Law is anticipated to provide a more
comprehensive approach, ranging from promotion, prevention,
treatment through to rehabilitation [1]. The Mental Health
Law protects patients with mental disorders, particularly those
with schizophrenia in a more comprehensive and integrated
manner ranging from education, therapy and psychological
support for people with schizophrenia so that they can be
productive again in society [6]. This legislation ensures that
mental health patients are treated humanely and are free of
shackling. According to Tyas [7], managing patients once they
are released from shackling is far more important.
screened
Fig. 1. PRISMA diagram search and selection process using
Google Scholar, BMC, Springerlink, Science direct, Scopus,
Proquest and Cochrane library databases.
Recovery of mental patients is a topic that has not been
adequately addressed in Indonesia [8] The purpose of this
paper is to identify the recovery process in Indonesia through
literature searches, which were conducted to identify aspects
relating to recovery in patients with mental disorders.
III.
RESULTS AND DISCUSSION
The literature search results on recovery can be seen in Table
1.
Table 1 summary table on studies included in the review
No
Author
Objective
Researc Sample
h design
size
II. REVIEW
Literature searches were conducted through Google
Scholar, BMC, Springerlink, Science Direct, Scopus, Proquest
and the Cochrane library. The key word recovery was used in
English data bases. Searches were conducted until August
2015. Searches in Indonesian using, 'pemulihan pasien
skizofrenia’ (recovery of patients with schizophrenia), were
used in Google Scholar and the words recovery AND
schizophrenia AND Indonesia were used for English data
bases. Search results retrieved 66 articles consisting of 60
research articles 6 non research articles. Out of these 66
articles, two were in duplicate leaving 64 remaining articles. 42
of these 64 articles were excluded thus the remaining 22
articles were reviewed. The search and literature review
processes can be seen in Figure 1.
1
Wulansih
and
Widodo
[9]
2
Pah [10]
3
Murti
[11]
To determine the
correlation between
knowledge and
attitude with
relapsing
To determine the
listening process
between a mentor
and a schizophrenic
patient
To overcome the
issues of
fragmented services
Descripti
ve
correlatio
n
(n=50)
Case
study
(n=3)
Editorial
Identify applicable sponsor/s here. If no sponsors, delete this text box.
(sponsors)
©The Author(s) 2016. This article is published with open access by the GSTF.
21
GSTF Journal of Nursing and Health Care (JNHC) Vol.3 No.2, June 2016.
4
5
Fanani
[12]
Ambarw
ati [13]
6
Rikma,
Rahmi et
al [14]
7
Nurkholi
soh [15]
8
Handaya
ni, Sriati
et al [16]
To assess the
effectiveness of
clozapine (clorilex)
on the intensity of
symptoms in
schizophrenic
patients who are
resistant to
treatment
To determine the
effectiveness of
CBT as an
adjunctive therapy
in reducing signs
and symptoms in
chronic
schizophrenic
patients
To determine the
impact of Yumeiho
therapy on reducing
psychological and
physiological
symptoms in
schizophrenic
patients
To determine the
implementation of
therapy for
paranoid type
schizophrenic
clients in the
Madani Mental
Health transit house
program
To gain an
overview of the
level of patients’
independence in
controlling
hallucinations after
participating in
group therapy
activities on
perception
stimulation.
Randomi
zed
control
trial pre
and
posttest
design
(n=60,
experi
ment
30,
control
30)
Pre and
posttest
design,
single
blind
(n=40,
experi
ment
20,
control
20)
Single
case
experime
ntal
design
using
reversal
types (AB-A-B)
Descripti
ve
qualitativ
e
(n=4)
Descripti
ve
antipsychotic
medication
(n=6)
11
Purba
[19]
To determine the
differences in
inability to socialize
in schizophrenic
patients who are
provided with
rehabilitation
interventions with
those who are not
Observat
ional
survey
using a
causal
comparat
ive study
method
(n=80,
experi
ment
40,
control
40)
12
Sari,
Nugroho
et al. [20]
Dewi,
Elvira et
al. [21]
Quasi
experime
nt, One
group
pretest
post test
Descripti
ve
(n=72)
13
14
Wahyuni
, Yuliet
et al. [22]
To gain an
overview on the
ability to control
anger after having
therapeutic
communication.
To gain an
overview of the
needs in the lives of
people with
schizophrenia,
according to them
and their carers.
To find the
correlation between
the length of stay in
care and a patient's
ability to control
hallucinations
Correlati
on
(n=34)
15
Madalise
, Bidjuni
et al. [23]
To determine the
impact of health
education on the
implementation of
ADL (Activity of
Daily Living) in
patients with mental
disorders
(n=30)
16
Wangsa,
Ghofur et
al. [24]
To identify the
effects of group
activity therapy in
patients with a
history of violent
behavior on their
ability to express
feelings of anger
assertively
pre
experime
ntal
using
One
Group
Pre-TestPost-Test
Design
PreExperim
ent using
PretestPosttest
One
Group
Design
17
Kustiawa
n [25]
To determine the
impact of family
health education on
a family's ability to
care for clients with
Quasi
experime
ntal pre
posttest
using a
(n=50,
experi
ment
25,
control
(n=42)
9
Widyani
ngsih
[17]
To assess social
support supporting
the recovery
process
Qualitati
ve
(n=2)
10
Saputra,
Widodo
et al [18]
To determine the
correlation between
family support and
adherence to taking
Descripti
ve
correlatio
n
(n=95)
(n=90)
(n=35)
©The Author(s) 2016. This article is published with open access by the GSTF.
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GSTF Journal of Nursing and Health Care (JNHC) Vol.3 No.2, June 2016.
low self esteem
18
Khaeriya
h,
Sujarwo
et al. [26]
19
Utami,
Gafur et
al. [27]
To determine the
effect of therapeutic
communication on
willingness and
ability pertaining to
personal hygiene
regarding a client's
self-care deficit
To determine the
effect perception
stimulation group
activity therapy on
the ability to
control
hallucinations in
schizophrenic
clients
To know about the
empowerment
process of former
mentally ill people
To know the
21
public’s perception
of patients with
mental disorders
Subandi To explore the
22
recovery process of
[30]
the first psychotic
episode patients in
Javanese culture
The literature search results showed
20
Rahman
and
Hendrija
nto [28]
Romadh
on [29]
control
group
Quasi
experime
ntal one
group pre
posttest
design
matters are not appropriate to the specific recovery stages. In
point one, for example, Subandi [30] mentions that there are
several characteristics included in stage 1, which are not
applicable to this stage such as dispelling negative thoughts,
fantasies, and day dreaming; regular physical exercise; and
changing from a passive to a much more active disposition.
These are also included in the second stage as a part of the
efforts in the process leading towards recovery. According to
the author, it would be more appropriate to only include these
points in the second stage, that is, in efforts towards recovery.
Another inappropriate point in stage one is for socio-political
and religious interaction to play an active role in his/her own
life again. This point is more apt in the third stage, namely
harmonious integration with the community. This point
describes how schizophrenic patients interact with the
environment and their surrounding community [30].
25)
(n=50)
QuasiExperim
ental
Design
using
Onegroup
preposttest
design
Qualitati
ve: case
study
(n=34)
Descripti
ve
explorato
ry
Ethnogra
phy
(n=115
)
Subandi’s research [30] also outlines the obstacles of each
stage while literature on the recovery stages from the West
does not mention any obstacles encountered. Subandi wrote on
the obstacles of schizophrenic patients in achieving recovery.
He described an obstacle that one schizophrenic patient
encountered in stage one, namely the patient’s regret over
losing his position as school principal immediately surfaced.
Likewise, Subandi found numerous obstacles encountered by
patients with schizophrenia in stage two in efforts to achieve
recovery. These obstacles included: participants not
continuing medication because they felt that they had already
recovered; the unwanted side effects (dizziness, somnolence,
irregular menstrual cycles); and fear of becoming dependent
on medication. Subandi also describes the manifestations or
signs that a patient is in the process of achieving recovery.
Subandi considers these as part of a schizophrenic patient’s
effort in attempting to achieve recovery [30].
(n=11)
(n=7)
that the process of
recovery for patients in Indonesia or abroad are basically the
Most of the research in Indonesia examines factors associated
with relapsing. These factors include how knowledge,
attitudes, family support, adherence to taking medication and
stigma affect schizophrenic relapses. The research of
Wulansih and Widodo [9] states that there is a correlation
between knowledge and family attitudes with schizophrenic
relapses. This research supports the first and second stages of
the recovery process.
same, only the breakdown of stages is different. The process
of recovery in literature from the West includes seven stages,
while in Indonesia this process is divided into three stages.
The seven stages in the West includes: experiencing
schizophrenia as a descent into hell, igniting a spark of hope,
developing insight, activating the instinct to fight back,
Other research covers the measures implemented in supporting
the recovery process, namely individual and group therapies.
Individual therapies include cognitive behavioral therapy
(CBT), Yumeiho therapy, therapeutic communication, and
health education. Group therapy consists of sensory perception
therapeutic group activities on patients’ ability to control
hallucinations and anger. Therapy is also provided for families
through health education on a family's ability to care for
patients with low self-esteem.
discovering keys to well-being, maintaining a constant
equilibrium between internal and external forces, and
perceiving light at the end of the tunnel [31]. The three stages
in the recovery process in Indonesia includes Arising: gaining
insight, Effort: struggling to archive recovery and Harmonious
integration with the community [30].
Research conducted by Ambarwati [13] shows that CBT in
group treatments results in more meaningful clinical
improvements compared to control groups which is indicated
Analysis of the recovery stages experienced by patients in
Indonesia as explained by Subandi [30] shows that some
©The Author(s) 2016. This article is published with open access by the GSTF.
23
GSTF Journal of Nursing and Health Care (JNHC) Vol.3 No.2, June 2016.
by a reduced Positive and Negative Syndrome Scale (PANSS)
score. Although various research that supports stages one and
two of the recovery phase of patients in Indonesia has been
undertaken, evidence based standards in this research remains
weak including research methodology.
[6]
Tribunnews. Dua Dari 1.000 Orang Indonesia Alami
Gangguan Jiwa Berat.
2014; Available from:
http://www.peduliskizofrenia.org/sumber-daya/beritakeswa/item/dua-dari-1-000-orang-indonesia-alami-gangguanjiwa-berat.
[7]
Tyas TH. Indonesia Menuju Bebas Pasung Terhadap
Penderita Gangguan Mental.
2015; Available from:
http://www.voaindonesia.com/content/indonesiamenujubebas-pasung-terhadap-penderita-gangguanmental/2653154.html.
Publications on the recovery of psychiatric patients in
Indonesia still do not address the third stage of the recovery
process, namely harmonious integration with community. If
harmony cannot be created then patients will be susceptible to
relapsing. Community integration is important in the process
of recovery and is an indicator of a patient's well-being.
Patients striving to free themselves from the confines of the
illness and developing a personal identity is meaningful,
where they are able to carry out their role in the community
[32]. According to Pahwa and Bromley [33], community
integration is important in the recovery process. There are
three dimensions to community integration, namely physical,
psychological and social. Perhaps this is one of the reasons
why the recovery process of the mentally ill in Indonesia is not
optimal, proven by the extensive occurrence of shackling of
mental patients.
IV. SUMMARY
The process of recovery for people with mental illness in
Indonesia consists of a number of different stages although in
detail they actually outline the same processes. Literature in
Indonesia reveals that the vast majority of research is weak in
terms of the level of evidence. Additionally, research
publications in Indonesia remain focused on the first and
second stages of the recovery process, with little attention
given to the third stage regarding the integration of psychiatric
patients in the community.
[8]
Nurjannah I, FitzGerald M, Foster K. Patients'
experiences of absconding from a psychiatric setting in
Indonesia. International journal of mental health nursing.
2009;18(5):326-35.
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Wulansih S, Widodo A. Hubungan antara Tingkat
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Murti
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