International Review of Psychiatry, August 2006; 18(4): 363–370

The development of psychiatry in Indonesia:

From colonial to modern times

H. POLS

Unit for History and Philosophy of Science, University of Sydney, Sydney, Australia

Abstract
During the colonial period, mental health care policy in the Dutch East Indies was centred on the mental hospital, which
provided custodial care. In 1949, independent Indonesia inherited four very large mental hospitals, about 10 acute-care
clinics in the major cities, and an agricultural colony. During the 1950s, mental hospital care remained largely custodial.
In 1966, the Directorate of Mental Health adopted the three-fold principles of prevention, treatment, and rehabilitation
as the foundation of a comprehensive mental health care system. During the 1970s and 1980s, the number of mental
hospitals in Indonesia doubled and a variety of treatment methods were introduced. Special attention was given to the care
provided by dukuns, or indigenous healers.

Introduction projects were undertaken. During this period,

Indonesia is a nation in South East Asia consisting of
over 17,000 islands inhabited by nearly 220 million
people, who belong to more than 300 different ethnic
groups and speak more than 500 different languages.
It was a colony of the Netherlands for more than 360
years, was occupied by the Japanese during World
War II, declared independence in 1945 and obtained
it in 1949. Mental health care policy of the colonial
Dutch government in the Dutch East Indies was
centred on the mental hospital, which had a custodial
function. Indonesian individuals were confined to
mental hospitals only if they disturbed the social
order and a physician declared them insane.
Independent Indonesia inherited four very large
mental hospitals (each housing over 5000 patients),
about 10 acute-care clinics in the major cities, and an
agricultural colony for chronic patients. Initially,
mental hospital care remained largely custodial, with
ECT (electroconvulsive therapy) and ICT (insulin
coma therapy) treatments available on a modest
scale. In 1966, the Directorate of Mental Health in
the Ministry of Health adopted the three-fold
principles of prevention, treatment, and rehabilita-
tion as the foundation of a system of comprehensive
mental health care. During the 1970s and 1980s, the
number of mental hospitals in Indonesia more than
doubled, new forms of mental health care were
developed, and a number of original research
Indonesian psychiatry was presented as a model for
other South East Asian nations. Unfortunately,
during the 1990s, Indonesia’s mental health care
declined because of reductions in government
spending.
Mental hospitals
Psychiatry in the Dutch East Indies was essentially
based in the mental hospital. The reform of the care
of the mentally ill in the Netherlands was initiated in
the 1830s. Three decades later, Dutch psychiatrists
argued that similar reforms should be undertaken
in the colonies as well. To ascertain the prevalence
of mental illness and estimate the number of needed
beds, Drs Bauer and Smit (1868), two physicians
in charge of small hospitals in the Indies, conducted
a survey on Java. According to them, there were
around 550 individuals in need of institutionali-
zation in the whole archipelago. They found about
300 of these individuals in pitiful conditions in
military hospitals, prisons, or abandoned in the
community. They recommended that two large
mental hospitals be built. The first mental hospital
was located near Buitenzorg (Bogor) and began
receiving patients in 1882 (Bauer became the
first medical superintendent). A second mental
hospital opened near Lawang in 1902. Two addi-
tional mental hospitals were established near

Correspondence: Hans Pols, Unit for History and Philosophy of Science, Carslaw F07, University of Sydney, Sydney,
NSW 2006, Australia. Tel: þ 61 2 9351 3610. Fax: þ 61 2 9351 4214. E-mail: hpols@science.usyd.edu.au
ISSN 0954–0261 print/ISSN 1369–1627 online/06/040363–8 ß Institute of Psychiatry
DOI: 10.1080/09540260600775421
364 H. Pols
Magelang and near Sabang, on an island just north
of Aceh. Both opened in 1923. These large mental
hospitals treated patients of both European and
indigenous backgrounds. Indigenous patients were
only admitted on a so-called social indication, which
meant that they had become a public nuisance,
had been violent, or had disturbed the social order.
Care in these institutions was mostly custodial.
For European patients, available treatment included
continuous baths, bed treatment, and open air
treatment. For indigenous patients, there was
ample occupational therapy (mostly agricultural
work for the male patients). Physical restraint,
chemical restraint, and isolation were rarely used
(Travaglino, 1923).
Two other types of institutions were established by
the Dutch colonial government: acute-care clinics
and agricultural colonies. In the 1920s, several clinics
(doorgangshuizen) for the treatment of acute cases for
up to six months were established in a number of
metropolitan centres (Travaglino, 1919). If treat-
ment in these facilities proved unsuccessful, patients
were transferred to the larger mental hospitals.
Because the existing mental hospitals were severely
overcrowded, most of these institutions for short-
term care functioned as additional mental hospitals
rather than as clinics. These establishments were
opened in Surakarta, Batavia (Jakarta), Palembang,
Padang, Medan, Bajarmasin, Bangli (Bali),
Makassar, and Menado. In the 1930s, various
physicians argued for the establishment of agricul-
tural colonies for long-term chronic patients whose
condition could not be expected to improve. These
institutions could be run by nurses (mantris) and
indigenous physicians (Kerkhoven, 1993; van
Wulfften Palthe, 1933). Agricultural colonies
had been part of the larger mental hospitals already;
one separate institution for long-term patients was
established in the 1930s (Lenteng Agung, near
Jakarta). Mental hospital facilities in the Dutch East
Indies were always inadequate, which led to over-
crowding, poor care, neglect, and the placement
of individuals with mental illness in prisons
(Engelhard, 1925). Most indigenous individuals
with mental illness were tolerated in their commu-
nities; a few were placed in wooden blocks there
(Latumeten, 1928). During the second quarter of
the twentieth century, a number of psychiatric wards
in general hospitals were opened, mostly for
European patients.
Colonial psychiatric views on
the Indonesian people
Surveys conducted by Dutch colonial psychiatrists
always quoted a remarkably low prevalence of
insanity in the colonies. They believed that mental
illness, which they viewed as a disease of civilization,
hardly existed in primitive or less developed societies.
Dutch psychiatrists often expressed opinions about
specific forms of mental illness unique to the Indies.
They were inspired by Emil Kraepelin, who by
then had acquired worldwide fame as the leader
of psychiatric research because of his distinction
between dementia praecox (later renamed schizo-
phrenia) and manic-depressive insanity (later
renamed bipolar disorder) as well as his approach
to investigating the nature of mental illness.
Kraepelin spent three weeks at the Buitenzorg
mental hospital in 1904 to investigate differences
in incidence and manifestations of mental illness
in patients of indigenous, Chinese, and European
background (Bendick, 1989). He concluded that
the symptoms of schizophrenia were less severe in
indigenous patients and that their prognosis was
much better (Kraepelin, 1904a, 1904b).
Dutch psychiatrists in the Indies elaborated on
a number of mental afflictions specific to South
East Asia that currently are designated as culture-
bound syndromes. These are amok, latah, and koro
(see van Loon, 1927; van Wulfften Palthe, 1935).
Amok is the designation given to sudden violent
outbursts in men that generally occur after extreme
embarrassment, in which the individual attacks
everyone and everything in sight, often with a lethal
outcome. An attack can last several hours, after
which amnesia occurs. Very few cases of amok were
admitted to the mental hospitals because individuals
with this disorder were often killed to prevent further
bloodshed (for a critical view on amok see (Carr &
Tan, 1976). Latah occurs mostly in older women,
who, after being startled, imitate the movements of
the individuals around them. They often express
vulgar language as well. Generally, it was said that an
attack of latah occurs after dreams with explicit
sexual content (see also Winzeler, 1995). Koro is the
fear that the penis will retract inside the pelvis and
disappear.
Apart from providing observations for comparative
or cross-cultural psychiatry, Kraepelin hoped
that his research would also contribute to a
Völkerpsychologie (comparative anthropological
psychology), in which he aimed to analyze the
mental life of a great number of ethnic groups.
According to Megan Vaughan (1991), the views
colonial psychiatrists expressed about the nature of
the normal indigenous mind were far more influen-
tial in colonial society than their ideas about mental
illness or the treatment they provided to the mentally
ill. Her views can be substantiated with the publica-
tions of prominent Dutch colonial psychiatrists, a
number of whom expressed strong opinions about
the nature of the indigenous population of the

Indonesian archipelago, thereby providing a justifica-
tion for colonial social life with its inherent inequal-
ities (Pols, forthcoming-b). Their theories were
variations on the so-called myth of the lazy native
(Alatas, 1977).
One of the first physicians to write extensively on
the psychology of the indigenous population of the
East Indian archipelago was J.H.F. Kohlbrugge, a
physician who spent 13 years on Java around the
turn of the twentieth century. Kohlbrugge worked
as a physician on Java from 1892–1899 and from
1901–1906. According to Kohlbrugge (1907), the
lack of mental development of the Javanese (and
other ethnic groups in the colonies) was due to the
pervasive presence of animism and superstition,
which held it in a tight grip. In addition, the
oppressively hot climate deterred hard work and
impeded intellectual development. Kohlbrugge
argued that the Javanese were highly suggestible,
emotional, erratic, and child-like. The complete lack
of individualism, an intrinsic laziness, the inability to
plan ahead, the lack of development of rational
abilities and the strongly present emotions meant
that Javanese society would only develop slowly.
Kohlbrugge warned that Western education would
erode indigenous culture, causing social problems,
anomie, and the formation of a discontented urban
class which had lost its cultural roots. He recom-
mended that the colonial government limit itself to
maintaining law and order, and that the psychology
of the Javanese be studied to aid the formulation
of an appropriate colonial policy, suitable to the
nature of the psyche of the indigenous population.
Similar views were expressed in the 1910s and
1920s by P.H.M. Travaglino, the medical super-
intendent of the Lawang mental hospital, and
F.H. van Loon, director of Batavia’s clinic at
Grogol and lecturer in psychiatry and neurology at
the local medical school for the indigenous popula-
tion (STOVIA). After his arrival in the Indies,
Travaglino investigated the distinct manifestations
of schizophrenia in the Javanese. Following
Kraepelin’s earlier observations, he claimed that
visual and auditory hallucinations were rare among
Javanese schizophrenics, who also recovered more
quickly than their Western counterparts. According
to Travaglino (1920), Javanese schizophrenics were
also characterized by strong emotional expressive-
ness, of which running amok was a prime example.
Symptoms ranged from talkativeness, screaming,
singing and cursing to tearing up one’s clothes and,
at times, engaging in aggressive and destructive
behaviour. These patients were disorientated,
lacked concentration, and were highly agitated and
expressive. They also made irrational mental associa-
tions. Nevertheless, most of these patients recovered
within a week. On the basis of these and other
The development of psychiatry in Indonesia 365
observations, Travaglino concluded that the Javanese
people were positioned at an earlier and more
primitive phase in the process of evolution. Their
minds were childish, emotional, and irrational. He
presented similar views to reactionary political
groups which advocated free enterprise, the main-
tenance of law and order, and a reduction in
spending on education for the indigenous
population.
Van Loon (1928) argued that the indigenous
population in the colonies was highly instinctive,
suggestible, and emotionally charged while display-
ing little initiative and a poor development of
secondary functions. Their individuality was poorly
developed; they were therefore highly suggestible
and easily influenced by collective forces. Van Loon
presented his views in a prominent public forum.
The ideas of both these psychiatrists evoked strong
protests from Indonesian physicians, who expressed
their opinion through the Society for Indigenous
Physicians and the Indonesian Society (a group of
Indonesian students in the Netherlands), which
journals published a coherent and well-argued
critiques (Pols, forthcoming-a). They argued that
the investigation of Indonesian individuals with
mental illness should be conducted by physicians
who speak their language and who are aware of their
cultural conventions. They also protested against
the generalization of findings based on a small group
of patients in mental hospitals to the whole popula-
tion of the Dutch East Indies. Third, they questioned
that generalizations could be made about the over
300 different ethnic groups of the archipelago. And,
lastly, they questioned whether comparisons between
a generalized ‘East’ and ‘West’ would be meaningful.
Medical education and psychiatry
In 1851, a school to train a small number of
indigenous individuals to become vaccinators
mainly against smallpox, was established in Batavia
( Jakarta). During the following decades, this institu-
tion was transformed into a medical school, which
was renamed STOVIA (School ter Opleiding van
Indische Arsten [School for the Education of Indies
Physicians]). In 1920, with the part-time appoint-
ment of F.H. van Loon, who taught psychiatry and
neurology, psychiatry officially became part of the
medical curriculum. Teaching was adversely affected
by the absence of a psychiatric clinic (Latumeten,
1928; van Loon, 1926). For in-class demonstrations,
patients had to be brought from Grogol, which was
about 20 kilometres away. The hospital next door
to the medical school refused to open a psychiatric
ward, on the conviction that the sick and the insane
ought not to be treated in the same premises.
366 H. Pols
In 1927, the STOVIA was transformed into a
medical faculty which admitted both Europeans
and Indonesians; the degree it offered was equivalent
to those awarded in the Netherlands. A chair in
psychiatry and neurology was established, which was
occupied until 1942 by P.M. van Wulfften Palthe.
During the Japanese occupation (1942–1945), the
medical school was run by the occupation forces.
For the first time, Indonesian physicians participated
in teaching. During the struggle for independence
(1945–1949), a number of Indonesian physicians
ran an underground medical school parallel to
the re-established Dutch medical faculty. After the
transfer of sovereignty to Indonesia on 27 December
1949, most of the teaching staff at the University
of Indonesia and 18 Dutch psychiatrists left
Indonesia. In 1950, the Fakultas Kedoktoran was
founded as part of the University of Indonesia;
medicine was taught according to the model estab-
lished by the Dutch. Professor Slamet Imam Santoso
became the first professor of neurology and psychia-
try (for a biography see Oemarjati, 1992); Santoso
was later involved with the establishment of
the Department of Psychology to make more
psychotherapists available in Indonesia (see
Santoso, 1959).
Through a collaborative project with the
University of California at San Francisco (UCSF),
lasting from 1954–1960, medical teaching became
more efficient and practice instead of demonstration
based. Entrance to medical studies was limited on
the basis of academic promise while regular exam-
inations were scheduled (Smyth, 1957, 1963,
Wellington, 1970). The University of California at
San Francisco maintained a similar association with
Airlangga University in Surabaya from 1959–1965.
The graduates from the University of Indonesia
medical school staffed several new medical schools,
which were founded in the 1950s and 1960s in
order to educate a great number of physicians which
were needed in the newly independent country.
In particular the medical faculties at Gadjah Mada
University, Yogyakarta, and Airlangga University,
Surabaya, developed strong departments of psychia-
try. During the affiliation with UCSF, a psychiatric
clinic with 64 beds was established in the hospital
next to the Faculty of Medicine.
In 1961, neurology and psychiatry became estab-
lished in two different departments at the University
of Indonesia medical school and R. Kusumanto
Setyonegoro became the chairman of the department
of psychiatry (a position he held until 1972). In 1961,
there were about 32 psychiatrists in Indonesia
(Kelman, 1968). After visiting the USA as part of
the association of the University of Indonesia medical
school with UCSF, Kusumanto came to advocate
a holistic-eclectic approach, which emphasized
biological, psychological, and social factors in the
aetiology of mental illness (Setyonegoro, 1965),
which became the basis of psychiatric thinking
in Indonesia. In 1967, Kusumanto introduced
a structured three-year residency training program
in psychiatry (which was extended to four years
in 2000).
Postgraduate education in psychiatry has been
available to Indonesian psychiatrists on a limited
scale in the USA, Canada, the UK, and the
Netherlands. One initiative deserves special mention.
From 1972–1973, the University of Hawaii medical
school organized a training programme in com-
munity child psychiatry in collaboration with
the University of Indonesia medical school
(McDermott & Maretzki, 1975; McDermott et al.,
1974). Five psychiatrists spent a year on Hawaii for
advanced training; after returning they established
child psychiatry as a sub-discipline. Currently, there
are 35 child psychiatrists in Indonesia. This project
was followed by an anthropologist as well, who
made a number of observations about the specific
requirements of the mental health care system in
Indonesia (Maretzki, 1981a, 1981b).
In 1972, the Society for Indonesian Neurology,
Psychiatry, and Neurosurgery was established;
in 1983 this society dissolved and the Indonesian
Psychiatric Association (Ikatan Dokter Ahli Jiwa
Indonesia) was founded.
Mental health care in Indonesia
During the Japanese occupation and the struggle
for independence, the buildings of many mental
hospitals were diverted for other uses (mostly by the
military) while others were severely damaged.
After Indonesia achieved independence, Marzuki
Mahdi, who had previously worked as a physician
at Buitenzorg mental hospital, became the first
chairman of the Bureau of Mental Health in the
Ministry of Health. His main accomplishment was
to maintain the mental hospitals, which were in
very poor shape because of years of neglect. From
1958–1963, his successor Salekan, who had been
director of the Grogol mental hospital in Jakarta,
transformed the Department of Mental Health
into a Directorate within the Ministry of Health,
which increased its status. He also established
an information system where data on all patients
in Indonesian mental hospitals was maintained.
Under his guidance, Grogol mental hospital was
renovated extensively. Unfortunately, Lenteng
Agung was taken over by the military in the early
1960s. During the 1950s and early 1960s,
Indonesian mental hospitals were only able to
provide custodial care; opportunities for treatment

were extremely limited. Occupational therapy was
available and, in a few cases, ECT, which was
administered under rather primitive conditions.
Medication was only supplied in those rare cases
that the family could afford it (Kline, 1963).
During the 1950s, the mental hospitals established
during the colonial period kept functioning (with the
exception of Sabang, which was severely damaged
during the war). Generally, custodial care was
provided. In 1961, Kusumanto established the first
private mental hospital, the Dharmawangsa
Sanatorium, in South Jakarta, initially with 20 beds.
It was part of the first private mental health
foundation in Indonesia. Four more private clinics
were established in the Jakarta area in the years
following. The Dharmawangsa Sanatorium spear-
headed the reform of psychiatry in Indonesia in the
years following. In 1968, Jiwa, the Indonesian
Psychiatric Quarterly, started publishing from there.
It was very active in public health education. From
1972–1980, the Dharmawangsa Mental Health
Broadcasting Station operated from the site. This
radio station was solely devoted to public health
education on issues related to mental health.
Psychiatrists associated with the sanatorium organi-
zed short courses for government officials on the
nature of mental illness and the need for improved
mental health care facilities.
In 1966, the Ministry of Health organized a
national meeting of psychiatrists, where three prin-
ciples of maintaining mental health were adopted
as the basis for mental health care: prevention,
treatment, and rehabilitation. The conference pro-
vided new principles that could guide the organiza-
tion of mental health care in Indonesia, which was
expanded from hospital treatment to include pre-
vention and rehabilitation. The same year, a mental
health law separate from the general health laws was
accepted, which provided significant opportunities
for the expansion of the mental health care system
(the law was withdrawn in 1993 and integrated into
the general health laws). The law embodied the
integrated approach presented at the mental health
conference and prescribed an integrated community
approach within mental health care. In 1969, a
comprehensive system of national mental health
service was introduced, integrating the already
existing primary health care centres (Pusat
Kesehatan Masyarakat or Puskesmas) into the
national mental health delivery system. Officially,
the mental hospitals became part of a community
mental health programme with centres providing
both in-patient and out-patient services, by providing
consultation to neighbouring general hospitals,
and by engaging in public health education.
In 1971, Kusumanto was appointed as the
Director of the Directorate of Mental Health
The development of psychiatry in Indonesia 367
within the Department of Health (a position he
held until 1989). In this position, he laid the
groundwork for Indonesia’s mental health care
delivery system. Under Kusumanto’s influence,
psychiatry in Indonesia flourished; some commen-
tators have designated the period from 1970–1985
as the golden age in Indonesian psychiatry. Under
Kusumanto’s guidance, 22 new mental hospitals
were opened. As a result, there is a mental
hospital in 26 of Indonesia’s 31 provinces. The
training of psychiatrists was stepped up, with staff
members from the Department of Psychiatry
travelling to a number of medical schools on a
regular basis to teach psychiatry to medical
students. Successful efforts at public health educa-
tion were undertaken and a number of innovative
research projects were initiated. For all these
reasons, Kusumanto has been named the father
of Indonesian psychiatry. Under his initiative,
the ASEAN forum on child and adolescent
psychiatry started in 1977 in Jakarta, which was
held every other year after that. In 1981, he
became the founding president of the ASEAN
Federation for Psychiatry and Mental Health,
which was founded during the first meeting of
the ASEAN Association of Psychiatrists, held in
Bangkok. Because of his influence in Indonesia and
South East Asia, Kusumanto has also been called
the father of ASEAN psychiatry.
From 1975–1982, the Directorate of Mental
Health was appointed as a collaborative centre of
the World Health Organization—South East Asia
Regional Office. During this time, a number of
innovative research projects were undertaken.
The first community-based mental health survey to
ascertain the prevalence of mental illness in the
population, based on a sample of 100,000 individ-
uals, was undertaken in 1983. It was concluded that
the prevalence of the major psychoses was 1.44 per
thousand population. A comparison with groups of
individuals suffering from schizophrenia in London
demonstrated that Indonesian patients suffered
more from over-activity and less from delusions of
persecution, visual hallucinations, and depression,
illustrating the significance of cultural factors in
determining the symptoms of the major mental
illnesses (Salan, Mustar, & Gunawan, 1992).
A second research project focused on traditional
healing with respect to mental health problems in
Indonesia. Because there are only a limited number
of physicians and an even smaller number
of psychiatrists in Indonesia, most people consult
traditional healers (dukun) rather than physicians
when they are confronted with mental health prob-
lems. In some areas up to 80% will visit traditional
healers or religious representatives before consult-
ing physicians. Surveys were conducted in several
368 H. Pols
provinces (Salan, Mustar, Bahar, Sosrokoesoemo, &
Thong, 1982; Setyonegoro & Roan, 1983). As a
result, a policy of co-existence between traditional
healers and regular physicians was proposed. Unlike
public health initiatives with traditional midwives,
no attempts have been made to educate traditional
healers about the nature of mental illness or to make
them part of the mental health care system.
Nevertheless, it is now understood that both groups
are not operating in competition.
Popular attitudes
Popular attitudes towards the mentally disturbed in
Indonesia have always been characterized as tolerant
(see Kline [1963]; for Bali see Kurihara et al.
[2000]). Nevertheless, the use of a wooden block to
confine individuals whose behaviour has been found
disturbing has been reported (Latumeten, 1928).
The importance of religious beliefs and traditions,
which often predated the ascendance of Islam, has
been acknowledged by Dutch physicians and post-
war Indonesian psychiatrists. Both groups tend to see
superstitions and animism, which they believe is
inherent in these traditions, as an obstacle to the
modernization of society and a force against spread-
ing medical insights in the population. Similarly,
attitudes towards indigenous healing traditions
have been ambivalent. Practitioners of traditional
medicine or dukuns are viewed with suspicion. This
despite the fact that up to 80% (the actual number
varies with the specific location) of individuals who
consult mental health practitioners have consulted
a dukun first (Kline, 1963; Setyonegoro & Roan,
1983).
There have been only a few studies on the
treatments provided by dukuns and religious
teachers. Hirokoshi (1980) investigated the practices
at an Islamic asrama in West Java (see also
Horikoshi-Roe, 1979). According to her, traditional
beliefs dictate that good health consists of a
harmonious balance between hot and cold sub-
stances in the body. Mental disorder implies a
disturbance between the soul and the flesh, which
can be cured by religious training, moderation, and
baths, massages, and diet. She observed healing
practices in an Islamic asrama, where individuals
with mental afflictions resided and were under the
guidance of a religious teacher. As already men-
tioned, Indonesian psychiatrists have established a
relation of mutual tolerance towards traditional
healers. In the experience of mental illness, religious
beliefs, spiritual ideas, and modern medicine each
play a role (Good & Subandi, 2004). Several
psychiatrists and anthropologists have emphasized
the importance of cultural factors in the
symptomatology and experience of mental illness
in Indonesia (Gunawan-Mitchell, 1969; Maretzki,
1981a).
The psychiatrists Denny Thong, who has worked
from 1968–1986 on Bali, deliberately attempted to
integrate the activities of indigenous healers, named
balians on Bali, in the mental health care system
on the island (Thong, Carpenter, & Krippner, 1992).
Balinese beliefs explain mental disorder as a result of
a trespass against the community, the environment,
and the gods. Thong built a temple or banjar next
to the mental hospital in Bangli to make the
institution meaningful to the inhabitants of the
island. Subsequently, he invited balians to become
involved in the treatment of individuals with mental
health problems. This removed the stigma from
mental illness and made mental health intervention
acceptable and comprehensible to the local popula-
tion. This cooperation was highly successful (see also
Dean & Thong, 1972; Thong, 1976). Thong also
set up a family ward, along the model of the practices
of local balians or the asrama on Java, in which the
family could be involved in the treatment of the
mentally ill family member. It has been argued
that the involvement of traditional healers constitutes
the only feasible way of making mental health care
available to the Indonesian population (Connor,
1982). Initiatives involving traditional healers and
the traditional understanding of mental disorder
continue to be undertaken on Bali (Suryani &
Jensen, 1992).
Psychiatry and public health
In 1975, it was mandated that every province
establish a Board of Community Mental Health.
The mental hospital occupied a central position
in providing mental health care in each province.
Psychiatrists connected to the mental hospitals
needed to be available for consultations with the
local health centres and hospitals, and engage in
public health education as well. In this way, it
was hoped that psychiatry would become integrated
in the main health care delivery system, which was
centred around health centres (Pukesmas). In 2002,
a far-reaching reorganization of the administration
of the health care system took place, as the central
government advocated a policy of decentralization.
The Directorate of Mental Health became the
Division of Community Mental health, which was
part of the Directorate of General Community
Health. As a consequence, mental health became
the responsibility of the provinces. This led to a
period of decline for psychiatry, as most mental
hospitals were under-funded and it proved difficult
to integrate psychiatry in a general health

programme. In 2006, this change was partially
reversed, with the Directorate of Mental Health
now placed under the Directorate of General
Medical Care. The central government now provides
technical assistance to all mental hospitals, which
remain the responsibility of the provinces.
Conclusions
Currently, there are close to 500 psychiatrists in
Indonesia, which is a very modest number for a
population of about 220 million people. There is a
sense of crisis among Indonesian psychiatrists.
Funding for mental hospitals has declined over the
last 10–15 years, which led to a decline in levels of
service. Indonesia spends about 2.4% of its national
budget on health; of this amount, about 1% is spent
on mental health. The current condition of psychia-
try in Indonesia is unfortunate, especially when one
considers that in the 1970s and 1980s it was
considered to have an exemplary mental health care
system. There is a need for further opportunities for
training and opportunities for exchange with other
countries. In addition, there is a need for greater
funding for maintaining the mental health care
system and for research.
Indonesia faces several challenges in the field
of mental health. Research in several developing
countries has demonstrated that there is a significant
relation between poverty and common mental
disorders (Patel & Kleinman, 2003). Research in
Indonesia demonstrated that poorer mental health is
found in those with little education, poor housing,
and poverty. Individuals whose standard of living had
increased experienced far fewer symptoms (Bahar,
Henderson, & Mackinnon, 1992). Over the last
several decades, the differences between rich and
poor in Indonesia have increased. For wealthy
individuals, there are psychiatrists in private practice
and private mental hospitals available; the care these
provide matches that of any Western country. For
individuals of average wealth, only the public health
care system is available, which can provide, in most
instances, a moderate amount of care.
A last challenge currently faced by Indonesian
psychiatrists is the outcome of the 2004 tsunami
(Kua & Iskandar, 2005). A great number of
individuals have been severely traumatized. Most of
these individuals are not familiar with psychiatry or
mental health professionals; individualized psy-
chotherapy does not constitute the most effective
way of approaching these individuals. Currently, a
number of psychiatrists have initiated public health
programs where local workers are trained in the
principles of counselling, which they then provide to
traumatized individuals on the local level.
The development of psychiatry in Indonesia 369
Acknowledgements
This article has greatly benefited from discussions
with Prof. Sasanto Wibisono, Prof. R. Kusumanto
Setyonegoro, Dr Irmansyah, Dr Thjin Wiguna,
Dr Nurmiati Amri, Dr Loka Tjahjana, and
Dr Rusdi Maslim.
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