Social Representations of Mental Illness Among the Serang Regency Ciomas Community in Indonesia

How mental illness is perceived by the members of a particular society will determine their treatment of those they regard as mentally ill. A primary factor which shapes the understanding of mental disorders and those who suffer from them are the social discourses that revolve around them as social objects. This study was conducted in order to understand the social representation of mental disorders among community members of Ciomas Subdistrict in Serang, Banten, and how the community as a social group views mental disorders and related physical restraints through social discourse. The dynamics of common understandings of mental disorder was investigated via the dialogical approach of Social Representation Theory, specifically by using the concept of themata. Themata is an underlying deep structure of meanings that provides a basis to the establishment of a social representation. Through a qualitative focused group discussion, participants were asked to convey and describe their understanding of mental disorders. Three underlying antinomies were identified, where each contributes to shaping a common understanding of mental disorders, namely [1] supernatural– natural, [2] inhuman–human, and [3] nature–nurture. These antinomies not only explain the underlying understanding of mental disorders but also serve as a ground in understanding various treatments for people with mental disorders in the community, including physical restraints. Representasi Sosial Gangguan Mental pada Komunitas Ciomas Kabupaten Serang di Indonesia


Introduction
For a long time, physical restraint of persons has been a human rights issue closely associated with mental health. In Indonesia, physical restraints or pasung can still be found in most provinces. In some communities, pasung is one of the foremost solutions chosen as an alternative by families in which a member has mental disorders (Kementerian . A report by Human Rights Watch (2016) revealed that at least 57,000 people who are either considered mentally ill or actually have mental conditions in Indonesia had undergone pasung with varying methods and duration. Physical restraints can be done with chains, wooden blocks, or by locking a person in a room. The practice may take place in households, traditional healing centers, or even social institutions. Although widespread, pasung is far from the ideal solution needed to help those with such conditions. Restraining people with mental health conditions does not only deprive them of basic necessities like hygiene, education, and healthcare. Physical restraint has been linked with the loss of motivation and sense of responsibility, as well as increasing apathy and dysfunction in basic life and social skills (Keliat, 1996). Indeed, people who have been restrained are likely to experience trauma, resentment toward the family, feelings of inferiority and desperation that often leads to depression and suicidal urges (Lestari & Wardhani, 2014). Pasung also deprives patients of the treatments they need. Kept away by their families, many of these patients never received the opportunity to undergo necessary treatment therapies, let alone experience integration within society. Many families try to keep their family member's condition secret for fear of being stigmatized by others in their neighborhood (Subu, 2015).
Families have proven to be crucial in the chain of decision-making that puts patients in physical restraints. In Indonesia, where households may include extended family members, they can also have a role in such decisions. Several studies conducted in Indonesia (Minas & Diatri, 2008;Tyas, 2008;Suharto, 2014) show that family members often initiate the decision to apply restraint; in other cases, community figures or local authorities are the ones who push this option. The motivations for families to choose physical restraint as a form of treatment include socio-economic conditions (Tyas, 2008), and fear of violence, escape, or suicide (Minas & Diatri, 2008). They are not, therefore, all essentially negative or selfish.
Having realized the extent of this difficult issue and the potential problems it may create, the Indonesian government has initiated efforts that focus on the improvement of treatment facilities and programs. New hospitals are being built, and more funds are being directed to cover mental health expenses for underprivileged citizens (Kementerian Kesehatan RI, 2011). These efforts were then adopted by local authorities in order to help abolish pasung as a means of responding to mental health problems. Unfortunately, these efforts have often encountered obstacles, especially the resistance of families to release their family member from pasung and provide them with proper treatments (PPDI Kabupaten Blitar, 2015).
Ciomas Subdistrict in Serang Regency, Banten, is at least one step ahead in their efforts to battle pasung and promote medical treatment as a better alternative for treating mental health problems. An initiative from a local organization called Wana Wani Wauh Foundation has helped at least 140 patients who were put into pasung and assisted them with access to medical treatments. But even so, many families still struggle to interact with the patients and are tempted to put them back into pasung (A. Hananudin, personal communication, July 28, 2016). The organization realized that without tearing down the stigma surrounding mental health problems, other interventions will not yield the results they hoped for.
The activities of Wana Wani Wauh have created new dynamics within the Ciomas community beyond why social representation elaborates how social discourse forms meanings around social objects, and how these meanings are in turn represented in everyday interactions. Social representation elaborates how a meaning emerges in a dynamic and heterogeneous society: they are formed through discourse which in turn become sources of social knowledge (Wagner & Hayes, 2005). This social knowledge, which is a collective body of knowledge produced by a specific community or social circle, will later guide the community members' responses to people or things they encounter in daily lives. Moscovici (2000) described social representation as a collective elaboration done by a specific group toward social objects in order to regulate actions and communication. The social objects then are mediators of individual knowledge within their social contexts. Deaux and Philogene (2001) have argued that social representation guides actions and social relations, i.e., a group's actions toward social phenomena reflect their social representation, thereby, making social representation an important framework for understanding actions and breaking down meanings. Social representation acknowledges knowledge as being more a product of social interactions than mere individual cognition. Beyond individual cognition, social representation takes into account the social context which surrounds phenomena. These meanings are important to understand since they govern the actions and attitudes of the community toward the social object or phenomenon (Wagner & Hayes, 2005). The dialogical approach of social representation, in particular, focuses on the dialogical nature of social knowledge, that is, how common sense is formed through a dialog of contrasting views expressed through everyday discourse. This approach sees social representation in its dynamic properties, subject to diversity, difference, and even contradictions. Such diversity and contradictions are identified as "themata". Themata are the prototype of common sense (Holton in Liu, 2004), the basic assumption that inspires knowledge evident in a society, and a deep structure that provides a basis for the establishment of social representation (Liu, 2004). Themata serve as the base cognitive unit which forms how a particular society understands and communicates new information. Themata come in antinomies -two contrasting components -such as dark-light, big-small, and such. The contrasting property allows a dialog that forms or changes social representation about a social object (Markova, 2003). Themata reflect the dynamics of social knowledge formed within a culture through history, and how it is retained or changed through communication. Themata are not always evident in social discourse or actions. In many cases, themata were historically etched within members of society over generations and thus taken for granted. Themata can be held implicitly by members of a community until a social or historical context puts forward an issue that triggers its expression (Markova, 2003). In the Ciomas community, the issue of mental health was brought to light by Wana Wani Wauh, triggering social exchanges loaded with themata.
This research collected social exchanges and/or discussions in order to identify the themata which underlie the views expressed about mental disorder as a social phenomenon. The emergence of the organization within the society may also have challenged or changed the social representation of that particular phenomenon, creating an opportunity to capture the underlying dynamics of social representations and their contents.

Methods
The dialogical approach in assessing social representation stresses the dynamic aspect of the social representation. Themata identification in this approach was investigated using qualitative methods with open discussion to accommodate differing opinions and even contradictions. These contradictions are critical to identifying the antinomies within social representations in a given context. Flick (2000) and Moeliono (2012) described how the importance of context in social representation demands a qualitative approach in collecting comprehensive and thorough data and/or results. The focused group discussion (FGD) provides a means for open contradictions and discussions between participants like the ones they would normally engage in within natural social contexts and are therefore deemed as the ideal method of data collection.
The participants of this study were selected through convenience sampling by following some predetermined criteria. Participants must have had previous experiences or observations of people with mental health problems, whether as a close relative or as a mere neighbor. This research was carried out under the supervision of a thesis advisor (i.e., the second author). All participants agreed to complete informed consent forms before the discussions as part of an ethical clearance for the research. Details of the nature of the study and how the data will be gathered and used were known to the participants beforehand.
Throughout the study, researchers identified each participant's relationships and closeness with the people with mental health problems, and from the second FGD onwards, separated discussions for the families and for the general, local people. This was done to avoid inconvenience in relaying opinions, i.e., in fear of offending the other group, as the researchers anticipated that the two groups could have different meanings and experiences, and therefore required appropriate 'space' within which to express these fully.
From the second FGD onwards, groups were assigned based on the participants' contact with people with mental health problems. The first FGD comprised the mix of those two categories. The next FGD involved participants who interact daily and directly with people with mental health problems (family members or people living in the same house), while the other two other groups consisted of other members of the community including community leaders.
The data collection was conducted from July to September 2016. In total, the study involved 23 people in four separate FGDs. Eight of the participants were family members who dealt directly with people with mental health problems (Group 1), and the rest were local people or officials who dealt with them indirectly (Group 2).
Most participants belonged to the same ethnic or cultural Sundanese background. Participants tended to use a mixture of Sundanese and Bahasa Indonesia during daily conversations, and this was reflected during the discussions as well, although they tried to use Bahasa Indonesia most of the time. Participants ranged from 24 to 54 years old, most having completed elementary school or junior high school. The most common professions for the participants and residents in general were farmers, independent laborers, and shop or market merchants, placing most of them in a lower socioeconomic status group.
The only research instrument used was the discussion (FGD) guide. It consists of several statements that act as a stimulus to discussion. Participants are asked to give their responses and thoughts regarding the statements. The moderator then probes with deeper questions depending on the participant's responses. The stimulus statements are as follows (the order or appearance may vary between FGDs, December 2018 ½Vol. 22 ½ No. 2 depending on the flow of discussion): (1) Mental health is related with demonic possession; (2) Mental health has something to do with an empty mind; (3) People with mental health problems should temporarily be separated from their families and neighbors; (4) Physical restraint (pasung) may help people with mental health problems; (5) Mental health problems can be cured with medicines; (6) People with mental health problems can fully recover; and (7) People with mental health problems can be cured by traditional healers or shamans (dukun).
Those statements were selected with the counsel of the WWW Foundation as researchers tried to formulate familiar and easily understood stimulus for participants. Other than those statements, the researchers also showed a visual stimulus -an image of an adult man being physically constrained -and asked participants to share their comments or anything that came to mind. Before data collection, the researchers conducted an initial meeting with the founder of Wana Wani Wauh Foundation, Ade Hananudin, to further explain the purpose of the research and plan the details of data collections from the participants who had been selected by the Foundation from among local residents. During the FGDs, the researchers acted as moderators, and were helped by the Foundation in organizing locations, participants, and other logistics.
All four FGDs were conducted over the span of roughly one month, in local halls or local officials' headquarters. The duration of the FGDs ranged from 75 to 98 minutes, and each FGD involved at least five participants.
Researchers took audio recordings that were then transcribed and analyzed. The analysis went as follows: (1) identifying all the contradictions which arose during the discussions; (2) categorizing similar contradictions and determine a bigger theme of those contradictions; (3) establishing several main themata, which underlie all the contradictions; (4) discussing the themata as a framework to understand the social representation of mental health problems in the Ciomas district community.

Results
The data gathered was organized into a themata. Understanding social representation as a dynamic dialog that involves the tension between Ego, Alter, and Object, the dialogical approach in social representation understands themata in the form of antinomies. Therefore, this study does not concern in whether the beliefs held by the community were "true" or "false", but rather sought to identify the fundamental assumptions of those beliefs in order to understand how those beliefs came to be.

Supernatural-Natural.
In understanding mental health problems, both in terms of causes and treatments, the dimensions of the "natural" and "supernatural" were evident in the participants' remarks. Supernatural figures such as "setan" (demon or the devil)," jin" (genie, jinn, demon), or "roh" (evil spirits) are understood as the cause of mental health problems. Just as physical disease causes physical problems, these supernatural beings are considered capable of causing problems in a human psyche or "spirit". On the other hand, mental health problems are also seen as something of a physical or bodily matter, whereas things like "nerve disturbance", "brain dysfunction", or "abnormal cells" are seen as probable causes of mental health problems.
The physical is understood as something "natural", while the more abstract and intangible concept of the mental or psychological is understood as something "supernatural". Therefore, the only way to see psychological problems as something natural is to connect them with some bodily issues. When that particular route of thinking was taken, participants could distinguish between mental health problems and supernatural forces, i.e., when a condition can't be explained bodily or physically, it is then classified as something supernatural.
A study conducted in Sweden (Ohlsson, 2016) also concluded that people with mental illness have the tendency to objectify their problems as a form of physical distress, such as hormonal imbalances or problems in the brain which is conceived of in mechanistic, physical terms. The physical manifestation of the intangible concept of mental illness helps people to grasp the abstract notion and understand it as something real and concrete.
(discussing about the cause of mental illness -3rd FGD) Participant 5: "It's like this, if someone's soul is unoccupied, either because of daydreaming or something else, when his spirit is empty, then other spirits enter his mind." Participant 1: "I don't agree about it has something to do with evil spirits. (...) It's because of the nervous system." This distinction between the natural and supernatural extends to what is viewed as the proper treatment for mental (discussing about the role of spiritual healers in helping people with mental health problems) Participant 3: Then we get to the indication process of the illness, when we have a relative or neighbor whose spirit is disturbed, either to a medical worker or paranormal or spiritual healer, everyone has their own ability according to their scope. Medical workers can understand illnesses that can be detected medically. Sometimes there are complaints, but scanning and medical procedures can't seem to detect what's wrong.
And even if we go to the paranormal, they will heal the problems that can be solved with their prayer. But if they realize it's outside of their expertise, they will straightforwardly say, "This is a medical condition." The dependence on the concept of physical health to help understand mental issues helps the community to distance mental health issues from the supernatural world, but it also reduces the notion of mental health to something contingent on the physical realms alone. In turn, the recovery of people with mental health problems is considered complete when the physical issues are treated. This approach, therefore, shifts the focus of treatment to the physical realm through mere medication and alleviates the community from the collective responsibility of having failed to provide social interaction and/or other necessary interventions.
When medication was first introduced by the Wana Wani Wauh, various responses arose, as was reflected during the discussion. Even for those who accepted medication as a way to treat mental health problems, the supernatural view of mental health did not necessarily change. The efficacy of medication in alleviating psychological symptoms can also be attributed to the supernatural.
(discussing about the efficacy of medication in treating mental health problems) The meanings that revolve around pasung also have similar constructs. At first, pasung was understood as a supernatural intervention to drive away evil spirits. As new knowledge and insights emerge within the community, members of society began to assume a more nonsupernatural viewpoint on the practice. Pasung can also be seen as a method to facilitate the medication process.
Participant 2: Pasung is also connected to medication. So the people with mental defect are restrained until they lose their strength while being restrained. After a while, they can be given medication by their parents, until they come back to their senses.

Human-Inhuman.
Another antinomy underlying the meanings held about psychological problems concerns the humanity of the people who have them. The distinctions made between people with mental health problems and everyone else touches upon aspects of humanity such as "rights", "dignity", and "nobility". A person with mental health problems is considered something less than a whole human, i.e., someone with the dignity and nobility of an honorable being. The sentiment is evident through a direct comparison between people with mental health problems and the participants themselves. The actuality of mental health problems extends as far as a person's identity and humanity. The distinctions made between people with mental health shouldn't be surprising then when those meanings drive inhumane actions, such as the use of physical restraints.
(discussing the difference of dignity between people with mental health problems and everyone else) Participant 5: We're the same, when they have recovered. Participant 2: When they go back to normal, they will be the same as us normal people. We can distinguish between people with mental disorders and the healthy ones. There are differences. We, the people who interact with them daily, can see it. When they have recovered, recovered fully, they can be normal like us.
(discussing the possibility of people with mental health problems to recover) Participant 1: When I see that person, I thought, if he's brought to the community health center he can recover. Who knows, when he's healed, his honor can be elevated, and his family acknowledge him.
(discussing the characteristics of people with mental health problems) Participant 6: The body is the same as humans, but the spirit is not. The spirit is different. We are normal, he is insane. It's different.
Not everyone regards people with mental health problems as less of a human. Mental health conditions can be seen as something a person has instead of something that he or December 2018 ½Vol. 22 ½ No. 2 she is and therefore does not diminish their existential dignity and humanity. Other participants are convinced that people with mental health problems are as worthy of human rights as everyone else. And this group shows more compassion toward patients in pasung.
(discussing about whether people with mental health problems should be separated from their family and social setting) Participant 3: I don't agree when a member of a family is estranged, or worse, restrained, because first, they also have rights to live, to be taken care of, and to recover back to normal. Who can make those efforts other than their closest ones, especially family? When a relative with mental disorder is estranged, it means the family does not care about them. It means we are violating their rights.

Nature-Nurture.
The discussion about mental health problems also touches upon the classic nature/nurture debate, whereas psychological problems can be seen as something intrinsically interwoven into someone's nature or as something that has an environmental or social experience as a primary, constituent factor. This antinomy is often used in frameworks to understand how people are the way they are, and it has extended to the common notions people hold regarding mental health problems.
For instance, psychological problems can be seen as a condition rooted in the "nature" of the patients described by innate characteristics such as "weak spirit" or "free spirit". Those properties are seen as innate factors that determine people's vulnerability to "spirit disturbance" or mental health problems. The concept of nature is also reflected through notions of biological inheritance of mental health problems, for example: (discussing the cause of mental health problems) Participant 1: I think it's not contagious because it has something to do with the spirit; what happens to the spirit depends on us. If our spirit is not strong, we can be stressed. But if we have a strong soul/spirit, we will not end up like that. Even when we are stressed, if we have a free spirit, we will not end up like that.
Psychological problems can be seen as a condition rooted in the "nature" of the patients, described by innate characteristics such as "weak spirit" or "free spirit". Those properties are seen as innate factors that determine people's vulnerability to the "spirit disturbance" or mental health problems. The concept of nature is also reflected through notions of biological inheritance of mental health problems.
Another study (Dixit, 2005) found that a lack of selfcontrol or confidence is evident in factors that cause mental illness as understood by communities. That often leads a community to blame the patient for their problems.
(discussing the cause of mental health problems) Participant 4: Maybe it's inherited genetically. His relative was once in that condition, and he was restrained until he passed away. So his family have given up, "Maybe it's inherited," they said.
Other views are geared more toward nurturance than nature. Social environments, socialization processes, and experiences can all be seen as contributory factors on a person's mental health condition. Social support is seen as a more important factor than the nature of the human themselves, i.e., an individual's strength of spirit or religious faith.
(discussing the cause of mental health problems) Participant 5: Maybe one of the main causes of someone's vulnerability is the weakness of religious faith. And second, the lack of activity, or from genetic inheritance. Because no matter how hard we found life, if our faith is strong, Insya Allah we can endure that. Participant 1: But I guess it needs process and support.
In my opinion, even though someone has a strong faith, but receives no support, it won't work.
The social representation of mental health treatments also revolves around the same ground of nature or nurture. When a person's intrinsic nature is seen as a cause of his own mental health problems, the treatments seen to be appropriate involves changing or strengthening that nature. Those treatments focus on the individual, e.g., prayers, pasung, or medication. When the nurturing aspect is more prominent, others favor treatments which focus on the social aspects of the individual's existence in order to provide a positive nurturing environment, such as social interactions and inclusion of the family.
(discussing the role of medicines in the recovery of people with mental health problems) Participant 7: Can be healed through medications, I don't agree. (...) How the family treats that person is more important. Medicine is just a supporting factor contributing a small degree. Family is what determines whether someone can recover. Even if we give medicines, but we abandon him, I think it will not yield results.

Terminology Use in Referring to Mental Health
Problems. In Indonesia, mental illness or mental disorder almost always translates to gangguan jiwa, a term that can also mean "spirit disturbance". In other words, from that one term, it is evident that regulations, studies, and everyday discourse are loaded with many interpretations of the two separate words that constitute the term itself: gangguan (disorder, disturbance) and jiwa (mental state, but also spirit or soul).
Long before the concept of mental health problem emerged in the Ciomas community, the term "jiwa", or spirit/soul, already had a meaning closely associated with the spiritual realm. This fact foregrounds the spiritual meaning of mental disturbance as a dominant point of reference when understanding the terminology as a whole. The term's usage also prevents mental health problems from being understood in a scientific, psychological sense since "jiwa" is understood as the ancestral soul or spirit of the human being, i.e., the term itself strongly suggests a spiritual association.
Participant 5: It's like this, when someone's spirit (jiwa) is empty, whether because he's daydreaming or anything, when his spirit is empty, these evil spirits enter.
It's evident, therefore, that the term used to describe "the mental" or "the psychological" is in and of itself synonymous with the term used to describe "the spirit".

Discussion
FGD provides an ideal opportunity to present the researchers with social exchanges close to everyday discourse. However, in some discussions, it seemed that some participants were more respectful in the community than others, and this could have affected how other participants voiced their opinions when in their presence, i.e., some may have restrained themselves from conveying opposing arguments, in turn preventing the researchers from capturing a straightforward and authentic social discourse.
The FGD sessions in this research involved participants who belonged to the same community and therefore have known each other for long. Some participants referred to stories about something that happened in the community, and while that helped spark a discussion, sometimes some participants looked careful not to offend others that could have been involved in that particular event. This could have hindered the participants' openness in discussing certain issues or events. Researchers tried to mitigate this factor by separating family members and other community members from the second FGD onwards.
This research was conducted with the help of Wana Wani Wauh activists, who selected and invited the participants to join the discussion. In some discussions, the activists seem to have invited the people with mental health conditions who had been restrained in addition to their family members. Their attendance could have affected the group dynamics during the discussion, as other participants may have felt too self-conscious to be straightforward about their opinions.
There was also a slight difference in the stimulus given during the first two discussions. During the first two sessions, the participants were presented with an image of a person with mental health problems in physical restraint. The image was not presented in the last two discussions.
This research captures thinking processes in a community, as opposed to individual or even sums of individuals. The methodology and framework are sufficient to illustrate the dynamic group-thinking and uncover its underlying meanings that can then be further linked with behavior toward a social phenomenon. The insights gained regarding group-thinking explains the ubiquitous and somewhat enigmatic gap between individual attitudes and behavior, as meanings held by groups appear to influence behavior as much as, if not more than, individual meanings. This research, therefore, may help place social influence in the often-oversimplified attitude-behavior relationship (Terry & Hogg, 1996).
The findings in this study resonate with a similar study conducted in Bali (Kurihara, Kato, Reverger, & Tirta 2006), which stated that within the locality, the most dominant cause attributed to schizophrenia had to do with the supernatural. The study involved key relatives of people who were screened positive for schizophrenia. Its findings established a connection between the tendency to assume supernatural causes with a higher mean age and less education. Also, this group was also more likely to have family members with schizophrenia who had never received medical treatment. Such findings demonstrated how meanings and understandings are important factors in guiding family members' behavior toward people with mental illness.
(2008) examined non-conscious influences on behavior and how subtle, imperceptible primes can produce strong changes in behavior. Themata, as identified by this research, are by definition an imperceptible, often unconscious element, which collectively constitute social representation. Thus, the insights presented in this paper can help us to understand what has been the rather inexplicable force or influence that obfuscates the connection between individual conscious attitudes and behavior by explicitly connecting themata with behavior.
Also, this research may help to understand contradictions as an inevitable and healthy reality in groups, and that a solid community can hold all kinds of meanings and still operate soundly. Given the opportunity or stimulus to speak up and discuss, the otherwise unvoiced or even unrealized contradictions will surface, as has been noted by Markova (2003). Therefore, this research promotes a dialogical approach to understanding social representation as an ideal framework with which to understand contradictions in a specific community while the concept of social cognition limits understanding, i.e., the contradiction will lead to dysfunctional cognitive dissonance.