Human Rights and Mental Health: The Crisis We Don’t Talk About

The first smell that hits you when you walk into certain places, places where people with mental illness are kept. An open sewer running alongside a building. The stench of neglect. The odor of bodies that haven’t been washed in months, years, decades.

Tom Allard, an Australian journalist, walked into the Yayasan Galuh rehabilitation centre in Indonesia in 2010. He described it like this:

“At the entrance of the main building… the first thing that hits you is the overwhelming stench. An open sewer borders the structure on three sides and the odour is especially rank in the midday heat. But the fetid smell only hints at the utter wretchedness that awaits inside.”

Inside, he found people in chains. People in cages. People who had been locked up for years, sometimes decades, because their families didn’t know what else to do.

This is not a story about one bad place in one faraway country. This is a story about what happens to people with mental illness all over the world, including in countries we think of as “developed,” including in places where we like to believe human rights are protected.

By the end of this piece, I want you to understand something that took me years to fully absorb: that human rights violations against people with mental and psychosocial disabilities are not rare exceptions. They are pervasive. They happen in every country, in every type of setting. And they continue largely unnoticed, except when people in chains die.

Quick disclaimer before we dive in: I’m Maryam, a digital journalist with a background in psychology and counselling. This newsletter is just me, no corporate sponsors, no agenda, just someone obsessed with understanding why people are the way they are. What I’m sharing here comes from my research and my psychological lens. It’s an interpretive framework, not the final word. But I hope it gives you a new way to see.

The Hidden Crisis: Human Rights Violations in Mental Health

Let me ask you something.

When you think about human rights violations, what comes to mind? Political prisoners? Torture? Genocide?

Now let me ask you something else: when was the last time you thought about human rights violations in mental health care?

Here’s the uncomfortable truth: all over the world, people with mental and psychosocial disabilities experience violations of their most basic rights. Not occasionally. Not in a few bad places. Systematically. Pervasively. And mostly in silence.

A major study by Drew and colleagues, published in The Lancet in 2011 (link to Drew et al., 2011), brought together evidence from low- and middle-income countries. They consulted 51 people with mental and psychosocial disabilities from 18 countries. They reviewed reports from NGOs, UN documents, government reports and media.

The picture that emerged is devastating.

Here’s what they found:

People with mental and psychosocial disabilities are denied their rights to work, to marry, to have a family, to participate in their communities. They are physically and sexually abused. They are arbitrarily detained. They are denied access to health services. They are financially exploited.

In the health-care context specifically, two major concerns stand out:

First: lack of access to care. Millions of people with mental illness never receive any treatment at all. In Indonesia, for example, an estimated 750,000 people with mental illness get no medical treatment whatsoever.

Second: ill-treatment and abuse by health workers. The very people meant to provide care are often the ones inflicting harm. Physical abuse, neglect, degrading treatment, these are common occurrences in facilities throughout the world.

The WHO and UN, in their 2023 guidance (link to WHO/UN, 2023), put it bluntly: “The widespread human rights violations and harm caused by mental health systems has led to a legacy of trauma that impacts many individuals and communities and spans generations.”

Think about that. The systems designed to help have created intergenerational trauma.

Where Do These Violations Happen?

When we hear about abuses, we might imagine them happening in faraway places. In poorly run institutions. In countries with weak laws.

The reality is more disturbing. These violations happen everywhere. And the list of places where they’re most likely to occur tells us something important about the problem.

According to the respondents in the Drew et al. study, human rights violations are most likely to take place in:

1. General community settings in everyday life – Not institutions. Not hospitals. Everyday life. The street, the market, the neighborhood. This is where exclusion and discrimination hit hardest.

2. Home and family settings – The place where we expect safety is often the place where people are chained, confined and hidden from view.

3. The workplace or potential workplace – Denial of employment rights is one of the most common violations.

4. Psychiatric institutions and mental health services – The very places meant to provide care are often sites of abuse.

5. Hospitals and health-care services – General hospitals, not just psychiatric ones.

6. Prisons, police and the legal system – People with mental illness are overrepresented in prisons, where they face additional abuses.

7. Government and official services – Bureaucracies that deny benefits, refuse services and exclude people from participation.

8. Schools and the education sector – Children with mental health issues are often excluded or mistreated.

Notice something? These aren’t remote, hidden locations. They’re the places we all inhabit. Home. Work. School. The doctor’s office. The police station.

The violations aren’t happening somewhere else. They’re happening everywhere.

The physical conditions in residential facilities are often inhuman and degrading. Drew and colleagues documented overcrowding, outbreaks of preventable diseases caused by unsanitary conditions, poor physical infrastructure, inadequate food and pervasive tobacco smoke. “Deficiencies in the built environment of mental health facilities can impede effective treatment and recovery,” they write, “which can result in worsened mental and physical health of service users.”

Beyond the poor conditions, people are subjected to ill-treatment, physical, mental and sexual abuse. Neglect. Arbitrary detention, where people are locked in hospitals for years without their legal status ever being reviewed. Seclusion and restraint used as punishment or coercion. People chained to beds or posts for months or years.

And then there are the so-called “treatments”, unmodified electroconvulsive therapy (without anesthesia or muscle relaxants), beatings by traditional healers, exorcisms, burning as “cure,” shackles and chains.

The Most Common Violations: What People Actually Experience

Let’s get specific. What does a human rights violation look like in the life of someone with mental illness?

The respondents in the Drew study were asked to list the most common violations they’d experienced or witnessed. The list is sobering, not because it’s surprising, but because it’s so ordinary.

Here are the most frequently mentioned violations, in order:

1. Exclusion, marginalisation and discrimination in the community – This is number one. Not the dramatic abuses, but the everyday experience of being pushed out, ignored, treated as less than human.
2. Denial or restriction of employment rights and opportunities – People who want to work, who can work, are told they can’t. Or they’re never hired. Or they’re fired when their condition becomes known.
3. Physical abuse/violence – Beaten, hit, kicked, burned.
4. Inability to access effective mental health services – Services don’t exist, are too far away, are too expensive or are so poor that they’re not worth accessing.
5. Sexual abuse/violence – Rape, assault, coercion.
6. Arbitrary detention – Locked up without legal process, without review, sometimes for decades.
7. Denial of opportunities for marriage/right to found a family – Forced sterilisation, forced abortion or simply social exclusion from the institutions of marriage and family.
8. Lack of means to enable people to live independently in the community – No supported housing, no community services, no path to independent life.
9. Denial of access to general health/medical services – Turned away from doctors’ offices, hospitals, clinics because of mental illness.
10. Financial exploitation – Money stolen, benefits taken, resources controlled by others.

Read that list again. Notice that most of these aren’t dramatic atrocities. They’re the mundane cruelties of everyday exclusion. The job you can’t get. The marriage you can’t have. The doctor who won’t see you. The community that won’t include you.

This is what human rights violations look like most of the time: not violence, but erasure.

A Closer Look: Pasung in Indonesia

I want to take you to Indonesia now. Because Indonesia has a word for something that happens in many countries, but rarely gets named.

The word is pasung.

Pasung refers to the physical restraint or confinement of people originally criminals, then “crazy and dangerously aggressive people.” It takes different forms: chaining someone to a post, locking them in a cage, confining them with a traditional log.

In 2013, an estimated 57,000 people in Indonesia were held in pasung. Fifty-seven thousand human beings, locked up in chains and cages, in a country that banned the practice in 1977.

Indonesia’s 2014 Mental Health Law makes shackling a criminal offense. But laws on paper don’t always change reality on the ground.

For a long time, pasung attracted little attention. As Minas and Diatri observed in 2008 (link to Minas & Diatri, 2008), the practice “seemed to have aroused little human rights concern, except when mentally ill people in chains have died.”

Think about that. It takes death to get attention. The suffering of living people in chains isn’t enough.

Then, in March 2009, something changed. The Deputy Governor of Aceh province announced a program called Aceh Bebas Pasung, Aceh Free from Pasung. The goal was ambitious: release every person in pasung in the province and provide them with medical treatment and care. The program aimed to eliminate pasung from Aceh by 2011.

In August 2010, the Indonesian Ministry of Health followed with a national program: Indonesia Bebas Pasung. The goal was to eliminate pasung from the entire country by 2014.

That deadline came and went. Then 2015. Then 2017. Then 2020. Then COVID. The date has been postponed multiple times. Implementation is complicated by many factors, lack of resources, lack of services, lack of awareness, deeply held beliefs about mental illness.

But the programs themselves are significant. They represent something rare: governments acknowledging responsibility for human rights abuses against people with mental illness and taking action to stop them. As one observer noted, “Programs such as these have not been developed in any other low or middle-income country.”

The Families: Victims or Perpetrators?

Here’s where this story gets psychologically complicated.

When you hear about people being chained by their families, what do you feel? Anger, probably. Outrage. How could a family do that to their own flesh and blood?

I want you to hold that feeling for a moment and then I want you to consider something else.

What if the families are also victims?

Erminia Colucci, a visual psychologist and human rights advocate, went to Indonesia to make a documentary about pasung. She titled it “Breaking the Chains” (link to Colucci, 2015). She went in with a clear idea: there would be victims (the people in pasung) and perpetrators (the families who chained them).

What she found was much messier.

In scene after scene, she encountered families who weren’t cruel. They were desperate. Terrified. Exhausted. They’d watched their loved one become someone they didn’t recognise. They’d seen them wander off and get lost. They’d seen them become violent or become targets of violence. They’d tried everything, doctors, traditional healers, prayer and nothing worked. They had no money, no access to care, no support, no information. And they were afraid.

Afraid their loved one would get hurt. Afraid they’d hurt someone else. Afraid of what the community would say. Afraid of what would happen if they didn’t do something.

So they did the only thing they could think of. They put on chains. They built a cage.

In the film, we meet Narhim’s mother. She’s very old. She lives in a tiny hut with no electricity, lighting a candle made from a tomato can. Her son is in a cage beside her, a cage with no door, no way in or out. A traditional healer told her it was “his fate to be like this.” She doesn’t know about treatment. She doesn’t know where to go for help. She doesn’t have money to travel even if she did.

Who is the perpetrator here? An old woman in the dark, doing what she was told was fate?

Colucci filmed a scene where she sees both mother and son and suddenly understands: they’re both in cages. His is made of wood. Hers is made of poverty, ignorance, isolation and despair.

This doesn’t mean chaining people is acceptable. It means the problem is bigger than “bad families.” It’s a system that leaves families with no options. It’s a society that offers no support. It’s a world where “fate” becomes the only explanation.

The Power of Film: Documenting the Unseen

How do you show something that most people don’t want to see? How do you make visible the people who’ve been hidden away?

Erminia Colucci chose film. Not just any film, an ethnographic documentary that would capture not just the facts of pasung, but the cultural meanings, the beliefs, the customs, the daily realities.

But film comes with its own ethical challenges.

Colucci worked with a community organisation called Komunitas Sehat Jiwa (KSJ), run by and for people with lived experience of mental health issues. She followed them as they located people in pasung, approached families, negotiated releases and provided ongoing support.

But from the start, she faced difficult questions:

How do you get informed consent from people who’ve never seen a TV, who don’t know what a documentary is, who are deemed “mentally ill” and therefore incapable of consenting?

How do you decide what to film and what not to film? Is it okay to show a person completely naked? A person living in their own excrement? Where is the line between documenting reality and exploiting suffering?

How do you represent people in ways that don’t reinforce stereotypes, the “mad person” as spectacle, as object of pity or horror?

How do you position yourself? As a psychologist? A filmmaker? A researcher? A human rights advocate? What do you call yourself when you walk into someone’s home and ask to film their chained family member?

And perhaps most fundamentally: how do you ensure that the film does more good than harm? That it serves the people it depicts, not just your career or your audience’s curiosity?

Colucci organised workshops with KSJ volunteers to discuss the film’s aims. She made sure they agreed on key people and issues. She asked families for verbal consent before even approaching with paperwork. She sought consent directly from people in pasung whenever possible. She sent the finished film to key participants for their final word. She consulted with experts for nearly three years before releasing it publicly.

Even with all these precautions, she worried. Were participants truly informed? Was the power of the camera, that “pass into people’s lives”, being used ethically? Was she representing “human rights violations” and “mental illness,” concepts built on Western values, in ways that might do violence to local understandings?

These questions don’t have easy answers. But asking them, constantly, honestly, is part of the work.

The result is a film that doesn’t lecture or preach. It doesn’t use voiceover to tell viewers what to think. It lets viewers see for themselves, make their own meaning, become “active participants in the construction of the meaning of the film.”

Colucci wanted different audiences to get different things from it. For a layperson, it’s an introduction to something they’ve never seen. For a mental health professional, it offers deeper understanding of how mental illness is understood in another culture. For a human rights advocate, it shows the complexity behind the headlines.

And at its best, it does what only film can do: it makes you feel what can’t be captured in words. The weight of a chain. The heat of the sun on skin that hasn’t felt it in years. The breeze moving through hair that’s been locked in a dark room. The simple, profound joy of standing outside.

Traditional Healing vs. Biomedical Models: A Delicate Negotiation

Here’s another layer of complexity.

In Indonesia, as in many countries, mental illness is often understood in spiritual terms. Jinn possession. Black magic. Spells. Curses. If the cause is spiritual, the cure must be spiritual too.

Families take their loved ones to traditional healers. To religious leaders. To faith-based healing centres. Often they try multiple options, moving from one to another when nothing works.

And when nothing works, when the traditional remedies fail, when the family runs out of money and hope, they resort to pasung.

Colucci’s film shows this tension repeatedly. In one scene, a young man named Asep, who has been in pasung, is visited by KSJ volunteers. He’s deeply religious, steeped in Islamic teaching. He believes his healing comes from God, not from medicine.

Nurhamid, the KSJ leader, sits with him. He doesn’t dismiss Asep’s faith. Instead, he makes a distinction: spiritual matters are for the soul, but the mind, pointing to his head, needs something else. Asep considers this. “Oh,” he says. “The soul and the mind.”

It’s a moment of negotiation, not imposition. Acknowledging both frameworks, finding a way for them to coexist.

In another scene, Fery (a KSJ volunteer) talks about the challenge of working with families who believe in supernatural causes. He says: “It’s like converting someone from one religion to another.”

This is the delicate work of community mental health in contexts where biomedical explanations aren’t the default. You can’t just march in and tell people their beliefs are wrong. You have to meet them where they are, respect their frameworks and slowly, gently, introduce alternatives.

And you have to be honest about what those alternatives offer. Medication isn’t a magic bullet. It’s one part of a larger process. As Nurhamid tells one father, treatment involves many things: talking to your son, showing love, cleaning him, taking him for walks. The pills are just the beginning.

The film also shows the reality of traditional healing centres, the ones families turn to when nothing else works. Colucci opens the film inside one, without commentary, letting viewers see for themselves. Later, we learn that many of the people in pasung had been to such centres, sometimes multiple times, before being chained.

This isn’t about dismissing traditional healing. It’s about recognising that when traditional healing fails and it often does, because severe mental illness needs more than spiritual intervention, families are left with nothing. And nothing leads to chains.

The Long Road to Freedom: What “Bebas Pasung” Means

So what does freedom actually look like?

A government announces a program. A photo op shows officials releasing someone from chains. Headlines celebrate.

But freedom isn’t a moment. It’s a process. And the process is hard.

In Colucci’s film, we see what “bebas pasung” really involves.

First, someone has to find the people in pasung. They’re hidden, in remote villages, in back rooms, in cages behind houses. KSJ volunteers travel for hours on motorbikes, then walk for hours more, following rumors and tips.

Then they have to talk to families. Convince them that release is possible. That treatment exists. That their loved one can get better. This means countering years of fear, hopelessness and belief in fate. It means offering something concrete, medication, support, follow-up, not just promises.

Then they have to navigate the system. Government approvals. Health insurance cards. Hospital admissions. All of this takes time, money and persistence.

Then they have to provide ongoing support. Medication delivery. Home visits. Monitoring for relapse. Helping the person regain skills lost during years of confinement. Sudikin, in the film, had to learn to walk again after being restrained so long he’d lost the ability.

Then they have to fight for rehabilitation centres, places where people can recover not just medically, but socially and functionally. As one psychiatrist in the film says, many pasung victims need to start “back to zero.”

And throughout, they have to manage expectations. Freedom doesn’t mean cure. It means a different kind of life, with different challenges.

The film’s closing scene is a metaphor for this ongoing work. The rice fields that opened the film, full, ready for harvest, are now bare, with new seedlings planted. A new cycle has begun. And Fery, one of the volunteers, is taking out his notebook, writing down information about a new pasung case. The work never ends.

A Brief History of Mental Health Law

Laws about mental health haven’t always existed. And when they did appear, they weren’t always helpful.

Early mental health laws were often about control, not rights. About confining dangerous people, not protecting vulnerable ones. About legitimising coercion, not preventing abuse.

The WHO/UN guidance (link to WHO/UN, 2023) traces this history. Since the 1970s, legislation has been increasingly influenced by rights-based discourses. The focus shifted to regulating the use of mental health powers, involuntary commitment, forced treatment, restraint, seclusion. Laws began to include procedural safeguards, criteria for compulsion, appeals processes.

The European Court of Human Rights developed jurisprudence on these issues. The UN’s 1991 Principles for the Protection of Persons with Mental Illness (the “MI Principles”) prompted a new wave of law reform around the world.

But a few countries took a different path. Italy, in 1978, adopted Law No. 180, the Basaglia Law, named after psychiatrist Franco Basaglia. It didn’t just regulate coercion. It fundamentally reorganised mental health services. It banned new admissions to mental hospitals and began closing existing ones. It required the development of community-based services. It shifted the entire model from institution to community.

The Basaglia Law has been highly influential, especially in Latin America. And approaches based on it are now being piloted in the UK.

Today, most countries have stand-alone mental health legislation. A 2020 WHO survey found that 111 out of 171 countries (65%) have such laws. But having a law doesn’t mean having rights. Many of these laws are outdated, narrow and based on a reductionist biomedical model. They include provisions for limiting rights, involuntary treatment, restraint, seclusion, without adequate safeguards. They reinforce power structures and contribute to the oppression of marginalised populations.

The adoption of the Convention on the Rights of Persons with Disabilities (CRPD) in 2006 created new momentum for reform. But most countries have not yet challenged the longstanding biomedical approaches that underlie their laws.

The Convention on the Rights of Persons with Disabilities: A Paradigm Shift

In 2006, something important happened. The United Nations opened for signature a new treaty: the Convention on the Rights of Persons with Disabilities.

This wasn’t just another human rights document. It represented a fundamental shift in how disability, including psychosocial disability, is understood.

The CRPD was opened for signature on March 30, 2007. It entered into force on May 3, 2008, the first comprehensive human rights treaty of the 21st century.

Here’s what makes it different: it marks a “paradigm shift” in attitudes and approaches to persons with disabilities. It moves from viewing persons with disabilities as “objects” of charity, medical treatment and social protection, to viewing them as “subjects” with rights, capable of claiming those rights and making decisions for their lives based on their free and informed consent. As active members of society.

For people with mental and psychosocial disabilities, this is huge. It means:

• They have the right to legal capacity on an equal basis with others. They can make their own decisions, enter contracts, marry, vote.
• They have the right to live in the community, with choices equal to others. No more institutionalisation by default.
• They have the right to give free and informed consent to treatment. No more forced interventions without their permission.
• They have the right to participate in all decisions affecting them. No more decisions made about them without them.

The CRPD doesn’t just prohibit discrimination. It requires active support for people with disabilities to exercise their rights. It recognises that equal rights require different kinds of support.

This is the framework that should guide mental health law and policy today. Not the old model of “protecting” people by taking away their rights. But the new model of supporting people to exercise their rights.

What Actually Works: Strategies for Change

So what do we do with all of this? How do we move from documentation to action?

The respondents in the Drew study were asked what strategies would improve the human rights of people with mental and psychosocial disabilities. Their answers provide a roadmap.

Here are the major strategies they identified, in order:

1. Public awareness and anti-stigma campaigns – Education about rights and about mental health. Changing the beliefs that underlie discrimination.

2. Better training for mental health professionals, increased funding and better services, especially in the community – You can’t have rights without services. And services need to be where people live, not in distant institutions.

3. Empowerment, rehabilitation and community participation – Not just treating people, but supporting them to live full lives in their communities.

4. Effective and humane laws and policies – Laws that protect rights, not just regulate coercion. Laws aligned with the CRPD.

5. Support for organisations of people with mental and psychosocial disabilities – Nothing about us without us. People with lived experience must lead the way.

6. Monitoring and assessment of human rights in mental health services – You can’t fix what you don’t measure. Independent oversight is essential.

7. Integrating mental health into overall health and development policies – Mental health can’t be an afterthought. It must be part of every relevant policy.

The WHO/UN guidance adds more detail. It proposes that legislation on mental health must take a new direction, away from the narrow traditional “biomedical paradigm” that has contributed to coercion and confinement. New approaches should:

• Set a clear mandate for mental health systems to adopt rights-based approaches
• Enable person-centred and community-based services
• Raise awareness and challenge stigma
• Eradicate discrimination and coercion
• Promote community inclusion and participation
• Develop accountability measures

And crucially, this new direction requires the engagement and participation of those with lived experience in shaping the law. As the guidance puts it: “This collaborative approach is essential to create a mental health system that respects human rights, prioritises care and support over control and supports individuals in achieving their full potential.”

Conclusion: The Chains We Don’t See

I keep coming back to that smell. The open sewer. The wretchedness inside.

But I also keep coming back to something else: the moment in Colucci’s film when Yayah, released after 17 years in chains, stands outside and smiles. The breeze moves her hair. Someone comments on how fair her skin is, skin that hasn’t seen sunlight in almost two decades.

Simple things. The warmth of the sun. The freshness of the wind. The movement of a leg. Things that can be taken away for 17 years, for a lifetime, because of mental illness. Because of poverty. Because of ignorance. Because of fear. Because of a world that looks away.

The human rights of people with mental and psychosocial disabilities cannot be fully realised without resources. Without services. Without trained staff. Without community support. All of that costs money and money is scarce.

But much can be done now. With what we have. With what we know.

Well-formulated policies and laws, aligned with international human rights standards. Genuine involvement of people with lived experience. Public education that changes hearts and minds. Community services that offer real alternatives to chains and cages. Monitoring that holds systems accountable.

And maybe most importantly: the willingness to see. To not look away. To recognise that the chains are real, even when they’re hidden. That the cages exist, even when we don’t visit them. That the people inside are human beings, with the same rights as anyone else.

The rice fields in Colucci’s film are harvested, then planted again. Cycles end, cycles begin. New stories emerge, new work waits.

Fery takes out his notebook. There’s another person in pasung. Another family to visit. Another negotiation. Another chance at freedom.

Change needs awareness, services, inclusion, and lived experience leadership. We must see people fully; learn, act, read next blog: Adolescence: The Myth of Storm and Stress: A Psychological Deep Dive

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