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Epidemiology and Society Health Review| ESHR 
 

Vol 2, No 2 (2020) 
 

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Research Article 
 
The different mental health patient quality of life during 
shackling, treatment, and post treatment 
 
Arif Widodo1* and Supratman1 
do1 and Supratman1 
1 Department of Nursing – Health Science Faculty – Universitas Muhammadiyah Surakarta, 
Central Java, Indonesia. 
 
*Correspondence: arif.widodo@ums.ac.id.  Telp: +628164272436. 
Received May 05, 2020; Accepted May 28, 2020; Published May 28, 2020 
 

ABSTRACT 

Background: Mental health is a well-being mental state associated with happiness, joy, 
satisfaction, achievement, optimism, and hope. Good mental health allows a harmonious and 
productive life as an integral part of one's quality of life by taking into account all aspects of 
human life. This study aims to assess the different quality of life among mental health disorder 
patients during shackling, treatment, and post-treatment in Sukoharjo Regency. 
Methods: Quantitative descriptive was used in this study. Our population was all mental 
disorder patient in Sukoharjo District who has experienced with shackling and finished the 
treatment in the RSJD “dr Arif Zainudin," Surakarta during 2011-2015. We took total sampling 
and excluded patients who died, move to another place, and recover. Thirty out of thirty-four 
post-shackling patients in the Sukoharjo Regency participated in this study. A tested 
questionnaire was used to collect the data from the patient. The analysis was performed using 
univariate analysis – central tendency value analysis.   
Results: We found differences in patients' quality of life during shackling, treatment, and post-
treatment. The survivor had the highest quality of life in the post-treatment phase compared 
to the shackled and treatment period. 
Conclusions: The quality of life of post-treatment patients is better compared during shackled 
and treatment.  

Keywords: quality of life, post shackling patients, people with mental disorders 

 

INTRODUCTION 

The Indonesia Law Number 18 of 2014 concerning Mental Health, in Chapter 1, Article 1, 
states that mental health is a condition of an individual who can develop physically, mentally, 
spiritually, and socially. Accordingly, the individual realizes his ability, able to overcome the 
pressure, work productively, and contribute to the community (1).  

Mental health is a state of happiness, joy, satisfaction with the achievement of its business; it 
is a prosperous condition when someone enables to realize his potential, has good coping to 
stressors, productive, and can make a positive contribution to society (2,3). Furthermore, 
according to Johnson, mental health is an emotionally, psychologically, and socially healthy, 
as seen from satisfying interpersonal relationships, effective coping behaviors, positive self-
concepts, and emotional stability (4). 



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World Health Organization (WHO) report in 2003 stated that there were 450 million people in 
the world who had mental disorders (5). Human Rights Watch reported, Indonesia, that has 
more than 250 million of citizen only has 600-800 psychiatrists. It means that one psychiatrist 
should handles 300,000 to 400,000 mental disorder patients (6). 

According to Indonesia basic health research/Riskesdas, the prevalence of 
schizophrenia/psychosis increased from 0.17 % to 0.18% (7,8). The incidence of 
schizophrenia/psychosis in Central Java in 2018 was 0.25% among 34,490,835 citizens. This 
number implies 86,222,709 psychotic patients must be treated (8). The capacity of psychiatric 
care services in Central Java is under 1,000 beds. This condition proves that psychiatric 
services can serve not all patients at the mental hospital in Central Java. The remaining 
untreated patients were in the community; they need close supervision by the health authority. 
Mental disorder patients, especially psychosis, will experience a reality orientation disorder, 
mood changes, personality disorder, habits, and or withdrawal that end up isolating 
themselves (9). The most psychotic patients are schizophrenic patients, who may initially be 
calm, but sometimes unexpectedly become aggressive without apparent psychosocial 
stressors. Accordingly, the family and community shackled survivors to avoid unexpected 
events such as hurt and disturbing themselves and surrounding people.  

Factors that affect the quality of life of schizophrenic patients are essential to be studied to 
see the indicators of people's mental health. Factors which influence the quality of life of 
schizophrenic patients: 1) socio-demographic variables such as gender, marital status, 
education level, occupation, and income level, 2) clinical variables, for instance, psycho-
pharmaceutical use, side effects of drugs consumption, delay in getting treatment, and 
agitation (10). 

After shackling, survivors may recover from severe mental disorders, get back to the 
community for work, and live like ordinary people. However, the recovery process does not 
always run smoothly; sometimes, there are ups and downs. To reach the recovery process 
well, it needs support from various parties, especially from the survivor family or close friend, 
health workers, their fellow, and their surrounding communities. 

Based on the above background, we are interested in examining the differences in the quality 
of life of patients being shackled, the time of care, and post-treatment of patients after 
shackling in the Sukoharjo Regency. 

METHODS 

This study aimed to assess the different quality of life of mental health disorder patients during 
their shackling, treatment in hospital, and post-treatment in Sukoharjo, Central Java of 
Indonesia. We designed this study using quantitative descriptive. A tested questionnaire was 
employed to collect information from the respondent. Questionnaire consist of 23 Likert scale 
items: always, frequently, sometimes, ever, never. The favorable questions were scored from 
4 to 0 and vice versa for unfavorable questions. We involved all patients who recorded in 
mental health hospitals/RSJD “dr Arif Zainudin” of Surakarta and excluded patients: died, 
move to another place, and recover. The analysis was performed using univariate analysis by 
central tendency analysis.  

RESULTS 

Thirty out of thirty-four post-treatment patients in RSJD "dr Arif Zainudin" of Surakarta 
participated in this study. One patient died, two patients were moving to another place, and a 
patient has been recovering.  Characteristic of the respondent was presented in Table 1. 
 



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Tabel 1. The Distribution of Respondent characteristic frequency 
 

Characteristic Frequency 
N = 30 

% 

Sex 
Female 14 47,7% 
Male 16 53,3% 

Education  
Elementary 10 33,3% 
Junior High School 10 33,3% 
Senior High School         9 30,0% 
Bachelor/Diploma            1 3,4% 

Time of being mental health disorder survivor 
< 10 years 2 6,7% 
11 – 20 years 18 60,0% 
> 20 years 10 33,3% 

Time of being shackled 
< 10 years 18 60,0% 
11 – 20 years 10 33,3% 
> 20 years 2 6,7% 

Time of being treated in mental disorder hospital  
< 5 months 12 40,0% 
6 – 10 months 13 43,3% 
> 11 months 5 16,7% 

 

The majority of the respondent (53.3%) were male. Most of the respondents were graduated 
from elementary school. Sixty percent of respondents were mental health disorders for 11-20 
years. More than half of the respondents were being shackled for less than ten years. Most of 
them were being treated in hospital for 6-10 months (Table 1).  

The difference in the quality of life during shackling, treatment, and post-shackling can be seen 
in Table 2. During shackling, we found 37.90 of the mean. The shackling period experienced 
an increase in quality of life with a mean of 53.56. Subsequently, post-shackling experienced 
an increase in quality of life, marked with the mean 64.73. 

Table 2. Statistical Data on Quality of Life Scores when being shackled. 
 

Quality of Life Mean Median 
 Score 

SD 
Minimum Maximum    

Being Shackled 37.90 33.00 22.00 69.00 10.66 
 
Treatment 53.56     53.00        37.00         82.00 10.22 
Post-treatment 67.30 71.50 42.00 91.00 11.89 

 

Table 3 shows the different quality of life of the mental health disorder survivor. We 
found that the quality of life was different in the 3 different stages. In the shackled 



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period, the survivor had a low quality of life. It was different in the treatment period 
where the survivor in a moderate level of quality of life. Last, in the post-treatment, the 
survivor had a high or good quality of life. 

Table 3. Frequency distribution of quality life 
 

Quality of Life Being shackled  
      N (%) 

Treatment  
     N (%)   

Post-treatment  
         N (%) 

High 2 (6.7) 5 (16.7) 15 (25.0) 
Moderate 12 (40.0) 20 (53.6) 11 (36.7) 
Low 16 (53.3) 5 (16.7) 4 (13.3) 
Total 30 (100) 30 (100) 30 (100) 

DISCUSSIONS 

People with mental disorders who are depressed can get trauma, feel discarded, inferiority, 
despair, and hatred to their family (12). They also suffer from stigma and discrimination from 
other people that produce the worst situation for the survivor. Stigma, discrimination, and 
beatings by families most often experienced by people with mental illnesses (ODGJ). 
Shackling also occurs due to a lack of understanding of the community toward mental health 
(13).  

Previous research said that shackling is considered a necessary step to protect patients and 
others from the aggressive behavior of patients (14). The lack of finances and dissatisfaction 
with mental health care services forced the family members to seek alternative treatment. Poor 
knowledge and misunderstanding about schizophrenia are common in family members and 
community leaders. Improving mental health services, especially in rural areas and 
emphasizing accessibility and quality, is very important. Health education about 
schizophrenia, common misconceptions, and timely administration and appropriate treatment 
are urgently needed.  

The study results showed that the quality of life of patients during the treatment period was 
mostly moderate. This indicates that the quality of life of patients during the treatment has not 
entirely changed better compared to survivor in a shackled period. Shackling causes the 
patient not to be able to stand up, contracture, damage organs, ease for infectious diseases 
such as tuberculosis, death, separate from family, getting worst of mental disorders, slow 
healing, alienation, embarrassed, and violate human rights. 

Appropriate care and support to people with mental disorders can individually recover from 
their illness and have a satisfying and productive life. Recovery is the process in which a 
person can live, work, study, and participate fully in his community. The results are shown with 
a mean of 53.56 of the patients' quality of life during the treatment period. Efforts to restore or 
rehabilitate people with mental disorders aim to prepare shackling patients in the community; 
therefore, a psychosocial rehabilitation program is needed. Psychosocial rehabilitation service 
programs for people with a post-shackling mental illness are required to restore individuals 
both of their rights and functions as independent citizens; and also can improve their social 
skills both in the family and community. 

The study results showed that the quality of life of patients after treatment was mostly in the 
high/good category. This indicates that post-treatment patients have improved their quality of 
life. Problems that still happen after retention are in the form of stigma and discrimination. 
People with mental disorders often get stigma from the surrounding environment. The stigma 
is inherent in himself and his family. This is because people with mental illnesses are believed 



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to be dangerous and unpredictable, less competent, unable to work, must be treated at the 
mental hospital, and will never get healthy (15). Mental disorders lead to a decrease in 
productivity, increase maintenance costs, and tend to cause problems, such as persecution 
and torture. Appropriate care and support to people with mental disorders on an individual 
basis can recover from illness and have a satisfying and productive life. Recovery is the 
process in which a person can live, work, study, and participate fully in his community. Return 
is the ability to live a good and productive life. Rehabilitation is a variety of activities in the form 
of physical activity, psychosocial adjustments, and vocational training to prepare them and 
obtain a maximum function and adjustment. 

Quality of life is an individual's perception of his position in life, has to do with values and 
cultural systems related to ideals, hopes, and views, which are multidimensional 
measurements. They can not be measured only on physical effects and psychological 
treatment (16). It is explained that the factors related to a person's quality of life are age, sex, 
level of education, and employment (17).   

Previous research shows that the misuse of human rights shackling cases does not represent 
the family or society's ignorance or refusal of psychiatric treatment. But it is linked to the 
neglect of the government and the responsibility to provide essential mental health services 
for people with mental illness (18). Systematic strategies need to be developed to eradicate 
this practice. This will require the collaborative participation of policymakers, service 
developers and managers and health professionals, development NGOs, bilateral institutions, 
and civil society organizations, including those who have a vivid focus on promoting and 
protecting the most vulnerable human rights in low-resource settings. 

Finally, the only effective and sustainable strategy to eradicate this practice is to ensure the 
families and communities have affordable and equitable access to essential mental health 
services. Provision of basic community mental health services, where none existed before, 
allows the majority of people who have detained to receive psychiatric treatment and will be 
released from shackles. 

This study shows that the majority of post-treatment psychiatric patients have an adequate 
quality of life. This condition is possibly caused by families' ability to care for and utilize health 
services to increase the quality of life of patients after treatment. Caring for a sick family 
member is a form of affection that occurs between family members. The study's results are 
supported by previous findings that families' ability to care for post-shackling patients 
dramatically influences the quality of life of shackling patients (19). It is supported by the 
ignorance of the community or family who has a family member suffers from a mental disorder 
toward the treatment. In simple terms, the community needs to be given an understanding of 
shackling; it is following all acts of binding and physical restraint that can result in the loss of 
one's freedom. From this point of view, deprivation includes neglect, is contrary to humanity, 
and violates human rights (human rights) and to sufferers of mental disorders (19). 

This research shows the differences in quality of life during shackling, treatment, and post-
spackling. When on shackling, the mean was 42.06, the shackling period experienced an 
increase in quality of life with an average of 53.56. Subsequently, post-shackling experienced 
an increase in quality of life, namely the mean obtained 64.73. This study shows that there 
are differences in the quality of life when shackling, treatment period, and post-treatment in 
the working area of Sukoharjo District Health Center. This is because post-shackling 
psychiatric patients are free from restraints and have received proper care, but this also does 
not rule out recurrence and retention. Proper family care for people with a mental health 
condition affects the success of the patient's treatment. The results of this study are supported 
by previous research that providing schizophrenia patient relaxation is very effective in 



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reducing muscle tension, anxiety, and fatigue experienced by clients, which will affect the 
client's mental status (20). 

The family is the main "nurse" and the biggest support system for clients. Mental disorders 
experienced by clients will cause a variety of responses from the family and the environment, 
one of them is in the form of shackling one by the family of people with a mental health 
condition when they are deemed dangerous for the environment. Shackling done by the family 
is strongly influenced by family behavior, including predisposing, enabling, and reinforcing 
factors. The concept of family is elaborated through several aspects, namely ability, function, 
role, task, and family characteristics. All of these factors affect the ability of families to take 
care of mental disorder patients. 

The results of this study are supported by previous research, who stated that there is a 
relationship between relapses in schizophrenia patients (20). It shows that with a good attitude 
in the family can prevent the recurrence of schizophrenic patients. The family attitude of 
schizophrenia patients in this study attitude can be an effective or positive or negative 
assessment of an object, which is an effort to improve family attitudes in providing support or 
caring for schizophrenic patients. It is done by increasing their knowledge first because the 
level of knowledge will determine one's attitude and behavior. In this respect, someone can 
play a role in improving health at home and their behavior. 

Former research explained that prevention of containment could be carried out with 
simultaneous efforts to strengthen basic mental health services and health education 
regarding schizophrenia or mental illness, common misunderstandings, and the importance 
of timely and appropriate care needed, especially in rural areas (21). Generally, family 
members and the community assume that shackling is required for safety reasons because of 
the patient's aggressive behavior, such as physical violence against neighbors, stealing food, 
and others. According to community leaders, families often do not respond to patient requests 
to be released from shackles. Family members have a lack of finance to seek mental health 
care and are also dissatisfied with the services. Health service providers have insufficient 
knowledge and prevailing misconceptions about schizophrenia in the community. 

The form of care activities on the simple matter is possible to be carried out by the family; it 
gives a spontaneous feeling of care done by other family members. Furthermore, it can be 
concluded that the ability of the family to carry out the task of caring for sick family members 
will minimize the possibility of psychiatric patients who are being shackled. Shackling 
decreases the physical and social abilities of the patient in their life. Research shows that the 
impact of shackling decreases the ability to care for themselves, the cognitive abilities of 
patients, and the ability of patients to interact with social life. Mental illness is still carried out 
by families nowadays (22). The situation is contrary to the declaration of the Minister of Health 
of the Republic of Indonesia on October 10, 2010, namely Towards Indonesia Free Shackling. 
The reason is that it violates the law owned by the Indonesian state because mental disorders 
can be cured, and people with mental disorders are entitled to humanized treatment and 
treatment services. Thus, Indonesia Free Shackling has the meaning of efforts to make 
Indonesia free nationally from the practice of shackling and neglect of people with mental 
disorders. Another research concluded that psychosocial care for adolescents who live with 
parents with shackling patients should consider the psychological and social impacts as a 
result of caring for their parents with shackling (23). 

Using family approaches, we can improve the quality of a person's life. Health promotion from 
the labor force health to family and patients, it is a form of family care with and health workers 
to improve the quality of life of patients with a fitted mental disorder (24). A study said that 
there was a strong relationship between saving and household economic status (25). 
According to Indonesia basic health research/Riskesdas, the most contributing factor to 



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shackling in Indonesia is the household financial status (8). This factor is worsened by the lack 
of health care facilities and the distance from urban areas.  

CONCLUSIONS 

The quality of life of post-shackling patients in Sukoharjo regency when being installed has a 
low quality of life. There is a difference between the quality of life of patients when being 
shackled, the period of treatment, and post-treatment of shackling patients in the working area 
of Sukoharjo Health Center, namely the mean at shackling 37.90, the period of treatment 
53.56 and post-treatment 67.30. 

Authors’ Contribution 

All authors contributed equally to writing these articles. 

Funding 

This research was funded by LPPM Universitas Muhammadiyah Surakarta.   

Conflict of interest 

All authors declare that there is no conflict of interest. 

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