Talking about mental health

Following the 18th Amendment to the constitution of Pakistan, health became a provincial subject. Thereafter, the provincial assemblies adopted – and in certain cases updated – the former laws that loosely captured the subject of mental health such as the Mental Health Ordinance, 2001 and the Disabled Person (Employment and Rehabilitation) Ordinance, 1981.

Sindh and Punjab have a rudimentary legislative framework in place to address mental health while all four provinces and the Islamabad Capital Territory have enacted laws that govern the rights of disabled persons. These include: the Disabled Persons (Employment and Rehabilitation (Amendment) Act, 2012 (Punjab), Sindh Empowerment of Persons with Disabilities Act, 2018, Balochistan Persons with Disabilities Act, 2017, Khyber Pakhtunkhwa Disabled Persons (Employment and Rehabilitation) (Amendment) Act, 2012, and the ICT Rights of Persons with Disability Act, 2020. While the precise definition of a ‘disabled person’ varies across the provincial laws, the idea that a mental impairment constitutes a disability is reinforced across the board.

Symptoms of mental illness lie on a continuum of thoughts, feelings and emotions which are experienced by all humans; however, clinicians have identified certain arbitrary cut-off points wherein these symptoms become so severe that they constitute a mental disorder or illness. Traditionally to legitimize mental illness, mental disorders have been explained in terms of biological dysfunctions. The narrative that depression is caused by a chemical imbalance in the brain and is akin to a broken bone aims to increase the awareness and acceptability of mental illness in society.

A more nuanced theory is the network theory of mental disorders introduced by the Dutch psychologist Denny Borsboom in 2017. Borsboom argues that the biological, psychological and environmental aspects of mental illness exist in an interacting web and influence each other. According to the triple network model, an external event could be a biological trigger for a mental illness to manifest. Hence, a multi-sectoral approach is necessary to ensure good mental health, enabling individuals to deal with the stresses of life unique to their circumstances.

In academia the labels of ‘illness’ and ‘disorder’ used to discuss psychological suffering have been debated as they purportedly encourage the medicalization of human distress and can lead to the stigmatization of individuals. Dr Lucy Foulkes, a psychologist and author of ‘Losing Our Minds: What Mental Illness Really Is – and What It Isn’t’, has nonetheless argued that “some psychological experiences are so distressing and disabling that the labels of illness and disorder can be useful and necessary”.

In the United Kingdom, under the Equality Act, 2010, a person is considered to have a disability if s/he has a mental impairment; and if the impairment has a substantial and long-term adverse effect on his ability to carry out normal day-to-day activities. The classification of a person suffering from physical or mental impairment as disabled under the law may enable him/her to, avoid discriminatory conduct, equitably exercise his fundamental rights and maximize participation in all spheres of society.

To create an equal society, it is necessary to grasp that each person has different circumstances and hence resources and opportunities should be allocated accordingly to ensure an equal and just outcome. This concept has been endorsed by the superior judiciary in its discussion on the employment quota for disabled persons. Justice Mansoor Ali Shah has observed that compulsory employment of disabled persons through the quota system is half the story while, “the other half and perhaps the more important half is to provide the infrastructure, access, support, and facilities, so that persons with disabilities, once appointed to a post, can perform their job without feeling physically or emotionally incapacitated in any manner.”

Language plays a crucial role in ‘the more important half’ of all efforts, as social discourse is driven by ordinary parlance and hence the mainstream vernacular is central to the perception, understanding and acceptance of concepts such as disability and mental well-being. The use of terms such as ‘retarded’, ‘mental’ and ‘bi-polar’ in a derogatory context or as a form of insult is incendiary as it delegitimizes the reality and daily strife of disabled persons. The terminology that dominates conversations surrounding mental health is often influenced by legislation and jurisprudence.

In recent times, our superior courts have fastidiously analyzed the subject of disability in view of existing legislation and Pakistan’s international obligations including its accession to the UN Convention on the Rights of Persons with Disabilities. As chief justice of the Lahore High Court, Justice Mansoor Ali Shah had, while commenting on the terminology used to address disabled persons, astutely observed that: “a disability is what someone has, not what someone is. A disability is an umbrella terms [sic], covering impairments, activity limitation, and participation restrictions.”

The appropriate nomenclature used to address disabled persons was reiterated by Justice Mansoor Ali Shah upon his elevation to the Supreme Court wherein he observed that “words like ‘disabled’, ‘physically handicapped’ and ‘mentally retarded’ deeply bruise and offend human dignity of persons with different abilities. The federal government and the provincial governments are directed to discontinue the use of these words in official correspondence, directives, notifications and circulars and shift to ‘persons with disabilities’ or ‘persons with different abilities’.” Acceptance of persons with disabilities as equal and able members of society is likely to be a corollary of the adoption of appropriate terminology at an executive level.

A step towards addressing the national mental health challenges was Pakistan’s assent to the WHO’s Mental Health Action Plan 2013-2020. To advance its overall goal of promoting mental well-being, the action plain has the following objectives: (i) to strengthen effective leadership and governance for mental health; (ii) to provide comprehensive, integrated and responsive mental health and social care services in community-based settings; (iii) to implement strategies for promotion and prevention in mental health; and (iv) to strengthen information systems, evidence and research for mental health.

While there has been little progress in achieving the targets under the WHO’s action plan, Pakistan’s Federal Ministry of Planning, Development and Special Initiatives has recently launched a Mental Health & Psychosocial Support (MHPSS) initiative funded by Unicef. This initiative is key as it acknowledges the complexity of mental health problems and adopts an inter-sectoral approach to address the surmounting challenges while providing a template for the provinces to implement.

How we think, how we talk about and how we address the subject of mental health at an administrative level will portend the mental wellbeing of Pakistan’s young population.

The writer is an advocate based in Karachi.

Email: maria.shah257@gmail. com