Taboo disease

Young people, particularly women, suffering from depression are frequently told they need to get married.

Two men and a woman came visiting a working woman in Islamabad. They told her she was ill and they would take her to a hospital. She denied their claim and refused to go with them. Her protest was dismissed. She was gagged and forcibly taken away while her roommate watched helplessly.

Nine days later, the National Commission for Human Rights (NCHR) received a call from Shamera*, the roommate, who said her friend Almas* had been forcibly taken away and was being kept at a rehabilitation centre on the outskirts of Islamabad. A police team and officials from the Health Department accompanied the NCHR team that rescued the woman who is 35 years old and an MPhil student. She has a senior job at a multinational company. She has since been found sane and articulate, if shaken.

In a detailed interview at the Commission it transpired that Almas’s abduction and incarceration was a part of an attempt by her parents to persuade her to marry the man of their choice. The anger and frustration she had exhibited at the prospect of an unwelcome arranged marriage was diagnosed by a local psychologist as ‘depression.’ The psychologist also referred her to the mental health centre from where she was later recovered. The fact that a therapy centre connived and plotted in the abduction of a healthy adult woman raises important questions about regulation of mental health facilities in Islamabad.

While all the provinces have Mental Health Acts, no Mental Health Act governs the federal capital. Despite being a signatory to World Health Organisation’s Mental Health Action Plan 2013-2030, Pakistan has no national mental health plan. Nor has the government made sufficient budgetary allocations to address mental health. According to a Cambridge University article titled ‘Pakistan’s Legal Failure To Account For Mental Illness’, the government’s expenditure on mental health is 0.40 percent of its total health expenditure.

Other than psychiatrists, mental health professionals, including counsellors, psychologists and therapists in Islamabad are not regulated or licensed by any national accreditation body. According to the Islamabad Healthcare Regulatory Authority (IHRA), of the 20 plus private mental rehabilitation homes in Islamabad, none has a full time psychiatrist. The rehabilitation home that incarcerated Almas also had no regular licensed psychiatrist on full time duty.

The lack of regulation of mental health centres means that anyone can offer mental health counselling, treatment and rehabilitation housing without appropriate checks. This is particularly alarming in Pakistan, where estimates indicate that approximately 40 percent of the population (88 million) suffer from common mental disorders.

Mental health is both a cause and consequence of poverty, violence, extremism and political unrest. According to a PBS report A Curse From God — the Stigma of Mental Illness in Pakistan, the country “has been in a state of post-traumatic stress, from the Afghan war, ethnic tension, religious violence and terrorism.”

Pakistan has approximately 500 registered psychiatrists for a population of over 220 million people. This averages one psychiatrist for 440,000 people in the country. Some 90 percent of Pakistanis who suffer from some sort of mental disorder remain untreated. The shortage of certified psychiatrists gives space to self- proclaimed therapists and counsellors who exploit the poor and unknowing. More often than not, young people, particularly women, suffering from depression are told that they simply need to get married. Thousands of troubled persons are taken to shrines where they are beaten and chained to have djinns exorcised. Ignorance and limited availability of proper mental health practitioners lead to quackery and opportunism.

Pakistan has about 500 registered psychiatrists for a population of over 220 million. This averages a psychiatrist for 440,000 people in the country. About 90 percent of Pakistanis who suffer from some sort of mental disorder remain untreated.

Archaic methods of drugging patients - even use of electric shock therapy - are commonplace. Complaints of blackmailing patients are also common. Almas recounted horror stories of several patients at the centre where she had been kept. She spoke of being locked away in solitary confinement, of being repeatedly drugged and remaining in a state of disorientation. One can only imagine the vulnerability of people with actual mental illnesses.

In Pakistan, the shame and stigma attached to mental health also means very few people seek medical help and treatment when they need it. Fear of being labelled, of being discriminated and fear of societal disapproval forces family members and patients to remain in denial or seek alternate non-medical support and redress. Thus, therapy centres and non-medical, unregulated counselling agencies have sprung up throughout Pakistan.

In 2018, the federal capital set up the Islamabad Healthcare Regulatory Authority (IHRA) as an autonomous health regulatory body enacted under the Islamabad Health Regulation Act. According to its mandate, the IHRA aims to improve the quality, efficiency and safety of healthcare services delivery by adopting evidence-based regulatory standards for registration and licensing of healthcare establishments, health professionals and equipment, and developing and enforcing minimum standards of safety for patients, healthcare professionals and other staff in healthcare establishments in the ICT.

According to the Act, healthcare professionals include psychiatrists and psychologists but not therapists or counsellors. Therapy and rehab centres operate outside the purview of the regulators. Without licensing, regulation and standards, quackery and exploitation continue. Almas’s mother had paid the rehabilitation home Rs 200,000 to house and ‘treat’ her daughter for ‘depression.’

In order to address the huge gaps in licensing and standardisation of mental health facilities, the NCHR and Taskeen Sehatmand Pakistan, a non-profit organisation working for prevention of mental illness in Pakistan, are developing a policy brief on mental health and human rights. In its fact finding report, the NCHR has collected quantitative data on number and types of mental facilities available in Islamabad. The NCHR has also developed a gap analysis of mental health legislation in Pakistan and in collaboration with Taskeen drafted a Mental Health Bill for Islamabad which will be made public shortly.

It is about time the discourse on mental health was brought to the fore. Public education to increase knowledge about mental illnesses and the implementation of laws and policies will ensure that regulated support is available to those in need. Acceptance and education on mental illnesses by society and proper regulatory mechanisms provided by the government are essential to combat this problem. State regulatory mechanisms include standards regarding consent, dignity and care, proper staffing and monitoring and evaluation systems.

Almas’s is likely just one of many sad and horrific stories that takes place in our federal capital, just the tip of the iceberg with regard to mental health problems in Pakistan.

We need to talk more openly about mental health and without discrimination. It is time Pakistan realised that invisible disabilities, such as mental health, are among the most neglected yet essential issues for development and human rights in the country.

The writer is the chairperson of the National Commission for Human Rights

Taboo disease