The loud knocks on the front door break her concentration. It is late evening. She is working frantically to complete her office presentation, now only halfway done despite the early morning deadline. She hears noise, arguments and a scuffle as her roommate attends to the unknown evening visitors. Within moments they are in her room. Two men and a sour faced woman shouting down at her, commanding her to accompany them to hospital. They assert she is ill and needs their help. Her denial, her urgent protests, get no response. A rough cloth gags her mouth. She remembers seeing her roommate crouching in a corner as she is physically carried out into the evening darkness of her little apartment in E 12 Islamabad.
Rabiya Javeri Agha
Chairperson
National Commission for Human Rights
Nine days later, the National Commission for Human Rights receives a troubled call from Shamera, the roommate, who informs that her friend Almas has been forcefully locked in a rehab on the outskirts of Islamabad since that eventful day. With police and officials from the Health department in tow, the Commission rescues the girl. She is 35 years old, an M Phil student and a senior level employee at a Multinational Company in the city. She is sane but shaken. She is articulate and clear on the injustice meted out to her.
In a detailed interview at the Commission it transpires that Almas’s abduction and incarceration was simply an attempt by her parents to convince her to marry the man of their choice. The anger and frustration that she felt towards an unwelcome arranged marriage was diagnosed as ‘depression’ by a local psychologist who referred her to the mental health center in E 12. The fact that a therapy center connived and plotted in this unjust act of abduction of a perfectly healthy adult woman raises important questions about regulation of mental health facilities and therapy centers in Islamabad.
While all the provinces have Mental Health Acts, there is no Mental Health Act in the Federal Capital. Despite being signatory to WHO’s Mental Health Action Plan 2013-2030, Pakistan has no national mental health plan nor has the Government made sufficient Names changed for privacy budgetary allocations to address mental health. According to an article by Cambridge University entitled ‘Pakistan’s legal failure to account for Mental illness’, the government’s expenditure on mental health is 0.40% of its total health expenditure.
Other than psychiatrists, mental health professionals, including counselors, 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 twenty 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.
Little regulation of mental health centers means anyone can offer mental health counseling, treatment and rehabilitation housing without checks and balances. This is particularly alarming in Pakistan, where estimates indicate that approximately 40% of the population (88 Million) suffers 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.”
Despite these alarming facts, Pakistan has approximately 500 registered psychiatrists for a population of over 220 million people. This averages 1 psychiatrist for every 440,000 people in the country. According to data, some 90% of Pakistanis who suffer from some sort of mental disorder remain untreated. The shortage of genuine, certified psychiatrists gives space to self- proclaimed therapists and counselors who exploit the poor and unknowing. More often than not, young people, particularly women, suffering from depression are told they simply need to get married. Thousands of troubled persons are often taken to shrines where they are beaten and chained to have Jinns exorcised. Ignorance and limited availability of proper mental health practitioners leads to quackery and opportunism. Archaic methods of drugging patients-even using electric shock therapy- are commonplace. Complaints of blackmailing patients is also not unknown. While incarcerated at the rehabilitation center, Almas recounted horror stories of the various patients at the center. She spoke of being locked in solitary, of being repeatedly drugged and existing in state of constant disorientation. If an educated MPhil student can experience this surreal horror, one can only imagine the vulnerability of persons with actual mental illnesses who are more than likely to experience higher levels of physical and sexual abuse.
In Pakistan, the shame and stigma attached to mental health also means very few seek the proper medical help and treatment that is needed. Fear of being labelled, of being discriminated, fear of societal disapproval, forces family members and patients to remain in denial or seek alternate non-medical sources of support and redress. Thus the mushrooming of the therapy centers and non-medical, unregulated counselling agencies all throughout Pakistan.
In 2018, the Federal Capital set up Islamabad Healthcare Regulatory Authority (IHRA) as an autonomous health regulatory body enacted under the Islamabad Health Regulation Act. According to its mandate 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 & 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 do not include therapists or counsellors. Therapy and rehab centers operate outside the purview of the Government. Without licensing, regulation and standards, quackery and exploitation continues to take place. Almas’ mother paid the rehabilitation home Rs. 200,000 to house and ‘treat’ her daughter for ‘depression’ against an unwelcome marriage.
In order to address the huge gaps in licensing and standardization of mental health facilities, NCHR, along with Taskeen Sehatmand Pakistan, a non-Profit working for prevention of mental illness in Pakistan, is developing a policy brief on mental health and human rights. In its fact finding report NCHR has collected quantitative data on number and types of mental facilities available in Islamabad. 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 that the discourse on mental health is 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 huge and neglected problem. State regulatory mechanisms include standards regarding consent, dignity and care, proper staffing and monitoring and evaluation systems.
Almas’ story is just one of many sad and horrific stories that takes place regularly in our Federal Capital. As she sat before us at NCHR, quivering in fear and sobbing over the recollection of her surreal ordeal, we realized that her ordeal is just the tip of the ice berg with regard to mental health in Pakistan. We need to talk about mental health openly and without discrimination. It is time for Pakistan to realize that invisible disabilities, such as mental health, are one of the most neglected yet essential issues for development and human rights in the country.
