In every society and culture, there are certain words or phrases that, when being said out loud, consequently turn heads. These are the words that often have a particular stigma attached to them. Hence, the topics associated with the words are never talked about in open spaces. Mental health is one such example in Pakistan, among the many more.
What exactly are mental disorders? Mental disorders are defined as the psychological and behavioral disorders that lead to impairment in critical areas of functioning in everyday life. These include a wide range of illnesses such as anxiety, depressions, several personality disorders, eating disorders, schizophrenia, and many more. Contrary to popular belief, these are not only caused by one’s life experience. Genetics, traumatic exposures, the stress in early life, and your surroundings all play a role in the development of these disorders. Mental healthcare practitioners, including psychiatrists and psychologists, diagnose these disorders mostly by using the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). According to the World Health Organization (WHO), up to 450 million people suffer from mental disorders in the world. However, a large proportion of them do not seek help.
The overall scenerio in Pakistan is not so different from the rest of the world. In fact, the mental health sector is probably the most neglected sector in Pakistan. In 2016, Dawn Newspaper published that there are 50 million people in Pakistan suffering from mental disorders and that the number of trained psychiatrists is only 400. This statistics that shows the number of people with mental disorders is probably much higher considering the fact that most people are not diagnosed due to the scarcity of psychiatrists and social norms.
State of Mental Healthcare System in Pakistan
The scarcity of clinical psychiatrists is not the only reason that Pakistan’s mental healthcare system is flawed. The last time any legislation regarding mental disorders was passed was in 2001. The latest policy change occurred in 2006. Mental health was made a provincial topic rather than owned by the federal government, and currently, only Sindh and Punjab have mental health acts in place (Tareen & Tareen, 2016). Moreover, there is no policy regarding the conviction of a mentally ill person. In fact, schizophrenia – a disorder that leads to hallucination, delusion, and disordered thinking – was removed from the list of mental disorders as it did not fall in the legal definition of such disorders in Pakistan. Therefore, any schizophrenic convict may be up for execution in case of murder (Janjua, 2020). Only 0.4% of the healthcare expenditure of the country is allocated to mental health, and there are only five mental hospitals currently operating in Pakistan as compared to hundreds of hospitals for the other sectors.
The stigma; What will people say?
One of the primary reasons that people prevent themselves or their families from seeking mental health advice is due to the stigma associated with the term ‘mental health.’ There are many definitions of stigma. Still, to put it simply, it is a sign of shame related to an event, quality, or person. In rural areas of Pakistan, people would believe their loved ones are possessed rather than just ill and used to take them to the shrines instead of hospitals due to poverty, stigma, and superstitions (BBC, 2016). People are also afraid to hear what others might say if they consult a psychiatrist or psychologist. This fear leads them to ignore any symptoms present around them and disregard them completely. Furthermore, this inevitably leads to the formation of an ignorant society. In fact, anyone who decides to go for a career in mental health is constantly discouraged by others and sometimes even to the point that they are forced to go with another profession.
Another reason for this negligence is a severe lack of education regarding mental health in Pakistan. Since we are young, we are taught about the importance of nutrition and the effects of malnutrition on our physical health. What schools fail to teach us is the importance of our mental wellbeing. Is it appropriate to completely disregard mental health as long as we are physically healthy? Moreover, no counseling facility is provided to the students at school to help them deal with stress which is leading to an increase in anxiety, depression, and an overwhelming suicide rate in Pakistan, especially in students.
Some people are more susceptible to mental disorders than others, and these are the ones who require interventions by mental health professionals to get back on track with their lives. Pakistan is a developing country with a long history of terrorist attacks being conducted in it. The people who come in direct contact with the destruction and tragedy of these attacks need help from professionals to overcome and move on. Psychological first aid should be provided to reduce the occurrence of Post-Traumatic Stress Disorder (PTSD). One such example includes the students, teachers, and their families who bore the brunt of the terrorist attack on Army Public School, Peshawar, in 2014. The proper way for them to deal with the trauma would have been through therapies, but unfortunately, there were not enough mental health professionals who could help them.
Since getting independence in 1947, Pakistan has faced multiple wars and tensions on her borders. The soldiers who come back from these missions often suffer from PTSD but they wouldn’t be provided with the help they need. Additionally, there are other issues that pave the path for the rise of mental disorders such as domestic abuse – an endemic on the rise in Pakistan – which is not only harmful for the victim but also the other family members.
Other than that, several students suffer from depression, anxiety, and stress in school and university life. These are caused due to the burden of studies, peer pressures, and the need to maintain a cheery personality with others at all times. Such instances are often disguised so well that if that person ends up committing suicide, his/her peers say that ‘He/She was happy all the time’. This is why we need mental health education so that we, as a community, may learn to recognize the symptoms and patterns, eventually guiding anyone suffering, for getting help.
Even in the current situation, the COVID-19 pandemic, people have become more vulnerable to mental disorders. Constant checking of the rising COVID-19 cases and deaths, being quarantined in their homes for long periods of time, not being able to meet with their families for months, witnessing a plane crash in a residential area of Karachi, and many people losing their jobs due to lockdown has taken a toll over the whole country.
It is beyond time that we start realizing that mental health is just as important as physical health.
In Pakistan, the lack of knowledge and awareness regarding the mental health sector is so extreme that we still believe there are only 2 ways a psychiatrist or a psychologist helps a person and those are either talk therapy or medicine. Different disorders require different types of therapies and ‘talking’ is not the cure for all. In this advanced world, several different types of therapies have been introduced that are used according to the disorder and the patient. For example, we do not have Cognitive Behavioral Therapy (CBT) mostly used to treat depression and anxiety. This is used to change the patterns of thoughts and behaviors that cause difficulties. Moreover, there is Electroconvulsive therapy (ECT) in which seizures are electrically induced to treat mental disorders. It is an extreme form of therapy and only used when other methods fail to provide results.
These two are not the only types of psychotherapies available around the world. However, they show the great differences present in the modern methods of treatment of mental disorders. A wide range of treatments are known to mental health professionals but in Pakistan, there are not enough professionals who might be specialized in these methods.
What do professionals have to say?
For a better understanding of the ongoing state of mental health in Pakistan, I reached out to a couple professionals. Iqra Nasir, a behavioral therapist, said that there are a lot of people suffering from mental disorders in Sindh but they cannot afford the treatment as there are no such hospitals in close proximity. Contrary, , in several cities there are no schools for children with special needs such as down syndrome and autism. She believes that the government needs to get involved and make more governmental hospitals for the mentally ill people and establish at least one special needs school in each city.
Inamullah Ansari, the Director of Mental Health Emergency and Human Resilience Solicitors Drug Crimes Criminal Defense Lawyer, says that we need to implement psychiatry facilities in teaching hospitals where consultant psychiatrists are available. More public awareness programs should be launched on the media platforms (Ansari, 2015).
Muhammad Tahir Khalily, Senior Clinical Psychologist, believes that mental healthcare needs to be incorporated as a core service in primary care and supported by specialist services. There is a strong need to provide adequate training for general practitioners and postgraduate training for mental health professionals to meet the current demands. A collaborative network between stakeholders in the public and private sector, as well as non-governmental organizations, are required that promote mental health care and advocate for changes in mental health policy (Khalily, 2011).
Involvement of government
The government needs to provide the country with an up to date mental health legislation and a refined legal definition for mental disorder. A person with a mental disorder needs the help of a psychiatrist and does not need to be locked up for a crime that he/she does not even understand. On the other hand, prisons should be seen as a correctional facility and the convicts should be helped to become better by the time they have served their sentence, thus forensic psychologists should be present in these facilities at all times.
In Pakistan, people encourage their children to follow professions like medicine, engineering, or finance. Children are primed from the beginning to believe that these are the only areas of study one should pursue. We need to let children know that there are multiple options out there for them to consider instead of just these. The government should also encourage the study of psychiatry and psychology by providing incentives that would make youngsters willing to pursue these fields as it has become prominent that Pakistan needs many more mental health professionals working in the country to help all the people who might need them.
Provision of hospitals and services
We are in dire need of more mental hospitals across the country. The five that are currently operating are located in major cities – Lahore, Rawalpindi, Islamabad, Peshawar, and Quetta – which makes them inaccessible to a lot of people who are not willing to travel long distances or cannot manage to find the time for travelling. Mental health treatments should be available to people easily, which is why more hospitals need to build on immediate notice and the inside workings of the old ones should be updated to provide humane treatment to all the patients.
Conversely, there should be online treatment facilities which could be used to educate parents. People who are unable to travel to the nearest hospital should have access to psychiatrists online. Multi-stakeholder collaboration should be promoted among the private hospitals, pharmaceutical agencies, and international companies to advance local, national and global efforts in favor of good mental health.
In recent years data and technology has played a vital role in treating mental illness and avoiding crisis. By using cell phones and health apps, data can be used to monitor a patient’s progress, behavior patterns, and activities to signal it out that help is needed before a crisis, such as a panic attack, occurs. Moreover, mental health care applications should be advertised and encouraged such as 7Cups, which is an app run mostly by volunteers who are trained to listen to people and then refer them to professionals associated with the app.
Mental health Education in Schools
We cannot ignore the significant role that education plays in spreading awareness about a matter and helping in stemming the stigma surrounding something. Psychology should be integrated in the curriculum of schools, either as a permanent subject or a small mandatory course for all students to take. Along with this, every school should have at least one counsellor available on the campus during school hours to help students through any difficulty they might be facing in school or at their homes. Workshops should also be held for the teachers and other staff which educates them in distinguishing symptoms present in students and helping them.
Moreover, mental health workers from Pakistan and other countries should be invited to schools with the help of the government to come forward and raise awareness regarding the matter. Such events should be hosted regularly and have compulsory attendance for the students and their parents along with the school teachers. There are a variety of ways in which these events could run. The visiting professional could use recent articles regarding a problem that is common in Pakistan and explain to the audience how important it is to solve the issue. They could hold a question and answer session with everyone to clear any doubts in the minds of the audience and help them better understand mental health.
Special Need Schools
As mentioned by the psychaitrist Iqra Nasir, Pakistan also needs to invest in schools that are trained to provide education to students with special needs. Most of the schools that fall under this category in Pakistan are for the visually impaired and serve no purpose for the children who suffer from mental disorders such as autism or ADHD. Due to the lack of special need schools, children with mental disorders are prevented from getting the education that is their basic right. There are children with learning disabilities such as dyslexia who fail to get diagnosed and are admitted in normal schools where they lag behind. Unless such children get specially trained teachers and environment to express themselves in other ways and learn in unique styles, they will always be seen as less than other children. These reasons alone should be enough to help establish special educational institutes all over Pakistan.
The role of the NGOs
NGOs are playing a significant role in spreading awareness about mental health and providing help. Their numbers, too, are low but even with their limitations, NGOs could lead in creating more awareness and transforming the mental health status in Pakistan.
Having mental disorders is not a choice or a lifestyle disease, unlike many physical diseases that could be prevented by correcting your lifestyle. Mental health is a grave concern in Pakistan and should be regarded as one. We must have more educated conversations on it so that we can finally break free from the toxic stigma placed on us by our ancestors.
Also, Read: OPINION: We need to talk about mental health
Isna Maqsood is a second-year BSc. Psychology student at Queen Mary, University of London. She aspires to become a clinical psychologist willing to work for mental health awareness in Pakistan, through writing and practical work. She could reach; https://www.linkedin.com/in/isna-maqsood-869ab11a3