Today, in Pakistan, there is secrecy around mental illness — of a daughter about to be married into another family and of a son out of fear of not being able to shoulder the burden of providing for the family.
While stigma is a word that is often thrown around to describe our attitudes toward mental illness, the word requires us to go back in history. The attitudes toward mental illness among families and the state have a dark colonial history.
During the colonial rule with passing of the Lunacy Act of 1912, role of magistrate became central in referring people to psychiatric hospitals. This power was often exercised to remove vagrants from streets. Magistrate’s help would be sought strategically by families in order to admit relatives in psychiatric hospitals. These powers were instituted in the figure of magistrate in 1912, and have existed to this day, even with passing of the Punjab Mental Health Ordinance of 2001, which has sought to de-criminalise mental health. In the post-colonial context, the power of magistrate remained central in admission of prisoners in mental hospitals.
Even with the state’s attempt to de-criminalise mental health, family members still seek to admit patients to exclude them from households or to exact revenge. The Supreme Court only last year while adjudicating over the Safia Bano case added schizophrenia to the list of mental illnesses that may be used for diminished responsibility; however, many patient-prisoners still continue to await their trials while suffering violence (bureaucratic and physical) within prisons.
During the colonial rule with passing of the Lunacy Act of 1912, role of magistrate became central in referring people to psychiatric hospitals. This power was often exercised to remove vagrants from streets.
Then there were also colonial biases related to the low prevalence of schizophrenia and combat trauma among Indian troops. During World War I, military psychiatrists and physicians were particularly concerned about the increasing rates of self-harm among Indian soldiers and considered it a consequence of desire to evade service. During World War II, when Indian psychiatrists took positions left vacant by the British officers, they reproduced similar ideas about soldiers from specific martial races being less susceptible to mental illness.
After the partition, the country inherited a weak system of psychiatric care. Still there were important de-colonial moves by psychiatrists of the time. Ibraheem Khalil Sheikh, trained in psychoanalysis and author of the novel on Sindhi psychiatry which presented fictionalised accounts of actual cases in Ibrat Kada, went against orders of the British authorities, magistrates and violent families. He is seen in his accounts as delaying death sentencing by pleading for patients’ illness or providing protection to soldiers and desperate patients who faced abuse at the hands of wealthy families, feudal lords and the state. Treating mental illness as ibrat (moral signs), his work is now a lost treasure. The post-colonial psychiatric landscape, however, re-inscribed suspicions of malingering in even more intense forms, with denying, downplaying and suppressing symptoms.
As Sunniya Pirzada, the daughter of a 1971 war veteran has shown, the complex neurological symptoms experienced by her father during combat, were treated as signs of malingering. His demands to get a retirement were denied under the pretext that he was not mentally sound to make the decision. There appears to be no discussion around problems of combat trauma, as in other parts of the world, such as the United States, where soldiers’ mental health has been a rallying point to demonstrate the impact of wars, starting from the Vietnam War.
There is a politics of concealment within families mainly to protect honour, where as my research as an anthropologist has shown, symptoms of illness are treated as signs of abuse within wider families, without engaging in candid conversations about best ways to extend support to the sick family member.
Currently, the country has 400 psychiatrists for over 220 million people. Perceptions toward psychiatric hospital continue to be plagued by lack of empathetic care provided to soldiers, violence reported by patients who have been institutionalised, extraordinary wait times to get relatives institutionalised, as many shared with me when I conducted my fieldwork.
Given problems of economic precarity and increasing incidence of violence and displacement due to the War on Terror, Pakistan has continued to face an increasing burden of mental illness. Many mental health problems remain under-diagnosed till extreme conditions, where patients’ families are left with no choice but to institutionalise the patient. Researchers have explored the intersections between psychiatric morbidity and terrorism, which has resulted in psychiatric discourses used once again in the service of militarisation and security, as in the context of rehabilitation centres, like Sabaoon, Sparley and Rustoon set up by the army in the aftermath of the War on Terror.
Currently, the country has 400 psychiatrists for over 220 million people. Perceptions toward psychiatric hospital continue to be plagued by lack of empathetic care provided to soldiers, violence reported by patients who have been institutionalised, extraordinary wait times to get relatives institutionalised, as many shared with me when I conducted my fieldwork. In the absence of de-institutionalisation of psychiatric services, to seek free care in psychiatric hospitals like Punjab Institute of Mental Health, Giddu Hospital or the Lady Reading Hospital, families travel from cities around the country, only to experience bureaucratic backlogs and corruption. Currently, the country needs urgent de-institutionalised psychiatric care with the right amount of balance between lay skills of community workers and professional skills of peer supports and psychiatrists.
Others find private psychiatric hospitals or clinics the next best option, but exorbitant fees result in illness becoming a burden for families resulting in caretakers discontinuing treatment. In this context, it is no surprise that families seek treatment from traditional healers. Some healers with whom I have conducted fieldwork invoke jinn affliction as the predominant cause of illness – physically violating patients at times. Still, in many cases, families continue to trust them, because they provide treatment using local cosmologies and ideas, encouraging people to engage in faith-based efforts for recovery and provide strategies to overcome deep-seated family problems.
While it is easy to rebuke traditional healers, as many psychiatrists in my research did, they do provide a template for professional psychiatric services to follow, by providing free, empathetic care while also taking into account people’s beliefs about etiologies of illness. This is not to say that traditional healers should in anyway replace professional psychiatrist, but that the two may partner to accept their strengths and weakness and deferring to the other, instead of competing with each other, so patients may benefitt as they seek treatment in the medical marketplace.