Some things are great facades: the toothy grin of 24-year-old Salma, the quiet confidence of 36-year-old Nida, the dismissive arrogance of 37-year-old Umeed, the peculiar eccentricities of 23-year-old Uzma, or even the exclamatory fit of laughter from 28-year-old Razia*.

These women have all been deeply hurt; but unlike a visible injury, their wounds are invisible. They are ill because of the severity of trauma suffered. Their minds, in a state of shock, have given up on operating in a way that we would dub ‘normal’. They have been unwell and were in treatment at various mental health institutions in Karachi, but society largely rejects them as lunatics. In truth, these women hold the secrets to the dirtiest dichotomies of society today.

“My brother-in-law raped me,” says Salma, “but nobody believed me. My husband told me I was lying, and accused me of having an affair with someone. My parents did not quite comprehend what happened; they told me to compromise, whatever the issue. There was nobody to fight in my corner or plead my case. Everybody thought I had gone crazy.”

Two weeks later, while Salma was still grappling with the reality of having been raped by family, the husband divorced her. “I lost my mind; my world had come apart because of something that was done to me, not done by me. I could not live with it, I went suicidal.”

Salma’s parents admitted her to one the city’s mental health institutions, hoping that some focused treatment through psychotherapy and medicines would help Salma recover and heal. Doctors had made it clear to the parents that they could not put a deadline for recovery; every individual heals at a different pace. Salma was released after about four months, but healing from the trauma of sexual violence took much more out of her.

“At the institute, they wanted us to have structure in our lives. We woke up at particular times, were told to shower at particular times and have food at particular times too. There were activities in the day, and doctors would visit in the evening. The rest was up to you,” she narrates.

“The worst part was the psychotherapy. It was difficult. The doctors wanted me to be comfortable with my reality so that I could deal with it. But who can possibly be comfortable with being raped by family? I am scared of people now, I know how savage they can be,” Salma says.

Much like Salma, Nida too is a victim of sexual assault. Nida is a single woman, unmarried by choice, and worked at an NGO in Karachi. Much like Salma, Nida too has given up hope of ever getting justice.

“It was a paternal uncle,” Nida curtly says. “He was a religious man, which is why I trusted him. Because of him, I lost faith.”

She was first admitted to an institution recommended by the same uncle who had raped her. Nida’s parents agreed.

“All doctors encourage structure and routine. As part of a regime, the mental health facility used to instil discipline in its patients. We were told to seek forgiveness from the Almighty for the calamity that had fallen on us. I was angry, I didn’t want to pray, but they would inject me with a sedative every time I protested,” narrates Nida.

It was rage that landed Umeed into a mental ward. “I lost my mind after my husband defrauded me, stole money from my bank account, and moved to Canada with my children. I should be angry about that.”

Umeed used to be a small business owner. She was newly divorced when she had to be admitted — the first time.

“My mother-in-law picked my children up from school, took them to her house, and decided to keep them there without ever asking me for my permission,” she says.

Umeed spent over five hours consumed in a maddening search for her children. It was only after she spoke to her ex-husband that she realised that the children were safe but that they now were the subject of a custody battle in court.

“My life was on hold, the lawyers had already been involved. One day, when I called my ex-husband to speak to the children, he didn’t answer. Then the next day, his phone was switched off. I got worried. I kept calling him for another two days. And then, I received an email from him: he was in Canada, he had taken the children too, and he wasn’t returning. I was livid,” narrates Umeed.

Out of control, Umeed admitted herself to a psychiatric ward in one of Karachi’s largest hospitals. This point was later used by the husband first in a Pakistani and then in a Canadian court to prove Umeed wasn’t mentally fit to shoulder the burden of mothering. “Nothing could be further from the truth, those children are my life.”

Umeed could not bring her children back to Pakistan. Business was floundering and her partner needed her to pick up the slack. The failure pushed her towards drug abuse. “Heroin became my choice drug of the day, every day for some eight months. Without it, I was unable to confront the idea that I could not protect them or save them, or that I could not even wish them on their birthday or even talk to them,” she says.

Umeed returned to the ward for addiction treatment; she kept returning intermittently for the next six years for treatment. She sold her share in the business two years into the treatment.

“Our divorce wasn’t really sour, we both wanted to go in different directions. But it is my right to be angry at my ex-husband for stealing my children away. People tell me to have faith, that one day my children will return to meet me. But I can’t forgive or forget. There are kids involved. Family and friends focus on my rage but subconsciously or unconsciously, by telling me to move on and concentrate on the now, they undermine what happened to me,” says Umeed.

Uzma’s father was a drug addict. She is the youngest sibling in a family of 12; her elder siblings are married and didn’t live with the parents. She was only 16 when trauma hit her.

“My father regularly used to hit my mother; she was the one who not only protected all of us, but also had my five sisters wedded and settled in their homes. She would hide money from my father; if she didn’t, we wouldn’t have had food to eat,” she says.

One night, as the altercation between the mother and father grew louder, her father picked a butcher’s knife and slashed her mother. “He was under the influence I think, but I don’t quite know. She died,” says Uzma.

Devastated and distraught, Uzma fell into depression. But she didn’t know what was coming next.

“My father returned home late one night, saw there was food to eat, and began asking me about where the rest of the money was hidden. That money is what my brothers had given me, just so that I could sustain myself. I refused. So he tore my clothes, pushed me onto the street, and locked our door,” narrates Uzma.

“I was standing there, all alone in the darkness, with a torn shalwar kameez. I started shouting and screaming. I passed out from screaming so much, because that’s all that I can remember. When I woke up, I was at a mental health facility, having been injected with lots of sedatives. They said I was out of control when I was brought in. I stayed there for the next three months, partly because I wanted to figure out who I’d be staying with next. It was obviously not going to be my father.”

Today, Uzma works as a secretary in a bank and lives with her eldest brother.

Razia was in the driving seat when her car collided with a speeding trawler on the Baloch Colony Bypass. Her father, mother and younger brother, all died in the accident. Razia miraculously survived, even though surgeons had nearly given up hope because of the blood loss suffered.

“When I finally woke up, after five days, I heard the news. I went into severe depression. I would cry all day long, nothing felt right. One day, I left home, and started walking towards the railway station. I don’t know why, I don’t remember if I was going to take a train elsewhere or commit suicide,” says Razia.

Her domestic help managed to track her, and called her elder brother to come to the scene. Razia was rushed home.

“My brother admitted me to a mental health facility and paid an advance on the room. We got an air-conditioned room, with a working television,” narrates Razia.

But after a month, the brother’s visitations first decreased, then stopped altogether. Razia was shifted to the general ward by the end of the second month, one with occasionally-operational fans and no television. Soon, the head nurse would also assign Razia to toilet-cleaning duties.

“I stayed there for about 20 months. Then, I made contact with my best friend; I believed that I had healed enough to take on my brother,” she says.

Once liberated, Razia discovered that her brother had indeed sold all property to which she was heir to, and embezzled the money.

“I didn’t want to fight, I simply wanted to construct a new life for myself,” Razia says. “I moved in with my best friend, and slowly rebuilt myself. I still share an apartment, but I pay rent now, I cook food, and try and find something worthwhile to do.”

*Names changed to protect privacy

The writer tweets @ASYusuf

Towards a new horizon

They are not possessed by evil spirits, they are merely mentally ill. All they need is a chance to reclaim their lives, long and fraught with hardships as the journey may be

By Sumera S. Naqvi

Ahmed* was in the prime of his life — 25 years old — and lived in a remote area of Sindh, when he started displaying symptoms of schizophrenia: hallucinations, delusions, distorted speech and disorganised behaviour. The family, baffled by his unexplained behaviour, approached an aamil at a nearby shrine. He was chained at the shrine to restrict his mobility.

For over 10 years, Ahmed remained in chains and stayed at the shrine. Fortunately for him, someone advised his family to send him to Karwan-e-Hayat, a charity organisation in Karachi that works not only on the treatment but also rehabilitation of poor and underprivileged mentally ill patients.

“It was very difficult to cut his chains when he was brought to our hospital at Keamari,” says Dr Ajmal Kazmi, former medical superintendent and consultant psychiatrist at Karwan-e-Hayat.

“His rusted chains needed to be broken with the help of a big hammer.”

Ahmed was admitted for about a year. He was provided intensive psychotherapy to treat his illness, and also enrolled at the day-care rehabilitation programme that Karwan-e-Hayat provides to patients free of cost.

After a long and sometimes arduous journey, the young man recovered. Today, Ahmed carries out his personal errands and is also working part-time as a guard.

Psychology and psychiatry has evolved tremendously over the years. Karwan-e-Hayat is one of the few organisations in the country that employs evidence-based programmes of rehabilitation. One such programme is the Illness Management Recovery (IMR) programme and its various modules; doctors believe that the programme is designed to make recovery more focused and goal-oriented.

“This programme was initiated in Pakistan by Karwan-e-Hayat,” says Dr Kazmi. He explains that the goals of treatment and therapy vary from patient to patient: some want to return to their job, others want to be able to tend to their families again. The idea is to make patients more self-reliant and in charge of managing their illness. The regime also works on reducing the incidence of relapses of the person’s mental illness.

In Pakistan, there are an estimated 15 million people who are faced with mental illness, while an estimated 2m reside in Karachi alone. Severe triggers in the environment such as poverty and unemployment, including familial and other social pressures, can lead to or exacerbate mental illnesses. These manifest in different forms, which are quite misunderstood on the one hand, but on the other, they delay the treatment process. Mental illnesses in Pakistan are routinely mistaken and misunderstood for someone being possessed by evil powers or spirits, for exorcism, or aaseb, when for instance, a person countering schizophrenia would simply be hallucinating or even under a delusion.

In the early 1900s, governments all over the world started realising that there was a huge cost involved in the treatment and maintenance of mentally ill patients who were kept in hospitals. Government budgets reduced in the face of the burden of other diseases. While treatment could take years before the patient would feel better, they would have nowhere to go as most families would abandon them for either not being able to handle them or having little understanding of the illness.

Until the 1950s and the 1960s when treatment of mental illness meant isolating the patient for years or until he gets better, it was the period of ‘de-institutionalisation’ that changed the onus of treatment to a more rehabilitative nature. A patient who was faced with mental illness would succumb to an isolated life, with limited outside window or support. This also meant the patient would be treated in isolation without social interaction or vocational training.

Today, psychiatric rehabilitation offers hope for mentally ill patients to return to living a normal life after treatment. According to a seminal work by German psychiatrist Dr Wulf Rössler, rehabilitation forms a substantial chunk of recovery:

“All patients suffering from severe and persistent mental illness require rehabilitation. The goal of psychiatric rehabilitation is to help disabled individuals to develop the emotional, social and intellectual skills needed to live, learn and work in the community with the least amount of professional support. The overall philosophy of psychiatric rehabilitation comprises two intervention strategies. The first strategy is individual-centred and aims at developing the patient’s skills in interacting with a stressful environment.

“The second strategy is ecological and directed towards developing environmental resources to reduce potential stressors. Most disabled persons need a combination of both approaches. The refinement of psychiatric rehabilitation has achieved a point where it should be made readily available for every disabled person.”

While stigma attached to mental illness still hinders such progress in terms of more employment opportunities for people with mental disorders who have recovered, modern psychiatry has moved toward a more rehabilitative or recovery approach. This means that a person with mental illness is treated holistically with not only a team of social workers, clinical psychologists, psychiatrists and occupational therapists who would work in unison to help the patient return to normal life, but the family is also be taken into account to be counselled and helped in sustaining rehabilitation of the person with mental illness.

Day care services in mental hospitals and clinics comprise a comprehensive rehabilitation programme that is filled with focused relaxation techniques and fun-filled activities. These activities are dovetailed with vocational training to help the mentally ill salvage their life skills and also equip them of a vocation.

Psych-rehabilitation activities have helped patients regain a sense of orientation of themselves in a structured manner. “I have always enjoyed the chat session scheduled in the mornings,” says a female client with mental illness at Karwan, “as they have been extremely therapeutic for me.” She finds it comforting as people narrate their experiences, share a prayer or a dua, or even a joke while a clinical psychologist or a social worker leads the discussions.

Yoga, music, painting, chat sessions, discussions based on the talk therapy on light issues, etc are part of the day care rehabilitation services. These are extremely therapeutic for both inpatients and outpatients. Case management and family psycho-education are other evidence based modules of the comprehensive rehabilitation programme. Social workers, occupational therapists and clinical psychologists follow up on home-based clients and counsel the families that may not be able to cope with the patients’ mood swings or mania, as in the case of Bipolar Disorder.

Rehabilitation of people with mental disorders is being researched for more effective results, but it goes without saying that mental illness still struggles to find a clear status where it is considered just another illness of any organ of the body that needs to be treated. Rehabilitation remains an uphill task, since mental illness remains a very misunderstood area of illness even in this day and age. Unless we remove the stigma associated with mental illnesses, those who are ill shall continue to suffer in silence.

Matters of the mind

Prof Syed Haroon Ahmed has been involved in treating patients of mental illness for decades. Here he shares his insights into the scope of the mental health problem in Pakistan

By Shazia Hasan

What are the biggest and most serious mental disorders?

Fluctuating from high to low, schizophrenia and bipolar disorder are two flagship mental disorders in the world today.

Around 10 per cent of the population of any developing country including Pakistan suffers either from schizophrenia or bipolar disorder where people suffer from false beliefs or delusions that cannot be corrected by logic, and exhibit symptoms of hyperactivity.

There can be a disturbance in their way of thinking. For instance, they think that so and so is after them or after their money. There can be a disturbance in their emotions or incongruous emotions where they have no control and are either laughing away or talking to themselves, which is also known as non-social speech. Sometimes they can be suffering from hallucinations and false perceptions where they visualise something or someone that others around them can’t see. All these come under schizophrenia and bipolar disorder.

What follows the two big mental disorders mentioned?

Well, the rest include depression which afflicts twice as many women as men. Then there is Obsessive Compulsive Disorder (OCD) where people keep washing their hands or repeating an activity to the point of obsession. Additionally there are widespread cases of anxiety and so on.

These disorders are not only extremely common but are also the ones most likely to be ignored as they largely pose a problem for the patient and not society at large.

If they are so common then why do they go untreated for so long?

All these problems are treatable provided the patient receives help in time. But as is normally seen, when the patient’s family notices any behavioural changes in him or her they ignore them at first or think they will pass. In the cases of the acutely disturbed, the realisation comes more quickly when they see the patient’s distrust in everyone around them or when patients become physically violent. There are also cases where patients refuse to believe their parents are in fact their parents, which is called capgras syndrome.

However, for minor illness where patients are not so hostile, it may take up to one to one-and-a-half years for the family to even realise that something is wrong. Even when they do realise this they may not seek treatment immediately.

First comes the denial; they say their son or daughter is all right or that someone has cast a spell on him / her or that he / she is possessed. They drag them to faith-healers, which wastes more time. In fact, faith-healers ruin the case.

Then in many cases, after they realise that he or she is not possessed after all, they just leave them to their own devices. While when they believed that he or she was possessed, everyone was around him / her, but when the relatives realise that isn’t the case, that’s when they desert him / her.

Of course there always are exceptions. Sometimes someone in the family steps forth to take care of the disturbed person, and sometimes people also look into committing patients to a facility.

How many mental hospitals or facilities are there in Pakistan?

Not many. There are only 3,000 beds here in the shape of four mental hospitals — in Hyderabad, Lahore, Peshawar and Mansehra. Another 3,000 beds are in private practice, which include small hospitals and teaching hospitals like Civil Hospital or the Aga Khan. So since the hospitals are few, it is always better to take care and rehabilitate them at home. Or at least that’s what ends up happening.

So if a mentally ill person is being rehabilitated at home, what should the caregivers be mindful of?

It is not right to find out about someone’s diagnosis and leave him or her alone to fend for themselves. In fact, two attitudes are not good when dealing with such a person. First, he or she should not be isolated and second, one should not become overprotective. Suppose there is a very caring family member who makes the patient too dependent, then you now have a mentally unwell individual who is also effectively an invalid on your hands. It is better to recognise the problem early and seek treatment early to make the person a productive member of society.

Can you tell us what kind of mental disorders were common earlier, or was it the same as today?

Earlier, hysteria was seen as the most common mental disorder. Sigmund Freud in the 18th century associated hysteria with the uterus so he said that it was a very common problem amongst girls.

These days we say if some girl suffers from hysteria, get her married. But I say no, don’t do that please because then the family she marries into complain and say they’ve been deceived and that will make the situation worse for all concerned. Marriage, really, is no treatment for hysteria.

Of course hysteria has a new name — conversion disorder.

But now the most common mental disorder is depression, which used to be around 3-5pc in incidence but has risen dramatically these days. Some of the reasons are that there is now more awareness and far more social stressors. Everyday issues such as no electricity/water and the absence of implementation of laws gives way to frustration. Now 20pc of the population suffers from depression. And females suffer more from depression than men.

So can we say that depression is largely stress-related?

Well, different people deal with stress differently. Some get into malingering and some suffer from hysteria. While malingering they are using a symptom like a headache or tummy ache to avoid a painful situation. So it is a conscious thing which they are doing.

But hysteria is in the subconscious where the anxiety grows so much that it manifests itself in symptoms like blindness, fainting fits, loss of voice, etc.

When the stress level grows and continues, the previously mentally-ill can even have a relapse or a psychosomatic disorder like headache, stomach-ache, even heart attack or cancer; continued stress can cause physical conditions. Too much stress also sees some to opt out and go into depression. Others resort to smoking, drinking, doing drugs, etc to manage anxiety. This is almost always counterproductive.

In the modern day does electroshock therapy still have a place in the treatment of mental disorders?

Shock therapy or electro convulsive therapy (ECT) started being used around 1935, when at a mental asylum in Europe some severely schizophrenic patients who also happened to suffer from epilepsy would noticeably calm down for a few days after suffering from an epileptic fit.

It was then discovered that giving patients electric shocks brings on similar epileptic fits and helps calm them. But yes, it is no longer used as much as it used to be. Of all the patients I get, I only send one or two for ECT in a year, and only when it is a matter of life and death, as with patients who are so depressed that they become suicidal.

Do mental illnesses run in families?

The major illnesses like schizophrenia and bipolar disorder by and large are genetic, while others are environmental. So you may say that some are natural while the others, like anxiety, are nurtured. Also sometimes someone has grown up in a very healthy environment and his or her symptoms don’t show but they are nevertheless carriers. Sometimes the majority of a family is fine but some grandmother had a problem, which a grandchild inherits.

Why do people say that there is a thin line between genius and madness?

They say this because there is, in fact, a thin line separating a genius from a disturbed person. Look at it this way, a genius won’t do anything that a normal person would. They swim against the tide, think out of the box, etc.

For instance, there is the creative genius, like the artist Sadequain, who would paint obsessively. I have seen him paint. He just went on and on without taking any rest. He would be sick, would be suffering from a tooth abscess and all but would not stop. There are so many writers and painters like that.

Did you know Ted Turner, who started CNN suffers, from bipolar disorder and takes lithium salt to keep it under control?

What in your view is the definition of a completely sane and normal person?

Someone who can take care of oneself, one’s family and respect the law.

Published in Dawn, Sunday Magazine, October 12th, 2014