You’re walking back to your car after picking up groceries from the nearest medico store. Your heart rate is picking up, you’re feeling jittery, and it seems like your body is going into combat mode — it’s either fight or flight because there is a predator on your trail. You don’t have to be sure because the reaction of your autonomic nervous system is assuring you that your every move is surely being watched. However, every time you glance over your shoulder to check, no one is there. Except, of course, the usual market rush and the little boy selling kitschy toy guns on the side of the road. You quickly rush into the car, yank the door shut, and lock it, as a feeling of hopelessness overcomes you. Was it all in your head?
This is what it’s like to undergo a persecutory delusion — a common symptom of schizoaffective disorder. Meet Saadia Yousafzai: bright and early on a March morning, her aunt brought her to a psychiatric rehabilitation centre, known as The Recovery House (TRH), situated on the bustling Tipu Sultan Road in Karachi. After fighting schizoaffective disorder — a combination of psychotic symptoms, such as delusions, and mood episodes, such as depression — for 15 years with various medications, Yousafzai was finally admitted into TRH’s six-week residential rehabilitation programme, to give therapy a shot.
Yousafzai was once a vivacious young woman in her twenties, who, at a glance, met the general standards of Karachi’s cutthroat social culture: in appearance she wasn’t heavy, she had studied marketing in school, secured a job, was a lovely piano player, and as far as everyone knew, she was mentally sound.
However, when Yousafzai hit 30, the symptoms of schizoaffective disorder began to settle in: she cornered herself into isolation, her self-esteem dwindled, and she had persecutory delusions that an elaborate conspiracy was being manufactured against her. Yousafzai’s doctor had prescribed effective medications, but due to a prescription change she experienced a relapse that brought her to TRH by her aunt under duress.
Dr Gulshan Parvani, a visiting consultant psychiatrist at TRH, explained that the TRH team’s approach was to examine every potential variable affecting her disorder: “We took into account her social network, employment history, input of immediate relatives, and even her relationship with her charming Labrador, Marley — all to implement her treatment.”
Skype sessions were arranged with Yousafzai’s elder brother to facilitate crucial discussions vis-a-vis anti-psychotic medications, and contact was maintained with her employer to ensure she had a job to return to. Yousafzai shared that although she was tremendously resistant in the beginning of the rehabilitation process, “TRH has rectified the problem of my loneliness, and has enabled me to do things through monitoring myself, which would not have been possible if I were alone in my apartment during my illness. Being at TRH made me a little more confident, and lessons were learnt — I realised how important it is to be consistent with medication. Not only for health reasons, but also economic reasons, because I support myself financially.”
According to WHO’s Mental Health Atlas, among Pakistan’s population of 190 million, there were only 342 psychiatrists per 100,000 people in 2011. Now, there are roughly 520 — a leap to take pride in — but hardly enough. With the number of facilities that are community-based and provide in-patient services holding at 624, the math brings the number of beds to approximately two for 100,000 people.
In terms of doctors, a lamentable reality check: only 13.1 per cent of Pakistan’s medical students aspire to become psychiatrists. Hanaa Durrani, a current student of the Institute of Business Administration, stated that she has always been passionate and curious about psychology; but, alas, her family pushed her to pursue a more promising degree in the field of Accounting & Finance. She said, “The concept of working in counseling or therapy is just so alien here that I had to stick with a business school that would guarantee me a respectable job as per the requirement of Pakistani culture. There is little acceptance of this profession when you think in terms of your independence and financial stability in the long run because mental health is so taboo.” Durrani is now volunteering at TRH.
Because of the stigma attached even to a career affiliated with mental health, Pakistan’s government allocates insufficient resources towards strengthening the Psychology discipline in Pakistan’s universities. As a result, our next generation of psychiatrists and therapists is gradually transmuting into a mere illusion. Meanwhile, the current supply of those with the skills to address our mental health crisis continues to fail at meeting demand.
Within the past couple of years, WHO’s statistics have been circulating throughout news publications, while scant progress has been made. Over 14 million Pakistanis suffer from some form of mental illness, with two million in Karachi alone — and although rehabilitation centres do exist in Karachi — many behave more as psychiatric asylum centres. Some of TRH’s current clients complain about the hospitals or rehab centres they transferred from. “It was a mess — the patients were treated with disrespect, and conditions were unhygienic. Even the chai we were served was filthy,” said a TRH client, referring to a psychiatric hospital in Karachi. A staff member at TRH reported that one of Pakistan’s major psychiatric hospitals allegedly chains their patients to their beds.
When asked about her family and friends’ response to her disorder, Yousafzai replied: “Not many people knew, and the possibility of word getting out was prevented because I went on medication just in time. My family has not been supportive, and no one could understand. No one. The only person who can understand is someone who has the disorder, and I haven’t come across many people who have this disorder.”
Advocacy for positive reception of mental illness in Pakistan is lacking, making a vast mobilisation for mental health development even more unlikely. If stigma is reduced, with government collaboration, institutions can evolve so that patients are treated more like those at rehabilitation centres akin to TRH — less like chained prisoners, and more like patients receiving assistance for their illness.
Pakistan’s public must recognise that protracted illnesses like schizoaffective disorder have challenged individuals with relapses; they’re battles — ones that require an exceptional willpower to fight. For World Mental Health Day, we should applaud our heroes for their resilience — not only because of their fight to overcome schizoaffective disorder, but also because it’s with a society still struggling to accept it.
The smile Yousafzai wore was almost begrudging; the look in her eyes was pessimistic and beaten, as if winning the battle against schizoaffective disorder wasn’t so rewarding—there was no support from the beginning, no one cheering her on.
This World Mental Health Day, clean out your bookshelves and take a few good reads to TRH. The Caravan of Life Trust’s psych rehab facility will be accepting book donations as a part of its next project to provide its patients with their own library.
*Names have been changed to protect identity.
*This article does not reflect the views of The Recovery House, World Health Organisation, or any other institution.
Published in The Express Tribune, October 10th, 2015.