TICKING BOMB: INSIDE PAKISTAN’S UNCHECKED MENTAL HEALTHCARE BOOM
Experiencing extreme self-esteem issues, Sehr* gathered that her mental health was in a downward spiral. Her therapist was on a break, so she asked around for recommendations and was referred to a psychotherapist at Therapy Works.
In the first session, Sehr informed the therapist that she was sensitive to anger and loud talk. “It gives me anxiety,” she told BBC. “When I shared my spells of low esteem, she [therapist] responded angrily.”
The therapist crossed her on why she allowed people to body shame her. “What did you do to yourself? How much did you hurt your inner child? she asked and may have meant well in making me liable for boosting my self-esteem, but it just made me feel responsible for what people said.”
The 26-year-old found herself unable to speak up due to the therapist’s angry tone. She quit after three sessions.
Sehr’s story is not an isolated incident as mental healthcare has gone unchecked in Pakistan for decades. It took a young woman’s brutal murder in Islamabad to trigger a debate after the suspect, Zahir Jaffer, turned out to be a psychotherapist.
In recent years, Pakistan has grown on the idea of professional help even if it’s discreet. But the critical shortage of qualified and ethical practitioners is being exploited by untrained professionals offering unsupervised, and sometimes dangerous, services.
Although psychiatry falls under Pakistan Medical Commission (PMC), Vice-President Ali Raza said he is yet to come across a complaint against a psychiatrist. “If people are reluctant to talk about mental health, they’re even more hesitant to file a complaint.”
Dr Asma Humayun, who runs UNICEF’s Mental Health and Psychosocial Support Services (MHPSS) in Islamabad, supposed that limited knowledge of scientific protocols prevents people from challenging the treatment they have been offered.
In the absence of a licensing authority in Pakistan, qualified psychologists look towards the American Psychological Association (APA) and British Psychological Society (BPS) which require a minimum of a Ph.D. to obtain the title of a psychologist — in Pakistan, that label is increasingly being used by undergraduates who lack specialised training in methods of psychological and psycho-diagnostic testing and treatment (psychotherapy and counseling).
Similarly, Psychotherapists turn to British Association for Counselling and Psychotherapy (BACP). In an email to BBC, the body confirmed that it does not have “any accredited courses nor approved qualifications based in Pakistan. We don’t have any organisational members based in Pakistan either.”
This is in stark contrast to Therapy Works and CPPD-Pakistan’s claim of offering BACP-accredited diplomas.
Earlier this month, Islamabad Capital Territory Administration (ICTA) sealed the offices of Therapy Works in connection with Noor Mukadam’s murder case. Its offices in other parts of the country are still open.
In interviews with BBC, a partner at CPPD-Pakistan insisted the counseling school offered a BACP-accredited advance diploma. The BACP, however, clarified that CPPD’s “UK-based Advanced Diploma in Humanistic Integrative Counselling (Professional Training) is accredited by us. Their Advance Diploma based in Pakistan isn’t accredited by us.”
A day after talking to the BBC, the CPPD partner retracted his statements, saying that he did not “have the authority to give anything without their [CPPD-London] approval” and requested this correspondent to “not mention his name”.
Dr Murad Moosa Khan, Professor Emeritus of Psychiatry, Aga Khan University, linked the growth of unsupervised mental healthcare centres to a rise in social problems in the country, causing distress in the population that leads people to seek professional help.
“An unemployed individual with a severe financial crisis may present symptoms such as headaches, insomnia, loss of appetite, and anxiety. These are often misdiagnosed as depression and generalized anxiety disorder (GAD),” he explained.
“Social problems get medicalised with unscrupulous mental health professionals preying on the patients’ vulnerabilities rather than looking at the root cause.”
Pakistan’s mental health boom has come sans awareness about the roles of psychiatrists, psychologists, and psychotherapists.
Dr Khan, a specialist, said he sees a range of patients coming in for problems such as complex schizophrenia and bipolar disorders to a daughter-in-law and mother-in-law dispute. As a specialist, he feels he should deal with more complex problems.
“This is what happens where there is no healthcare system,” he said, adding that unchecked mental healthcare is a spinoff of the unregulated private health sector. “Primary healthcare acts like a gatekeeper — screening patients and dealing with minor problems. If the problem is complex, it would be referred to secondary care — specialists. If it cannot be handled there, then they are referred to tertiary which is specialised.”
Few months into the Covid-19 pandemic, Sehr realised she wasn’t feeling the best. This time she went back to her original psychotherapist — who is an associate member of the APA with an MPhil degree and training in CBT, PCT, and Psychodynamic therapies.
“I have come very far with my progress — I take my mental health very seriously and see a therapist when I don’t feel well so it doesn’t affect my daily life, work, and relationships,” she told BBC.
“But therapy is also a slow process and some days, even good therapy can push you back as you open about trauma,” reflected Sehr, adding that sometimes it took months to recover. “A good therapist helps you stick to the process of healing.”
“Part of the reason why mental healthcare practitioners & facilities get away with it in Pakistan is that all mental disorders such as depression, schizophrenia, bipolar disorders, OCD, etc are abstract constructs. There are no blood tests or brain scans to prove one way or another. Tests that are done are to rule out physical disorders, not rule in mental illness,” stressed Dr Khan.
“Hence, it is relatively easy to play on peoples’ vulnerabilities and tell them ‘you have depression’ or ‘you have schizophrenia’ or ‘you are suffering from trauma’, or ‘you are suffering the consequences of abuse’ and offer them treatment- either medications or counseling or therapy- even when what the person is experiencing may be the result of adverse circumstances- which may not require a psychological intervention but addressing the underlying problem- poverty, employment, domestic violence, bullying etc.”
Although Pakistan is a signatory to WHO’s Mental Health Action Plan 2013–2030, little progress has been made in legislating and addressing the inequitable distribution of resources and provisions for psychological support across the country.
“There is an urgent need to advocate for a licensing and regulatory body and raise public awareness,” said Dr Khan.
Many associations and societies such as the Pakistan Psychological Association (PPA), Pakistan Association of Clinical Psychologists (PACP), Pakistan Psychiatric Society (PPS), and Board of Mental Health Professionals (BMHP) have propped up across the country, but none have the authority to enforce ethical practice. Only government can do that.
In that spirit, Associate Professor of Clinical Psychology at the Institute of Clinical Psychology (ICP) Dr Sobia Aftab said a group of clinical psychologists has proposed a definition of clinical psychologists to the Sindh Mental Health Authority.
When health was made a provincial subject in 2010, provinces adopted the federal Mental Health Act 2001 with little revision. Dr Humayun, one of the psychiatrists who drafted the legislature, termed it too “outdated” to be implemented today.
The grieved party can file complaints at the provincial health commissions or take legal action against the negligence, but the reach is limited in the absence of a licensing and regulatory body.
“The provincial healthcare commissions in Islamabad, Punjab, and Sindh have also failed to curb quackery and restrict illegal mental health educators and treatment centres,” said Dr Aftab.
Meanwhile, SMHA is yet to set up rules and regulations. In June, the Pakistan Allied Health Professionals Council Bill 2021 was introduced in the National Assembly.
Special Assistant to Prime Minister on Health Dr Faisal Sultan said the bill looks to set educational and licensing standards and regulations for several allied health professions, including psychology and counseling.
The council will set out specific curriculum and requirements to qualify for a license — this would include graduation, post-graduation, and training.
The bill awaits Parliament’s approval.
The story originally appeared in BBC Urdu.