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.

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

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.

*Name changed to protect privacy

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