I have personally witnessed individuals with mental disorders in east and southeast Asian towns and villages chained to their beds; caged in small cells built behind houses; hospitalised in for-profit asylums where they are kept in isolation in concrete rooms with a hole in the floor for urine and faeces; abused by traditional healers such that they become malnourished and infected with tuberculosis; scarred by burns resulting from inadequate protection from cooking fires; forced to dress in prison-like clothes in asylums with shaven heads and made to perform child-like dances and songs for gawping visitors; knocked to the ground and forcefully held down for electroconvulsive therapy when psychotic in an emergency room; laughed at by the police; hidden by families; stoned by neighbourhood children; and treated without dignity, respect, or protection by medical personnel.For example, the Human Rights Watch report, "Like a death sentence", describes abuses against people with mental disabilities in Ghana. The three public psychiatric institutions in Ghana and 8 prayer camps in the southern parts of the country were visited. All the camp leaders interviewed considered mental disability to be caused by evil spirits or demons. Most people brought to the camps for healing for mental disabilities were chained to logs, trees or other fixed spots. Hospitals were found to have poor sanitation. Individuals are routinely institutionalised by their family or police and denied the right to refuse or appeal their confinement, which may include forced treatment, physical abuse and seclusion. The report of the UN Special Rapporteur on torture expressed concern about the use of electroshock with the use of restraints, without adequate anaesthesia.
The call for "scaling up" of mental health services in low and middle-income countries (LMICs) has caused controversy. For example, books by Suman Fernando, Mental health worldwide: Culture, globalization and development, and China Mills, Decolonizing global mental health: The psychiatrization of the majority world have criticised the Movement for Global Mental Health. This is because LMICs may do better to develop their own solutions rather than emulate high-income countries (HICs). Do LMICs really want to develop the same pharmaceutical emphasis as so-called developed countries? Being disempowered and living in conditions of persistent poverty may not be improved by perceiving the emotional consequences of such social disadvantages as a brain problem. Wellbeing may be more than a medical problem.
As Suman says, "care is needed in how the concept of 'human rights' is interpreted" and may not mean having the right to the same psychiatric treatment practiced in the West. As he also says, "Perhaps asylums should never have been introduced in LMICs". Human rights are violated in these institutions, which requires urgent attention. Some religious healing activities may need to be controlled. Suman agrees that injustices must be remedied, but I'm not sure if I agree that legislative changes (which clearly must take account of local services rather than merely being copied wholesale from legislation in HICs) should have less priority than community service development. I do agree, though, with his view that a paradigm shift envisaged by Bracken et al (2012) (see previous post) is required to create a psychiatric practice "sufficiently flexible to play a constructive role in mental health systems worldwide". Such an approach must be driven by the human rights of people with mental health problems.