Breaking The Chains That Bind The Mentally Ill

Love, respect, integration into communities, work, housing, food and clean water: That's what mentally ill people, like all human beings, need. Instead, in many parts of the developing world, people with mental illness are chained, nearly starved and even locked in a cage with a wild animal like a hyena to scare the demons out of them.

The World Health Organization's Chain-Free Initiative was launched in 2006 to help improve mental health services around the world. On this year's World Mental Health Day, organized by WHO to raise awareness of mental health issues, the theme is schizophrenia, a severe mental disorder characterized by false beliefs, hallucinations and unclear thinking. We talked with Dr. Taghi Yasamy, senior medical officer in the Department of Mental Health and Substance Abuse at WHO, about the plight of people with schizophrenia.

"Chain-Free Initiative" is a provocative title. What does it mean?

In general, many people in low-income countries believe that schizophrenia is the result of possession by evil spirits. Beliefs like that are very common, and people use different techniques to try to get rid of the evil spirits. For example, they'll chain people — to beds in the house, to trees outside. They might give them only water, bread and pepper. They believe the spirits will leave because they don't like pepper. They might leave [the mentally ill person] in chains for as long as 40 days with just bread and water. Or they'll expose them to a wild animal, thinking the animal will scare the spirits away. In some places, they'll brush the skin harshly to get the spirits out. In the lowest income countries, it's common to see such things.

Do the patients' families try to protect their mentally ill members?

The stigma is strong in many countries. So families try to hide these patients. They want to confine the person, and they do unethical things like putting the patient in a cage. In places where they are not rich enough to afford a cage, they might chain [the patient] to a tree.

Do countries with somewhat higher levels of income do better?

In some places where the literacy rate is higher and they have more resources and a good number of educated people, they develop institutions to care for mentally ill people. But the demand is so high, people rush to these centers. There may be nothing for the rural areas, but in large urban areas the institutions fill up, and there is not enough manpower to care for everyone. The few mental institutions become just like jails, and within them, people can still be chained. The institutions might say that it's to keep the patients safe so they can't hurt themselves. But this is a violation of human rights.

How does the Chain-Free Initiative work?

In Somalia and Afghanistan, where we started the Chain-Free Initiative, there are now chain-free hospitals. We established a committee within hospitals that included patients, families and staff. We train the staff, we involve the relatives and friends who will be helping to provide services. They have become more humane places for treatment, not places to contain people. When ]the patients] feel better, they go back to the community.

How does the community receive returning mentally ill patients?

Patients need follow-up. We get permission from the family first, and then educate the community. We explain that the patient is not being possessed. He is ill. If there is a good primary healthcare system, mental health care can be integrated into the services within the primary care health centers. Providers at these centers have already been trained to immunize children and on mother and child nutrition. We've developed guidelines and tools to help them deal with mental illness.

Even in the developed world, there is a lot of stigma associated with mental illness.

That's true. These are the invisible chains of the mind. People all over the world need a higher level of psychological literacy. In high-income countries, between a third and a half of people with mental illness don't get services. This is often due to attitude, not access.