What causes 'mental illness' among Pakistanis

Hamida Khatoon, an attractive young woman in her thirties, thought life had taken a turn for the better when her unemployed husband found a job in Saudi Arabia. Though she was left on her own with the children, she had several compensations: their own flat, colour ­TV, VCR, expensive new clothes and a suddenly affluent lifestyle seemed, at first, a fair exchange for the temporary loss of her husband.

But gradually, the stress of coping on her own with the children and the day-to-day problems her husband used to attend to, added up. Feeling depressed and suffering from persistent headaches, she turned to tranquillis­ers in an attempt to forget her loneli­ness.

She finally ended up in a psychiatric clinic where the doctor diagnosed that her problem was "stress caused by an absence of standards to guide their lives. Faced with new possibilities of advancement, these people were unable to put limits to their ambition, and suffered the consequences of a destabilisation of their value system".

Two years ago outside a masjid in Golimar, Karachi, a crowd of the faithful stoned an infant to death for the 'crime' of being illegitimate.

In February 1983 a group of 38 people from Chakwal followed an 18-year-old girl to make a pilgrimage to Karbala on foot and through the sea. Unquestioningly accepting the girl's reports of supernatural voices and signs telling her to lead her family to Karbala, they had made elaborate preparations for the journey, with every appearance of rationality. The story ended tragically, with 18 people drowning in the sea, but the faith of the survivors remained unshaken.

Isolated cases? Or symptoms of a growing national malaise? One in every 10 Pakistanis suffers from major mental illness according to the president of Pakistan Psychiatric Society. In addition, 25-30 percent of those who seek medical help for physical complaints are in fact suffering from psychosomatic manifestations of mental illness.

Mental illness is usually regarded as a problem which afflicts the affluent, a rich man's disease. But increasingly the stresses of a rapidly changing society are taking their toll in this country: the incidence of depression, anxiety, schizophrenia, hysteria and compulsive obsession, at an individual level, and mob violence, like Karachi's recent sectarian riots, at a collective level, has risen sharply.

All developing countries are af­fected by socio-economic changes and the dislocation they produce, but Pakistan's situation is compounded by a number of factors: migration which has given rise to the "Dubai syndrome", urbanisation (which has produced "high-rise complex") the refugee problem (the "Afghan factor") and religious and political repression which has blocked the constructive expression of frustration and anger.

Incidents such as the stoning of the infant and the Hawkes Bay tragedy are symptoms of what psychologists term social neuroses. They believe acts of mob violence or collective madness are generally caused by frustration and a deteriorating cultural environment.

Social neurosis, which often erupts into violence, is a manifestation of displaced aggression on the part of frustrated individuals who cannot satisfactorily channel their anger against the real source of the frustration. The person does not know what to attack, but feels angry and seeks an object to direct his aggression against.

At other times, circumstances may block a direct attack on the cause of the frustration, and aggression is again displaced towards an innocent person or object.

"The practice of 'scapegoating' is an example of displaced aggression," says a psychiatrist. "An innocent victim is blamed for one's trouble and becomes the object of aggression. Prejudice against minority groups has a large element of displaced aggression or 'scapegoating'."

Dr. Yasmin Ahmed, a psychologist at the Medicare Clinic, says that our present economic system has created a vacuum. It has given rise to tensions and frustrations which there are no means of resolving. It is the interaction between these tense and frustrated people which often results in such mad-mob behaviour.

"Once a collective mind is formed, it blocks the intellectual and moral ideals of the individual concerned. Feelings, attitude and behaviour are communicated and accepted without logic. Thus, a group of people could collectively stone an infant to death by sheer contagion. The more frustrated and insecure the group of individuals, the greater the possibility of such behaviour."

It is generally recognised by psychiatrists that all disorders arise within the context of a particular so­cial framework. Certain socio­-economic conditions give rise to specific mental disorders.

Rapid population growth and increases in the cost of living have alsocontributed to mental illness by increasing the level of competition.

Depression and anxiety, for example, have been shown to be significantly associated with unemployment and economic depression, cultural disintegration, erosion of ethnic identity, breakdown of social support structures and excessively high performance demands.

Rate of neurotic and psychosomatic illness in general appear to be higher in culturally uprooted communities, and in refugee and migrant populations, than in settled populations, and in women than in men.

Stress is known to be one of the main causes of psychosomatic illness. Poor nutrition, inadequate shelter and subhuman living conditions create stress which is compounded by perceptions of injustice or even aggression. They either make one unable to, or prevent from, organising to improve the situation.

People remain in a state of frustration, debility, apathy and despair — susceptible to mental and physical diseases, and crime, violence and drug abuse.

A WHO report notes that: "At a time when more individuals are exposed to the unsettling effects of being uprooted, and of social isolation, for example, it is likely that the prevalence of psychiatric disorders of a depressive nature will increase."

Rapid population growth and increases in the cost of living have also contributed to mental illness by increasing the level of competition. "Just as many individuals cannot resist the invasion of bacteria, and fall ill, many people cannot cope with the psychological strains of competitive living, and become emotionally disturbed," says one psychiatrist. "Such emotional disturbances, arising from poor ability to cope, can be found among some very intelligent students, who either drop out or become drug addicts or gangsters, and hence a menace to society."

The political environment also has a significant impact on the level of mental disorder. The Pattern of Mental illness, 1967-1973 by Dr Haroon Ahmed shows that the pattern of mental disorder varies with the changing political situation in the country.

The report points out that during 1967 and 1968, the distribution of schizophrenia, depression, anxiety and other disorders showed little variation apart from a slight increase, particularly in depression, in 1968. However, in 1969 there was a marked change in the pattern. While the reported cases of anxiety increased sharply, the number of cases diagnosed as depression dropped.

The major political changes taking place at the time may have contributed to this increase in the incidence of anxiety. After a long period of political calm following the 1965 war, 1969 saw a mass upheaval. Field Mars­hal Ayub Khan was forced to relinquish power and his successors promised to hold a general election. The 'One Unit' system of administration was dismembered and political parties were allowed to function without any restrictions.

"A sudden change in the country's political activities in preparation for a general election could have been a contributory factor to the drop in cases of depression, and the increase in cases of anxiety,'' says Dr Haroon.

While the combined figures for 1970 and 1971 of old and new patients were the highest ever, the number of new patients dropped to an all-time low, while relapses reached an all-time high, and the incidence of depression and schizophrenia declined. According to Dr Haroon, "this could mean that anxiety became goal-directed; emotions found violent expression and the borderline cases became involved in more meaningful activities, so that there were fewer new cases".

The traumatic events of 1971 were a major factor in the phenomenal increase in reported cases of anxiety and schizophrenia. "This could be called a rebound phenomenon," says Dr Haroon. "A general feeling of insecurity had followed a shock period, and the very basis of the 'Two Nation theory' on which the country was created was eroded."

Similarly, Dr Haroon notes, the current situation has led to a dramatic rise in depression. "An intense feeling of insecurity and fear, the absence of a clear objective in life and the motivation to live, has contributed largely to this rise in cases of depression."

According to a study conducted in 1981, 31.2 per cent of patients in the psychiatric ward of Jinnah Post Graduate Medical Centre (JPMC) in Karachi suffered from anxiety, while 29.7 per cent were depressive. Another significant development has been a marked increase in cases of Obsessive-compulsive disorder. This syndrome generally reflects suppressed emotions and a sense of guilt and deprivation, and 'compels' the victim to obsessively repeat certain acts, like washing hands or reading signboards.

Psychiatrists believe that the present repressive cultural and political environment have exacerbated such symptoms and religious fanaticism has encouraged guilt complexes which are manifested in peculiar compulsive/obsessive behaviour.

One such case is that of Iqbal Ghani, who haunted the residents of his neighbourhood for several weeks with his own particular obsession: he would wander the streets reciting his namaz loudly every night for two hours from 4 am till the morning azaan, shouting "Allah-o-Akbar" repeatedly in an agonised voice.

Socio-technological change has also altered, to a great extent, Pakistan's social, cultural and economic life. The term itself reflects the now widely re­cognised fact that there is a causal link between technological and social change. The introduction of new technologies, whether in the form of a new production process or a new product, creates new social roles and eliminates others.

Working on a production line in a factory, for instance, is a very different experience from the looser pattern of a small-scale workshop or agricultural labour. The absence of social interaction between workers, the noise of machinery, and the long hours of routine regimented repetitive acts of­ten combine to produce neurotic reactions like nightmares in which the individual sees himself chained to the machine.

New forms of work or family or community organisation resulting from technological change can have profound social effects. TV and VCR alone have wrought a profound revolution in social behaviour, seducing people into a one-way relationship where they give up communication with each other and passively absorb the mechanical stimulant which the media have to offer.

Industrialisation and technological advancement since Partition have brought about a radical change in social and economic relations. Although the majority of the population still lives in a feudal environment, the concentration of industrial areas has caused large-scale migration from rural to urban centres.

The increase in urban population and the scale of urbanisation in Pakistan has been one of the most rapid in the world. In­dustrialisation has created a new class, the urban proletariat, which largely consists of migrants from the NWFP and Punjab.

The migrant worker suffers the most from side effects of so­cial change and the symptoms are manifested through drug addiction and a variety of other psychological disorders. The culturally uprooted Pathan population of Karachi, which forms the bulk of its labour force, is particularly vulnerable to the stresses imposed by the new industrial structure. Most of them migrate at a very young age, and cultural displacement, disintegration of family life and economic hardship often result in psychological problem.

"Pathans are by temperament emotional people, and most of their psychological problems are caused by emotional as well social factors such as the absence of family life and poor living conditions," says Dr M F Khan, a former professor of pathology at Dow Medical College.

Dr Khan, who now has private clinics in Shershah and on Frere Road, notes that most of his patients, of whom an overwhelming majority are Pathan labourers "actually suffer from psychological problems such as anxiety and depression".

Although the level of mental disorder is greatest among younger people, Dr Khan finds a high incidence even among older patients. When migrants first arrive, the initial problems of adjustment are combined with the excitement of a new environment and job, and the effects of stress are not immediately apparent. However, as time passes, economic and social pressures and separation from the family begin to have an impact on their mental health.

The case of Azmat Khan, who migrated to Orangi Town from Hazara five years ago, is a classic example ofthis syndrome. Moving from one temporary shelter to another working as a part-time construction labourer and missing his family, he soon turned to charas and heroin as a means of relief. Feelings of insecurity began to haunt him, and soon he was suffering from paranoid delusions. One day he at­tacked a fellow worker with a hammer for a joke the latter had made about Pathans. Azmat lost that job and sank further into depression and apathy, until one day, in a fit of frenzied despair, he cut off his right arm, screaming, ''What use is it to me when I can't find work?"

Late marriages and separation from their wives also creates sexual frustra­tion leading to mental health problems among migrant workers. In the NWFP, a man has to pay as much as 80,000 rupees for a bride. "A labourer would have to save for about 25 years to collect this amount," points out Dr Khan. "Even when they manage to get married, if they can't take their wives with them, it has a depressive effect."

The plight of women migrants is even more pathetic. Used to living a relatively less-restricted life in the village, when they come to the city they are confined to a single room where they have to carry out their daily chores and rear children. "Cramped living conditions and reduced physical activity leads to obesity (due to over­eating) and depression in these wo­men," says Dr Khan.

Fatima, 23, is typical example. The blank expression on her face belies the mental agony she endures. Incapacitated by severe headaches and cramps in her legs, she refuses to leave the two-room shack in Korangi where she lives with her parents and 14 brothers and sisters. Poverty and stress have also impaired her mother's health. She wakes up constantly dur­ing the night and rushes to check if the door is locked — an obsessive compulsion.

Women in general are heavily affected by rapid social change and moderni­sation. They are gradually being liberated from their subordinate position, from some of their domestic chores and from their role as the primary agent of socialisa­tion. They are also increasingly moving into employment outside the home.

However, they are still subject to stress-inducing experiences, which include an increasing workload, conflict between commitment to marriage and child-rearing and commitment to occupational and social aspirations.

Such conflicts can lead to schizophrenia. Jamila, a bank employee, had been working for several years, and was used to an independent income and lifestyle. After marriage to a conservative man several years her senior, she found it difficult to continue with her job, as her husband would lecture her daily on the evils of women leaving the house to work.

The tremendous psychological conflict bet­ween her desire to work and her subconscious feeling of guilt at not obey­ing her husband's wishes was expressed in her attempts to overcompensate. She would stay up half the night cleaning the house and preparing special food for her husband, until she collapsed one day and refused to leave the bed. A study of outpatients attending the psychiatric ward of JPMC showed that a high proportion of schizophrenic patients were married, divorced or widowed women.

The mass exodus of Pakistani man­power to the Gulf has created its own set of serious psychiatric problems. Unlike Pakistanis living in the West, migrant workers in the Middle East cannot take their families with them, and their family life disintegrates. Culture shock, adjustment problems, lack of communication and particularly lack of emotional support com­pound the pressures.

Disintegration of the traditional family structure is one of the majorfactors behind the sharp increase in crime rates among youth.

But the wife and other family mem­bers left behind suffer even more. In the husband's absence, the wife has to shoulder the responsibility of rearing the children alone, as well as take care of the house and other work. These pressures, heightened by loneliness, create immense psychological stress and many such women exhibit symp­toms of what psychiatrists have come to call the ''Dubai syndrome". A study on this syndrome by Dr Haroon Ahmed shows that depression and psychosomatic diseases have in­creased among married women during the last decade.

The absence of the father has a se­vere effect on children, particularly boys. In a lecture last year on 'Social Change and Crime', Dr. Salim A Shah, the visiting chief of the US Centre for Studies in Crime, National Institute of Mental Health, pointed out: "In a society like Pakistan, with its traditional family relationships, when a large number of men go away, there is no male to provide the children with a socialising influence. That is some­thing which is already having a major psychological impact, giving rise to mental health and delinquency problems."

The implications of these social changes are not only an increased rate of delinquency and crime, but also emotional problems, learning difficulties and substance abuse.

Disintegration of the traditional family structure is one of the major factors behind the sharp increase in crime rates among youth.

"In societies like Pakistan, there is a rich tradition of the extended family. When any element in the socialising of the child is weakened, fragmented or severely disrupted by other social changes, one can safely predict that there will be an increased proportion of youngsters who will not be well-socialised and who will not have incorporated the behavioural norms which should guide their conduct," says Dr Shah.

Crime is only one index of the consequences of social change. Running away from home, family break-up or violence within the family may not be defined as crime but they are another index of the negative effects of social change.

During the critical process of identity formation, changing social conditions make adolescents particu­larly susceptible to development in a direction which may be harmful to health. Changing values tend to widen the generation gap, and in their conflict with parents, adolescents may indiscriminately reject traditional values, along with family guidance and support.

The double standards and hypocrisy endemic in our society have had a very unhealthy effect on the youth. "With society's norms and values in a state flux, youth have little confidence in the entire system. This lack of continuity and stability has introverted them," says Dr Haroon.

The most alarming manifestation of this alienation is the increase in drug addiction among young people. According to one study, 54 per cent of addicts surveyed were aged between 15 and 25, compared to 42 per cent in 1982.

The repressive socio-psychological environment not only manifests itself in major mental illnesses, it also gives rise to violence, crime and aggression. Discussing the relationship between social unrest, crime and the psychological environment, Dr Shah says, "The stresses and strains of social change and other accompanying factors will be manifested in increased crime, delinquency, mental disorder and social unrest. Even stress-related health problems are a reflection of the tensions in society."

The unprecedented growth in murders, sexual offences and violence are also a reflection of the socio-economic and psychological destabilisation which has occurred in Pakistan. It was recently reported that the crime rate in Karachi alone has increased by 18 per cent over the last two years. It is not only the rate of increase which is alarming, but also the nature of the offences committed.

The violent assault on and humiliation of the Nawabpur women, or the incident which occurred in Bhit Shah recently, where a gang of criminals attacked a cluster of labourer's huts and ab­ducted four women, cannot be dismis­sed as mere mindless violence. "Such behaviour," says Dr Yasmin Ahmed, "is never as impulsive as is commonly believed".

The findings of the committee investigating the Nawabpur affair show that it was not an isolated inci­dent —the feudal lords of the area often took part in such barbaric acts.

"Our society is generally regres­sing," maintains Dr Ahmed. "The growing violence against women, and their degradation, are obvious symp­toms of this regression. Our choice is violence because we are increasingly becoming a hypocritical society; it is often not injustice but hypocrisy which provokes violence. A prime example of this is the Nawabpur incident."

One of the factors complicating the study of human behaviour is the tendency for different individuals to react to similar situations in a variety of ways. Thus, one common response to frustration is active aggression, but equally is its opposite, apathy.

While on the one hand there is a growing tendency towards violence and aggression, on the other hand there is a failure on the part of many people to react to such distressing events. How else can the apathy of the of the inhabitants of Nawabpur, who never once reacted to the barbarism and cruelty in their midst, be explained?

Erich Fromm, one of the founders of psychoanalysis, explains these contradictory behaviour patterns in his book, The Sane Society:

"Despots and ruling cliques can succeed in dominating and exploiting their fellow men, but they cannot prevent reactions to inhuman treatment. Their subjects become frightened, suspicious and lonely and if not due to some external reason,their systems collapse at some point because fear, suspicion and loneliness eventually incapacitate the ability of the majority to function effectively and intelligently. They react with apathy or such impairment of intelligence, initiative and skill that they gradually fail to perform the functions which should serve their rulers. Or they react by the accumulation of such hate and destructiveness as to bring about an end to themselves, their rulers and their system. Which reaction occur depends on many facts: on economic and political ones and on the spiritual climate in which people live."

This was originally published in the Herald's December 1984 issue. To read more subscribe to the Herald in print.